Toyia James-Stevenson, MD
Assistant Professor of Clinical Medicine
Division of Digestive and Liver Disorders
Indiana University
Indianapolis, Indiana

Cristiano Spada, MD
Digestive Endoscopy Unit
Catholic University
Rome, Italy


Introduction

Incomplete colonoscopy is a significant risk factor for development of colon cancer if further testing is not done to complete visualization of the colon. Common reported reasons for incompletion include looping, patient discomfort, diverticulosis and suspected adhesions.1 Prior to the FDA’s February 2014 approval of colon capsule endoscopy for incomplete colonoscopy, the main options for completing colon visualization were: 1) attempting to repeat the colonoscopy, or 2) referring the patient for a radiology study such as air contrast barium enema2 or CT colonography.

Case Presentation

A 65-year-old Caucasian female was referred for colon capsule endoscopy after an incomplete screening colonoscopy due to inability to pass an area of extensive diverticular disease in the sigmoid colon. She was otherwise healthy with no medical or surgical history, and was not on any medications. The colon capsule study was notable for findings of a raised 15mm polyp in the descending colon near the splenic flexure. Colon capsule endoscopy also confirmed the previously documented sigmoid diverticulosis, and the patient passed the capsule without difficulty. She subsequently underwent a repeat colonoscopy under general anesthesia with a thinner pediatric colonoscope, which confirmed findings of a polyp at the splenic flexure that appeared flat on optical colonoscopy.

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Raised 15mm polyp on colon capsule endoscopy
 
Same raised polyp on colon capsule endoscopy
 
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Same polyp now with insufflation has flatter appearance on colonoscopy
 
Same polyp after submucosal injection in preparation for removal during colonoscopy

Discussion

Quality measures for colonoscopy include an expected cecal intubation rate of 90% for all colonoscopies, and 95% for screening colonoscopies.1 The definition of completion typically means full evaluation of the colon, including entire visualization of the cecum. This allows for improved detection of proximal colon polyps and cancers. The rate of incomplete colonoscopy varies depending on patient populations studied and the type of referral center. Most experienced colonoscopy centers document cecal intubation rates of 97% for screening populations.3 Patient risk factors for incomplete colonoscopy include advanced age, obesity and female gender.4,5 Women account for nearly two-thirds of incomplete colonoscopies,6 which may be related to more complex pelvic floor anatomy and potential for disorders like endometriosis or prior pelvic surgeries, all of which may contribute to restricted mobility of the colon.4

This case highlights the emerging role of colon capsule endoscopy in the United States for visualizing the colon in the setting of incomplete colonoscopy where inadequate bowel preparation was not the reason for incompletion. Potential benefits of colon capsule endoscopy over repeat colonoscopy or radiology tests include: a) avoiding the risk associated with repeat sedation and colonoscopy, particularly if no significant findings are noted, and b) the patient may experience less discomfort than that associated with radiology tests, along with avoidance of radiation exposure.

This case also demonstrates the differing appearance of polyps on colon capsule endoscopy as compared with colonoscopy. This is due to the lack of colon insufflation. Polyps on colon capsule studies often project away from the mucosa, as is the case with this polyp, which was later found to be flat on colonoscopy. When optical colonoscopy fails, colon capsule endoscopy is an important emerging tool for endoscopists to employ in order to achieve complete colon visualization.

References

  1. Neerincx M, Terhaar sive Droste JS, Mulder CJ, et al. Colonic work-up after incomplete colonoscopy: significant new findings during follow-up. Endoscopy. 2010;42(9):730-735.
  2. Rizek R, Paszat LF, Stukel TA, et al. Rates of complete colonic evaluation after incomplete colonoscopy and their associated factors: a population-based study. Med Care. 2009;47(1):48-52.
  3. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2006;101(4):873-885.
  4. Dafnis G, Granath F, Påhlman L, et al. Patient factors influencing the completion rate in colonoscopy. Dig Liver Dis. 2005;37(2):113-118.
  5. Agrawal M, Rahmani R, Levine C, et al. The effect of BMI on common GI procedures: preliminary data of a large prospective observational study. Am J Gastroenterol. 2011;106(Suppl 2):S518.
  6. Shah HA, Paszat LF, Saskin R, et al. Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology. 2007;132(7):2297-2303.



The risks of PillCam capsule endoscopy include capsule retention, aspiration, or skin irritation. PillCam COLON capsule endoscopy presents additional risks, including risks associated with the drug products used to prepare the patient for the procedure, which are currently used for colonoscopy, including allergies or other known contraindications to any preparation agents or medications used for the PillCam COLON regimen, according to laxative medication labeling and per physician discretion. Medical, endoscopic, or surgical intervention may be necessary to address any of these complications, should they occur.