Terashi S, Ozaka S, Kagoshima Y, Shimomori Y, Takahashi H, Minezaki D, Tsutsumi K, Fukuda M, Hirashita Y, Fukuda K, Ogawa R, Kodama M, Murakami K, Mizukami K. Bowel preparation for small bowel capsule endoscopy in patients with suspected or established Crohn’s disease. World J Gastrointest Endosc 2026; 18(2): 113762 [DOI: 10.4253/wjge.v18.i2.113762]
Corresponding Author of This Article
Sotaro Ozaka, MD, PhD, Assistant Professor, Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama, Yufu 879-5593, Japan. ozakaso@oita-u.ac.jp
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Feb 16, 2026 (publication date) through Feb 4, 2026
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World Journal of Gastrointestinal Endoscopy
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1948-5190
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Terashi S, Ozaka S, Kagoshima Y, Shimomori Y, Takahashi H, Minezaki D, Tsutsumi K, Fukuda M, Hirashita Y, Fukuda K, Ogawa R, Kodama M, Murakami K, Mizukami K. Bowel preparation for small bowel capsule endoscopy in patients with suspected or established Crohn’s disease. World J Gastrointest Endosc 2026; 18(2): 113762 [DOI: 10.4253/wjge.v18.i2.113762]
Co-corresponding authors: Sotaro Ozaka and Kazuhiro Mizukami.
Author contributions: Ozaka S and Mizukami K contributed equally to this manuscript and are co-corresponding authors. Terashi S and Ozaka S developed the study design and wrote the manuscript; Shimomori Y, Kagoshima Y, Takahashi H, Minezaki D, Tsutsumi K, Fukuda M, Hirashita Y, Fukuda K, and Ogawa R performed the small-bowel capsule endoscopy and acquired the data; Ozaka S and Mizukami K reviewed and corrected the manuscript; Murakami K, Kodama M, and Ozaka S provided oversight for the manuscript and revised it for important intellectual content; all authors issued final approval for the version to be submitted.
Supported by Takeda Science Foundation, No. 2025045981.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of the Oita University Faculty of Medicine, No. 3144.
Informed consent statement: Written informed consent was obtained from each patient before small-bowel capsule endoscopy examination. The authors declare that the study consisted of a retrospective assessment and was conducted in accordance with the Declaration of Helsinki.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sotaro Ozaka, MD, PhD, Assistant Professor, Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama, Yufu 879-5593, Japan. ozakaso@oita-u.ac.jp
Received: September 3, 2025 Revised: September 27, 2025 Accepted: December 10, 2025 Published online: February 16, 2026 Processing time: 154 Days and 20.5 Hours
Abstract
BACKGROUND
Although small-bowel capsule endoscopy (SBCE) is an important tool in the diagnosis of Crohn’s disease (CD), the necessity and consensus protocol of preprocedural bowel pre-treatment for SBCE in patients with CD have not yet been established.
AIM
To evaluate the diagnostic performance and mucosal visibility of SBCE with and without bowel preparation in patients with CD.
METHODS
Patients with suspected or established CD who underwent SBCE at our hospital between January 2015 and March 2025 were included in this retrospective observational study. SBCE was performed after bowel preparation with fasting only or with 1 L of polyethylene glycol solution with liquid simethicone. The primary outcome was the lesion detection rate. Secondary outcomes were the completion rate of the examination, image quality, gastric transit time, small bowel transit time, and adverse events related to SBCE.
RESULTS
Fifty-seven patients were included in the study. The detection rates of lesions were 95.6% in the non-preparation group and 96.6% in the preparation group, with no significant differences between the two groups. The two groups showed no significant differences in completion rates, gastric transit time, small bowel transit time, or visibility score. One patient in the preparation group experienced intestinal obstruction.
CONCLUSION
The diagnostic performance and mucosal visibility of SBCE for CD were not significantly improved by pre-procedural bowel preparation.
Core Tip: Small-bowel capsule endoscopy (SBCE) is an important tool in the diagnosis of Crohn’s disease (CD). The necessity and consensus protocol of preprocedural bowel pre-treatment for SBCE in patients with CD have not been established. This study aimed to describe the contribution of preprocedural bowel preparation in SBCE for patients with CD with small intestinal lesions by comparing the diagnostic performance and mucosal visibility. We believe that our study makes a significant contribution to the literature because it showed that the diagnostic performance and mucosal visibility of small-bowel capsule endoscopy for CD were not significantly improved by pre-procedural bowel preparation.
Citation: Terashi S, Ozaka S, Kagoshima Y, Shimomori Y, Takahashi H, Minezaki D, Tsutsumi K, Fukuda M, Hirashita Y, Fukuda K, Ogawa R, Kodama M, Murakami K, Mizukami K. Bowel preparation for small bowel capsule endoscopy in patients with suspected or established Crohn’s disease. World J Gastrointest Endosc 2026; 18(2): 113762
Crohn’s disease (CD) can involve all segments of the gastrointestinal tract, with a particular prevalence in the small intestine, including the terminal ileum[1]. Small bowel capsule endoscopy (SBCE) is a minimally invasive method of observing the small bowel mucosal surface and is widely used for diagnosis and for monitoring small bowel lesions in CD[2]. When SBCE is performed to diagnose CD, the findings should be evaluated based on better-quality images. However, SBCE often results in poor image quality owing to residual intestinal contents, such as air bubbles, drugs, and food residues, leading to missing important diagnostic findings. Therefore, various efforts have been made to improve the image quality of SBCE, one of which is preprocedural bowel preparation with a purgative agent before the SBCE examination. Although recent guidelines from the European Society of Gastrointestinal Endoscopy recommend bowel preparation before SBCE[3], there remains a debate about whether bowel preparation is necessary. Several clinical studies and meta-analyses reported improved visibility of the small intestinal mucosa and increased diagnostic yield with bowel preparation for SBCE[4-7]. Conversely, recent studies indicate that bowel preparation may improve the visibility of the small bowel, but does not improve the diagnostic accuracy and completion rate of SBCE[8-10]. Furthermore, Gkolfakis et al[11] reported no difference in diagnostic yield, image quality, or complication rate between bowel cleanser pre-treatment and clear liquid preparation. Reasons not to administer bowel preparation before SBCE include a potential for increased small bowel motility, which might result in higher miss rates, lack of change in diagnostic outcome, and patient inconvenience[12]. Therefore, the optimal protocol for pre-procedural bowel preparation before SBCE has not been established. It should be noted that small bowel lesions in CD are predominantly located at the terminal ileum, which tends to be the darkest, has a tendency to accumulate residue, and is known to have the worst image quality for SBCE[13]. Furthermore, the aforementioned meta-analyses were mainly concerned with diseases such as obscure gastrointestinal bleeding (OGIB), and the utility of bowel preparation for SBCE in patients with CD remains unclear. This study aimed to describe the contribution of preprocedural bowel preparation in SBCE for patients with CD with small intestinal lesions by comparing the diagnostic performance and mucosal visibility.
MATERIALS AND METHODS
Participants
This was a single-facility retrospective observational study based on a single-facility database. Patients with established or suspected CD who underwent SBCE at Oita University Hospital between January 2015 and March 2025 were included to evaluate the efficacy of preprocedural preparation with a purgative agent. Patients with established or suspected CD who underwent SBCE were enrolled. These were patients who had confirmed small bowel lesions in other modalities, such as ileocolonoscopy, double-balloon enteroscopy, and small bowel follow-through before SBCE. In patients with established CD, SBCE was performed at the time of initial diagnosis or when symptoms worsened. The exclusion criteria were as follows: Lesions that could not be confirmed by imaging studies before SBCE, history of intestinal obstruction, unknown preparation, history of intestinal fistula, history of implanted medical electronic devices, and inadequate data. All patients underwent a passage test using a patency capsule before SBCE. In all cases, written informed consent was obtained from all patients before SBCE.
Study design
Using electronic medical record data, patient characteristics were retrospectively analyzed, including age, sex, body mass index, past medical history, disease duration, disease type, treatment, and Harvey-Bradshaw index (HBI) at the time of examination. SBCE was performed using a PillCam SB2 or SB3 (Given Imaging Ltd., Yokneam, Israel). Patients who underwent SBCE by September 2022 received 1 L of a polyethylene glycol (PEG) solution with 60 mg of liquid simethicone for preparation. The SBCE was performed within 1 hour after preparation. This group was defined as the preparation group. From October 2022, patients who underwent SBCE with only fasting before examination were defined as the non-preparation group. On the day before the procedure, all patients fasted from 9 PM. All regular medications were taken after the examination. The images were evaluated using RAPID Reader 6.5 or 8 software on a RAPID workstation (Given Imaging Ltd., Yokneam, Israel). Gastric transit time (GTT) was defined as the time from the beginning of the stomach to entry into the duodenum. Small bowel transit time (SBTT) was defined as the time from the beginning of the duodenum to entry into the cecum. The sum of the GTT and SBTT results was defined as the total examination time. According to Ogino et al[14], SBCE findings were classified into three types: Erosions, ulcers, and a cobblestone appearance. An erosion was defined as a mucosal defect of < 3 mm; a mucosal break larger than ≥ 3 mm was defined as an ulcer under SBCE. To evaluate the visibility of the SBCE images, a modified scoring system described by Leighton et al[15] was used as follows (Figure 1): 1 = Poor. A large amount of fecal residue precludes a complete examination; 2 = Fair. Inadequate examination was performed. Sufficient feces or turbid fluid present to prevent a reliable examination; 3 = Good. Small amount of feces or turbid fluid not interfering with the examination; and 4 = Excellent. There was no more than a small amount of adherent feces. A total of nine images were scored: The main lesion and four images before and after the lesion, and the final score was the average of these values. All SBCE images were evaluated by two independent expert gastroenterologists who were blinded to the preparation methods used.
Figure 1 Images of the cleaning scoring system.
A: Poor, 1 point. A large amount of fecal residue precludes a complete examination; B: Fair, 2 points. Inadequate, but examination completed. Enough feces or turbid fluid present to prevent a reliable examination; C: Good, 3 points. Small amount of feces or turbid fluid not interfering with examination; D: Excellent, 4 points. No more than small bits of adherent feces.
Outcomes
The primary outcome was the lesion detection rate. Secondary outcomes were the completion rate of the examination, image quality, GTT, SBTT, and SBCE-related adverse events. The lesion detection rate was defined as the ratio of the number of cases with lesions to the total number of completed SBCE cases. The completion rate was defined as the percentage of capsule endoscopes that reached the cecum. SBCE-related adverse events, including nausea, abdominal distension, capsule retention, perforation, aspiration, and pancreatitis, were recorded during the examination. In addition, we evaluated the occurrence of clinical relapse within six months after SBCE in both groups.
Statistical analysis
Data were analyzed using the EZR software version 1.54. The differences between the preparation and non-preparation groups were examined using the Mann-Whitney U test to compare the median values of non-normally distributed variables and Pearson’s χ2 test or Fisher’s exact test for nominal variables. Differences between the study groups were considered statistically significant when the P-value was < 0.05. The factors associated with lesion detection via SBCE were evaluated using multivariate logistic regression analysis. Inter-observer reliability of mucosal visibility scores was assessed using the intraclass correlation coefficient [intraclass correlation coefficient (ICC), two-way random-effects model, average measures] [ICC (2, k)].
Ethical consideration
This study was conducted in accordance with the Declaration of Helsinki (revised in 2013). This study was approved by the Institutional Review Board of the Oita University Faculty of Medicine (No. 3144). Patients were not required to provide informed consent because the analysis used anonymous clinical data obtained after each patient agreed to the capsule endoscopy with written informed consent.
RESULTS
Patient characteristics
SBCE was performed in 71 patients with established or suspected CD during the study period. After excluding 14 patients, 57 patients were enrolled in the study. The final analyses were performed on 25 patients in the non-preparation group and 32 in the preparation group. Table 1 shows the baseline patient characteristics of the two groups. The median age of the patients was 17 years (range 16-24) and 28 years (range 18-42) in the non-preparation and preparation groups, respectively, and there were 56% and 59% males, respectively. The non-preparation and preparation groups included six and four suspected CD cases, and 19 and 28 confirmed CD cases, respectively. The median weight, body mass index, and smoking history were not significantly different between the two groups. The characteristics of patients with CD were compared with those of patients with established CD (n = 19 in the non-preparation group and n = 28 in the preparation group). There were no significant differences between the two groups in terms of history of diabetes, history of constipation, disease location, disease behavior, HBI, perianal lesions, C-reactive protein levels, and current therapy.
The completion rates of the SBCE were 92.0% in the non-preparation group and 90.6% in the preparation group, respectively. In two patients from each group, the endoscope failed to reach the cecum because of battery failure, and the capsule endoscope was retained in one patient in the preparation group. The detection rate of lesions was 95.6% (22 of 23 patients) in the non-preparation group and 96.6% (28 of 29 patients) in the preparation group, with no significant difference between the two groups. The two groups showed no statistically significant differences in the GTT, SBTT, and visibility scores (Table 2). The inter-observer agreement for mucosal visibility scores was good, with ICC (2, k) = 0.772 [95% confidence interval (CI): 0.497-0.885], indicating substantial reliability between the two evaluators. The SBCE findings of CD mucosal injury were classified as erosions, ulcers, and a cobblestone appearance. When the findings were compared between the non-preparation and preparation groups, erosions (59% vs 76%), ulcers (46% vs 55%), and a cobblestone appearance (9% vs 6%) were observed. Since disease severity is an important factor affecting the diagnostic performance of SBCE, we performed a subgroup analysis based on disease severity (HBI). Patients with established CD were divided into two subgroups: The active phase (HBI ≥ 5) and the remission phase (HBI < 5). In a subgroup analysis, lesion detection rates, SBCE success rates, and visibility scores were lower during the active phase. However, no significant differences in these outcomes were observed based on the presence or absence of bowel preparation across any subgroup (Table 3).
Adverse events associated with this procedure are shown in Table 4. Nausea was the most frequent bowel preparation-related adverse event, occurring in three patients (9%), and abdominal discomfort was observed in one case in the preparation group (3%). The condition of these patients improved without any treatment. One patient in the preparation group experienced intestinal obstruction. In this case, the intestinal obstruction improved a few days later, and the patient recovered with conservative treatment alone. Only one case of clinical relapse was observed in each group at the follow-up period up to 6 months after SBCE.
The necessity and consensus protocol for preprocedural bowel pre-treatment in SBCE have not yet been established. This study focused on patients with diagnosed or suspected CD and evaluated the utility of bowel preparation for SBCE. No significant difference was found in the lesion detection rate and mucosal visibility between the pre-treatment group that received PEG 1 L before SBCE and the non-preparation group, indicating that bowel treatment with SBCE for CD is not always necessary.
SBCE is a wireless capsule endoscope that can be used internally for non-invasive endoscopic observation of the entire small intestine and has good indications for CD. The role of CE in the practice of CD includes initial diagnosis, differentiation of other diseases, diagnosis of the extent of small bowel involvement, and monitoring response to treatment[2]. Previous studies have compared SBCE with other diagnostic modalities in CD. Magnetic resonance enterography (MRE) is valuable for assessing transmural inflammation and extramural complications, but its sensitivity for small superficial lesions is lower than that of SBCE (86.9% for SBCE; 82.0% for MRE)[16]. Balloon-assisted enteroscopy allows direct biopsy and therapeutic intervention but is invasive and usually limited to partial small-bowel assessment[3]. In contrast, SBCE provides the most comprehensive mucosal visualization, although its diagnostic performance can be influenced by bowel cleanliness. Therefore, our findings on bowel preparation should be interpreted in the context that SBCE primarily complements, rather than replaces, other imaging techniques in the diagnostic and monitoring algorithm for CD. The accuracy of CD diagnosis using CE has a sensitivity of 83%-88% and specificity of 53%-76%, especially for picking up small lesions[17,18]. Better quality endoscopic images are important in the evaluation of small bowel lesions, and one way to improve the image quality of SBCE is by using purgative bowel cleansing before SBCE[19]. In fact, the European Society of Gastrointestinal Endoscopy recommends a meal with minimal residue and taking 2 L of PEG solution before SBCE[3]. Conversely, the capsule endoscopy guidelines from the Japanese Association for Capsule Endoscopy state that the need for bowel preparation in SBCE is low, and the necessity for bowel preparation before SBCE remains controversial. Several clinical trials and meta-analyses have reported improved visibility of the small intestinal mucosa and increased diagnostic yield with bowel preparation for SBCE[4-7]. For example, Belsey et al[6] reported that use of any form of bowel preparation yielded significantly better visibility than fasting alone [odds ratio (OR) = 2.31; 95%CI: 1.46-3.63; P < 0.0001]. Similar results were seen for diagnostic yield (OR = 1.88; 95%CI: 1.24-2.84; P = 0.023). Kotwal et al[7] reported that a combination of PEG and simethicone showed significantly improved visualization quality compared to overnight fasting or purgatives alone. However, recent reports suggest that bowel preparation for SBCE improves the visibility of the small intestinal mucosa but has a limited impact on diagnostic yield and completion rates[8-10]. A meta-analysis of 40 clinical trials demonstrated that bowel preparation before SBCE did not increase the diagnostic rate of small bowel lesions (OR = 1.11; 95%CI: 0.85-1.44) nor the completion rate (OR = 1.30; 95%CI: 0.95-1.78), but improved visualization quality (OR = 1.60; 95%CI: 1.08-2.06)[8]. Chen et al[9] demonstrated that simethicone for bowel preparation is useful to improve visualization (respiratory rate = 1.41; 95%CI: 1.20-1.65) and reduce the gas bubbling of SBCE (respiratory rate = 2.05; 95%CI: 1.56-2.71), but no significant association was found for diagnostic yield. Furthermore, Marmo et al[10] emphasized that the timing of pre-treatment laxative ingestion was critical for bowel cleansing; the shorter the time lapse between the last intake of laxatives and the start of SBCE, the better the visualization. Furthermore, a meta-analysis of 12 randomized controlled trials showed no difference in diagnostic yield, image quality, GTT, SBTT, or complication rate with purgative bowel preparations compared to clear liquid preparation before SBCE[11].
Notably, these clinical studies were based on other gastrointestinal disorders, such as OGIB, iron-deficiency anemia, and abdominal pain, and there are limited reports examining the efficacy of bowel preparation for SBCE in patients with CD. Our study adds to the current literature by evaluating a real-world cohort of patients with CD and directly comparing PEG with simethicone against fasting alone, which reflects common clinical practices and decision-making. Despite the retrospective and single-center design, our results provide complementary evidence that may guide clinicians in tailoring preparation strategies for SBCE in CD, thereby contributing to the external validity of existing data. Kametaka et al[20] reported that pre-treatment with low-dose magnesium citrate significantly improved the visibility of distal ileum lesions, including 29 patients with suspected CD. However, Margalit Yehuda et al[21] showed that the visibility and performance of SBCE for monitoring the same patients with CD were not significantly influenced by bowel preparation by PEG. These studies evaluated image quality in detail, but not the lesion detection rate. The present study incorporated cases in which lesions were identified in the ileum prior to CE. To the best of our knowledge, this is the first analysis of the effect of bowel preparation on the detection rate of CD findings by CE. In this study, the detection rates of CD lesions were 95.6% in the non-preparation group and 96.6% in the preparation group, indicating good values in both groups. No significant difference was found in the lesion detection rate, including mucosal visibility, between the preparation and non-preparation groups in patients with CD. These results were consistent in subgroup analyses dividing patients with established CD into active and remission phases, suggesting that the lack of benefit from bowel preparation is not explained by disease severity.
Capsule retention and subsequent bowel obstruction are major concerns in patients with CD[22]. The frequency of capsule retention in patients with OGIB is 1.4%, while in cases of established/suspected CD, retention was observed in 8.2%/3.6%[23], 4.6%/2.4%[24], and 1.3%/1.3%[25], and the frequency of failure to perform the examination was reported to be 6.5%[25]. Therefore, it is recommended to confirm intestinal patency using a prior patency capsule and imaging examination, such as computed tomography enterography or MRE, to prevent capsule retention. In the present study, one case of intestinal obstruction occurred in the preparation group, despite prior assessment of the patency of the small intestine with a patency capsule. In this case, the time gap between performing the patency assessment and conducting the SBCE may have led to an incomplete patency evaluation. When performing bowel preparation in patients with CD, extreme caution must be exercised to prevent capsule retention and bowel obstruction. Moreover, the tolerability of the examination is an important factor in evaluating the need for SBCE preparation. Several studies have reported that bowel preparations using laxatives may decrease SBCE tolerability. Hookey et al[26] showed that the tolerance of the preparations was significantly higher in the clear fluids-only group (93%) than in the PEG group (13%) (P < 0.0001). Lamba et al[27] also reported that the use of purgative bowel preparation is associated with lower tolerance and better tolerability in the clear fluids-only group than in the PEG group. In the present study, nausea and abdominal discomfort associated with pre-treatment were observed only in the preparation group. Patients with CD are expected to undergo SBCE several times in their lives; therefore, an examination that is convenient and well-tolerated by patients is required.
The limitations of this study are as follows. First, because this was a retrospective study, the compliance and tolerability of bowel preparation were not evaluated along with quantification. There was a tendency for the preparation group to be selected from older patients, which could be considered a selection bias. Since age may influence the need for bowel preparation, we performed multivariate analysis, which showed that age, sex, bowel preparation, and high disease activity were not significant factors associated with lesion detection in SBCE (Supplementary Table 1). However, residual confounders such as disease location or behavior prevent the complete exclusion of this bias. Second, the small sample size was insufficient to assess the most serious adverse events, such as capsule retention, bowel obstruction, and intestinal perforation. Therefore, our findings should be interpreted with caution regarding safety outcomes. Moreover, tolerability is an important clinical factor, but it cannot be fully assessed through retrospective chart reviews alone. Using standardized questionnaires and scoring systems enables a more comprehensive evaluation of patient comfort and acceptability. Future prospective studies should incorporate such structured tools to better inform clinical decision-making. Third, although the present study was a single-center study involving only two experts evaluating intestinal visibility, this setup may be considered a limitation in terms of reproducibility.
CONCLUSION
This study’s results demonstrate that the detection rates and mucosal visibility of SBCE in patients with CD were not significantly influenced by preprocedural bowel preparation. Given the risk of bowel obstruction due to gastrointestinal stenosis and the reduced acceptability of patients, preprocedural bowel preparation for SBCE is not always necessary in patients with CD. Further multicenter prospective clinical studies with sufficient numbers of participants are required to address these limitations.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: Japan
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade B, Grade D
Creativity or Innovation: Grade C, Grade D
Scientific Significance: Grade B, Grade D
P-Reviewer: Jiao Y, PhD, Associate Professor, China; Shiota J, MD, Assistant Professor, PhD, Japan S-Editor: Bai SR L-Editor: A P-Editor: Xu ZH
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