Purgative Small Bowel Preparation for Capsule Endoscopy? Maybe, but Think Out of the Box!

Abstract

American [1] and European Society of Gastrointestinal Endoscopy [2]—either empirically or based on data about mucosa visualization—advocate the use of 2L of PEG prior to small bowel video capsule endoscopy (VCE), contrary to the device manufacturers’ recommendations. In their review, Cave et al. [3] recommend against the use of purgatives prior to VCE due to lack of adequate data. However, this particular authors’ argument is indeed well supported by the results of the most recently published meta-analysis on this matter [4]. Analysis of data from 12 randomized controlled trials with more than 1220 examinations challenges the usefulness of purgative preparation before small bowel VCE since it increases neither examination’s diagnostic yield [risk ratio 1.17 (0.97–1.40)] nor small bowel mucosa visualization [0.99 (0.95–1.04)] [4]. Agreeing with the authors that preparation before VCE remains an open discussion and that further studies with standardized definitions, homogenous patient populations, and adequately justified sample sizes are warranted, we propose to walk unknown and less comfortable paths, to examine the value of administrating purgatives after capsule ingestion. Indeed, preliminary results of RCTs from two independent groups of experts indicate that giving either one sachet of Picolax® dissolved in 250 ml of water 1 h after swallowing the capsule with 500 ml of water [5] or 45 ml of sodium phosphate with 1 l of water after the entrance of the capsule in the duodenum—confirmed by the Real Time Viewer®—[6] delivers better mucosa visibility and improved quality of bowel preparation compared to prep given in the evening before the day of the examination. Thus, let’s think out of the box to look if a properly conducted study can prove that a purgative approach like this can improve examinations diagnostic yield, as well.