Published online Jun 16, 2026. doi: 10.4253/wjge.v18.i6.117353
Revised: January 4, 2026
Accepted: May 21, 2026
Published online: June 16, 2026
Processing time: 187 Days and 7.8 Hours
The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized.
To compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for SBCE.
A prospective, multicentre, randomized study including patients submitted to SBCE was conducted. Patients ingested a booster once the capsule reached the small bowel, randomized into one of three protocols: (1) 1 L of polyethylene glycol (PEG); (2) 1 L of PEG and ascorbic acid; and (3) 1 L of water. The patients’ bowel preparation was evaluated with Small Bowel CLEansing Assessment and Report.
A total of 261 patients were included, 96 (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (P = 0.655, P = 0.193 and P = 0.589, respectively). The overall Small Bowel CLEansing Assessment and Report score was similar among the protocols (P = 0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5 ± 0.1 vs 2: 2.6 ± 0.1 vs 3: 2.3 ± 0.1, P = 0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (P = 0.850). The patients’ reported tolerability was higher in protocol 3 (protocol 1: 2.8 ± 0.1 vs 2: 3.0 ± 0.2 vs 3: 0.6 ± 0.1, P < 0.001).
Using 1 L of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield vs PEG with or without ascorbic acid.
Core Tip: This prospective, multicentre, randomized study compared complete examination rates, bowel preparation quality, diagnostic yield, and tolerability across three small-bowel capsule endoscopy protocols. A total of 261 patients from two Portuguese university-affiliated hospitals were included. After the capsule reached the small bowel, patients received one of three boosters: (1) 1 L of polyethylene glycol; (2) 1 L of polyethylene glycol plus ascorbic acid; and (3) 1 L of water. Outcomes were similar across groups, with higher tolerability in protocol 3. Thus, using 1 L of water as a booster was better tolerated without reducing examination completeness, bowel preparation quality, or diagnostic yield.
- Citation: Ferreira AI, Côrte-Real F, Souto MM, Xavier S, Pereira JR, Arieira C, Rosa B, Duarte MA, Cotter J. Bowel preparation with still water for small bowel capsule endoscopy: Less is more. World J Gastrointest Endosc 2026; 18(6): 117353
- URL: https://www.wjgnet.com/1948-5190/full/v18/i6/117353.htm
- DOI: https://dx.doi.org/10.4253/wjge.v18.i6.117353
Small bowel capsule endoscopy (SBCE) is a non-invasive procedure which allows the evaluation of the entire small bowel[1]. Due to its excellent safety and tolerability, the indications for SBCE have been increasing since its initial introduction 25 years ago and has become essential in the management of several small bowel conditions[1-3]. Currently, it is the first-line examination for suspected small bowel bleeding and for iron deficient anemia when small bowel evaluation is indicated[1,3]. SBCE is useful in patients with suspected Crohn’s disease (CD) in the absence of obstructive symptoms and in those with previously known inflammatory-type CD for monitoring and guiding the treat-to-target strategy[1-3]. Finally, SBCE can also be important for patients with celiac disease with unexplained symptoms despite appropriate treatment and in some cases for surveillance of polyposis syndromes[1-3].
The adequacy of small bowel cleansing is a crucial performance measure for SBCE to ensure a reliable assessment of the small bowel[4]. However, the administration of intestinal preparation for SBCE is still a matter of debate[2,3,5]. The European Society of Gastrointestinal Endoscopy published a technical review of SBCE in which it was recommended to administer 2 L of polyethylene glycol (PEG) prior to SBCE for better visualization[5]. It was also established that the use of anti-foaming agents was associated with better mucosal visualization[5]. Simethicone has been previously demon
Six studies have demonstrated that administering purgatives prior to SBCE improved the mucosal visualization[10-15], with two meta-analyses demonstrating that the use of purgatives can improve the diagnostic yield[16,17]. However, seven studies have revealed that there is no benefit in the administration of purgatives for SBCE regarding small bowel cleansing and diagnostic yield[18-24]. It should be considered that the use of purgatives can reduce the patients’ tolerability and adherence[18,20].
The optimal strategy for bowel preparation for SBCE has not yet been determined[2,3,5]. Therefore, the aim of this prospective, multicentre and randomized study was to compare three different protocols of intestinal preparation for SBCE, regarding the rate of complete examinations, quality of bowel preparation, diagnostic yield and patients’ tolerability.
A prospective, multicentre, single-blinded (for investigators) randomized study including consecutive patients submitted to SBCE was conducted at two Portuguese university-affiliated hospitals. The inclusion period was between March 2023 and September 2024. Patients under the age of 18, with contraindications to ingesting PEG solutions, such as drug hypersensitivity, bowel perforation, electrolyte imbalance or severe dehydration, or who refuse to take part in the study were excluded. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the Institutional Review Board of Unidade Local de Saúde do Alto Ave (No. 42/2023) and the Institutional Review Board of the Hospital do Divino Espírito Santo de Ponta Delgada (No. S-HDES/2024/662).
SBCE was performed using the PillCam™ SB 3 capsule (Medtronic®). Detailed written and verbal information was provided to each patient. Iron supplements were stopped for all patients in the 5 days before SBCE. On the day before the examination, all patients were instructed to follow a clear liquid diet and 12 hours fasting before the exam. On the day of the examination, in the morning, patients ingested a glass of water with 100 mg of simethicone and swallowed the capsule. One hour after ingestion, patients returned to the Department of Gastroenterology and the position of the capsule was visualized using the real-time viewer. If the capsule remained in the stomach at this point, 10 mg of domperidone were administered orally. One hour after administration of the prokinetic, if the capsule remained in the stomach, it was placed in the duodenum by upper endoscopy using a snare or a basket. After confirming that the capsule had passed into the small bowel, a booster was administered.
Patients were randomized into one of three protocols: (1) In protocol 1, the booster was 1 L of PEG solution; (2) In protocol 2, 1 L of PEG solution with ascorbic acid; and (3) In protocol 3, the booster was 1 L of water. Randomization was based on the final digit of the patient identification number, having resulted in participants’ allocation in a 4:4:2 ratio.
Two hours after ingesting the booster, the patients started a clear liquid diet and, four hours after, they could have a light snack. The recorder was removed after confirmation of the capsule’s passage to the colon based on the real-time viewer or after the end of the battery’s duration. The protocol for SBCE is illustrated in Figure 1.
All patients signed an informed consent form with information about the ongoing study, besides the informed consent for the SBCE procedure. At the end of the procedure, patients were given a simple questionnaire asking whether they were able to ingest the entire preparation (yes/no) and how they rate their tolerability of the preparation, using a scale from 0 (very easy) to 5 (very difficult to ingest).
Once the video was created using the Rapid Reader Software (Medtronic®), each patient’s examination was assessed by 2 gastroenterologists experienced in SBCE, blinded to the protocol randomized for each patient. Any discrepancies were reviewed, and the final diagnosis was established per expert consensus.
In the case of incomplete examination, an abdominal radiography was performed to confirm the absence of capsule retention in patients who did not notice the capsule egestion during the two weeks after SBCE.
The primary outcome evaluated was the quality of bowel preparation. The secondary outcomes were the rate of complete small bowel examinations, the diagnostic yield, the small bowel transit time (SBTT) and the patients’ tolerability.
The quality of the bowel preparation was assessed by the Small Bowel CLEansing Assessment and Report (SB-CLEAR)[25]. This scale divides the small bowel into 3 tertiles, obtained by dividing the time taken for the capsule to pass through the small bowel by three[25]. The bowel preparation value is assessed for each tertile, between 0 and 3: (1) A score of 3 means that 90%-100% of the mucosa was visualized in that tertile; (2) A score of 2 indicates that 75%-90% of the mucosa has been visualized; (3) A score of 1 means that only 50%-75% of the mucosa was seen; and (4) 0 indicates that less than 50% of the mucosa has been visualized due to the presence of a large amount of turbid fluid, bubbles or debris[25]. Subsequently, the scores for each segment are added together to obtain a final score[25]. A score of 8-9 points indicates excellent preparation, 6-7 points indicates good preparation and 0-5 points indicates inadequate preparation. If any of the segments has a score of 0 or 1, inadequate preparation is attributed regardless of the final score[25]. For patients with incomplete SBCE studies, where the SB-CLEAR score could not be applied, bowel preparation adequacy was assessed per the overall impression of the reviewing physicians, as adequate or inadequate; these cases were considered as missing values and were excluded from all tests including the SB-CLEAR scores.
To assess the diagnostic yield, the presence of specific findings, such as ulcers or erosions, villous oedema, stenosis, lesions with hemorrhagic potential (P2 of the Saurin classification[26]), active bleeding, polyps or tumors, was reported.
The SBTT was defined by the length of time between the first duodenal image and the first cecal image.
The patients’ tolerability was assessed using a questionnaire where the patients answered whether they were able to ingest the entire booster and how the tolerability was on a numerical scale.
Categorical variables were described as n (%), and continuous variables as mean ± SD if normally distributed, or as median and interquartile range if not normally distributed. Comparison of categorical variables was performed using the χ2 test. Means and medians of continuous variables were compared using the one-way analysis of variance test.
Regarding the sample size calculation and assuming a non-inferiority design, the expected rate of adequate preparation in the standard protocol was assumed to be 80% and a non-inferiority margin of 15% was predefined as the maximum clinically acceptable difference. Assuming equal preparation rates across groups, a one-sided alpha level of 0.025 and a power of 80%, a total sample size of a minimum of 255 patients was planned.
A P value less than 0.05 was considered statistically significant. Statistical analysis software IBM SPSS version 27.0 (IBM Corp., Armonk, NY, United States) was used for all tests performed.
A total of 261 patients were included, most were female (64.0%), with a mean age of 51 ± 18 years. The most common indication for undergoing SBCE was suspected CD (39.1%), followed by suspected small bowel bleeding or iron deficient anemia (37.5%). Ninety-six patients (36.8%) were included in protocol 1, ninety-three patients (35.6%) in protocol 2 and seventy-two (27.6%) were included in protocol 3. The baseline characteristics of the study population and the SBCE findings are detailed in Table 1.
| Variable | Study population |
| Gender | |
| Female | 167 (64.0) |
| Male | 94 (36.0) |
| Age (years) | 51 ± 18 |
| Hospital | |
| Unidade Local de Saúde do Alto Ave | 235 (90.0) |
| Hospital do Divino Espírito Santo de Ponta Delgada | 26 (10.0) |
| Indication for small bowel capsule endoscopy | |
| Suspected small bowel bleeding or iron deficient anemia | 98 (37.5) |
| Suspected CD | 102 (39.1) |
| Established CD | 47 (18.0) |
| Others (celiac disease or polyposis syndromes) | 14 (5.4) |
| Study protocol | |
| Protocol 1 (1 L of PEG) | 96 (36.8) |
| Protocol 2 (1 L of PEG and ascorbic acid) | 93 (35.6) |
| Protocol 3 (1 L of water) | 72 (27.6) |
| Complete examination | 243 (93.1) |
| Adequate bowel preparation | 228 (87.4) |
| Diagnostic yield | 103 (39.5) |
| Angioectasia or active bleeding | 12 (11.6) |
| Ulcers or erosions | 89 (86.4) |
| Polyps | 1 (1.0) |
| Villous atrophy or oedema | 1 (1.0) |
There were no significant differences among the three groups regarding gender and age (P = 0.454 and P = 0.725, respectively).
There were no differences between the number of patients allocated for each of the three protocols in both recruiting centers (P = 0.520), as well as there were no statistically significant differences regarding the adequacy of bowel preparation, complete examinations and diagnostic yield between both centers (P = 0.218, P = 0.090 and P = 0.912, respectively).
The rate of complete examinations was comparable among the three groups (in protocol 1: 94.8% vs protocol 2: 91.4% vs protocol 3: 93.1%, P = 0.655). There were also no significant differences in the SBTT (in protocol 1: 207 ± 13 minutes vs protocol 2: 201 ± 14 minutes vs protocol 3: 242 ± 14 minutes, P = 0.086).
The rate of adequate bowel preparation was similar among the three groups (in protocol 1: 87.5% vs protocol 2: 91.4% vs protocol 3: 81.9%, P = 0.193). Additionally, the overall SB-CLEAR score was also comparable among the different protocols (in protocol 1: 7.6 ± 0.2 vs protocol 2: 7.9 ± 0.1 vs protocol 3: 7.6 ± 0.2, P = 0.236). When analyzing the score separately for each tertile, the preparation of the third tertile had a lower score using protocol 3 compared to the other groups (in protocol 1: 2.5 ± 0.7 vs protocol 2: 2.6 ± 0.6 vs protocol 3: 2.3 ± 0.7, P = 0.021). However, it did not compromise the adequacy of the small bowel visualization, maintaining a mean score above 2 in this tertile.
The interobserver agreement for the overall SB-CLEAR score was excellent [intraclass correlation coefficient (ICC) = 0.87], as well as for each tertile (first tertile ICC = 0.91, second ICC = 0.89 and third ICC = 0.85).
The diagnostic yield was comparable among patients from the three protocols (in protocol 1: 42.7% vs protocol 2: 35.5% vs protocol 3: 40.3%, P = 0.589), and it was also similar for each tertile among the protocols (first tertile P = 0.407, second tertile P = 0.163 and third tertile P = 0.850). The comparison of the rate of complete examinations, adequate bowel preparation and diagnostic yield among the groups is represented in Figure 2.
The percentage of patients who were able to ingest the whole booster was higher in protocol 3 compared to other protocols, although without statistically significant differences (in protocol 1: 84.4% vs protocol 2: 82.8% vs protocol 3: 94.4%, P = 0.068). The patients’ reported tolerability was higher in protocol 3, compared to both protocols 1 and 2 (in protocol 1: 2.8 ± 0.1 vs protocol 2: 3.0 ± 0.2 vs protocol 3: 0.6 ± 0.1, P < 0.001). Only minor side effects were reported by the patients and included headache and nausea, without significant differences between the protocols (P = 0.632). The comparison of the other outcomes among the three protocols is detailed in Table 2.
| Variable | Protocol 1 (1 L of PEG) | Protocol 2 (1 L of PEG and ascorbic acid) | Protocol 3 (1 L of water) | P value |
| Small bowel transit time (minutes) | 207 ± 13 | 201 ± 14 | 242 ± 14 | 0.086 |
| Small Bowel CLEansing Assessment and Report (points) | 7.6 ± 0.2 | 7.9 ± 0.1 | 7.6 ± 0.2 | 0.236 |
| First tertile | 2.5 ± 0.1 | 2.7 ± 0.1 | 2.7 ± 0.1 | 0.165 |
| Second tertile | 2.6 ± 0.1 | 2.7 ± 0.1 | 2.6 ± 0.1 | 0.242 |
| Third tertile | 2.5 ± 0.7 | 2.6 ± 0.6 | 2.3 ± 0.7 | 0.021 |
| Diagnostic yield | ||||
| First tertile | 12 (12.5) | 9 (9.7) | 12 (16.7) | 0.407 |
| Second tertile | 9 (9.4) | 17 (18.3) | 8 (11.1) | 0.163 |
| Third tertile | 34 (35.4) | 30 (32.5) | 26 (36.1) | 0.850 |
| Ingestion of the entire booster | 81 (84.4) | 77 (82.8) | 68 (94.4) | 0.068 |
| Tolerability, in a scale from 0 to 5 | 2.8 ± 0.1 | 3.0 ± 0.2 | 0.6 ± 0.1 | < 0.001 |
This prospective, multicentre, single-blinded randomized study compared three different protocols of intestinal preparation for SBCE. The optimal strategy for small bowel preparation has not yet been determined[2,3,5] and there is a high heterogeneity among different centers in the administration of purgatives for SBCE[27]. In our study, we adopted a booster-based strategy, instead of a bowel preparation strategy, and our patients ingested a booster after the capsule reached the small bowel. Previous studies have shown that the timing of the ingestion of purgatives is critical to small bowel cleansing and the shorter the period of time between the last dose of purgatives and SBCE, the better the mucosal visualization. In fact, taking the booster after confirming that the capsule has reached the small bowel is better than ingesting purgatives in the previous day[28-31]. This provides better removal of bile, debris and dark fluids, which led to increased rates of adequate bowel preparation, increased mucosal visualization, shorter SBTT and increased diagnostic yield[28,31].
We compared three different boosters with the same volume, 1 L of PEG solution, 1 L of PEG solution with ascorbic acid and 1 L of water. It has been previously demonstrated that the volume of the purgative solution (1 L or 2 L) did not have an impact on the small bowel cleansing[30,32]. Using lower doses of purgatives is equally safe and better tolerated by patients[11,30]. The protocol with ascorbic acid was used considering the previous reports demonstrating its efficacy and safety[28,33,34].
The rate of complete examinations, the SBTT, the rate of adequate bowel preparation, the overall SB-CLEAR score and the diagnostic yield were similar among the three protocols in our study. Different purgative solutions administered prior to SBCE, namely PEG solution, sodium phosphate and magnesium citrate, have been previously demonstrated to improve the mucosal visualization in eight studies[10-15,30,35]. However, most of the studies failed to provide evidence that purgatives also improve the diagnostic yield and the rate of complete examinations[10,11,14,35]. Additionally, seven studies have revealed that there is no benefit in the administration of purgatives for SBCE regarding small bowel cleansing and diagnostic yield[18-24]. Therefore, our study suggests that, more than the solution itself, the effect of volume can lead to the capsule’s progression and small bowel cleansing.
By analyzing the SB-CLEAR score separately for each tertile, the preparation of the third tertile had a lower score using protocol 3 compared to the other groups. Nonetheless, it did not compromise the adequacy of the small bowel visualization, maintaining a mean score above 2 in this tertile. This was also confirmed by the similar diagnostic yield for each tertile among the protocols. The distal ileum is a site with frequent abnormal findings in several small bowel diseases[1,3] and its visualization in SBCE can be poorer due to increased dark intestinal fluid and bubbles[12]. It is important to note that the quality of bowel preparation is as important as the diagnostic yield, because in patients without findings in SBCE we need to be sure that an inadequate bowel preparation and debris have not impaired the mucosal visualization and thus the diagnostic yield. Therefore, a SBCE examination with adequate bowel preparation is crucial for a conclusive examination and reliable results.
In our study, we also evaluated the patients’ tolerability to each protocol. In protocol 3 (1 L of water), the percentage of patients who were able to ingest the whole booster was higher and the patients’ reported tolerability on a numerical scale was also higher. The patients’ reported outcomes are important measures to consider in SBCE, since the use of purgatives can reduce the patients’ tolerability and adherence and can make it a more invasive procedure[18,20]. Furthermore, protocol 3 was the cheapest option since there was no need to buy intestinal preparation solutions.
Our randomized study has many strengths, namely its prospective and multicentre nature and the number of patients enrolled. There was the advantage that two experienced gastroenterologists evaluated each examination and were blinded to the protocol randomized for each patient. We included patients who underwent SBCE for all the indications as recommended by the different gastroenterology societies[1-3]. We evaluated the small bowel cleansing using a validated and simple score, SB-CLEAR. Finally, our study also evaluated the patients’ reported outcomes measuring their tolerability to the administered protocol.
However, our study also has some limitations. Patients were instructed to follow a strict protocol and the effect of the patients’ compliance influences the quality of bowel preparation. However, detailed written and verbal information was provided to each patient and the effect of non-compliance should be similar for each protocol. Other limitations include the exclusive use of the PillCam™ SB 3 capsule (Medtronic®) for all procedures and the substantially lower patient enrollment at one participating center, both of which may limit the generalizability of our findings. In addition, data on the number of patients requiring domperidone administration or endoscopic capsule placement for each protocol could not be retrieved, which may have introduced bias.
In conclusion, our study should be regarded as hypothesis-generating and suggests that the use of 1 L of water as a booster in small-bowel capsule endoscopy is better tolerated by patients and may represent the most cost-effective option. Although it was associated with a lower mean SB-CLEAR score of the third tertile, it did not compromise the rate of complete examinations, the global scores of bowel preparation or the diagnostic yield, when compared with the use of PEG with or without ascorbic acid.
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