Low-volume bowel preparation provides safe and effective pan-enteric capsule endoscopy in suspected or established Crohn’s disease

Table 1 Details of the low and high-volume preparation protocols according to date and time of pan-enteric capsule endoscopy

		Low-volume protocol	Standard high-volume protocol
Day	Time	Instructions
1 day	All day	Clear liquid diet	Clear liquid diet
	19:00-21:00	1000 mL PEG 3350 with ascorbic acid (MoviPrep©)	2000 mL PEG 3350 (Meroken©)
PCE day	07:00-09:00	1000 mL PEG 3350 with ascorbic acid (MoviPrep©)	2000 mL PEG 3350 (Meroken©)
	10:00	PCE ingestion	PCE ingestion
	11:00	Optional: 10 mg metoclopramide if alert “0’’	Optional: 10 mg metoclopramide if alert “0’’
	Small bowel detection - alert “1”	150 mL lactulose + 1500 mL of water	180 mL oral sulfate solution mixed in 300 mL of water + 1000 mL of water
	3 hours later - alert “2”	90 mL lactulose + 500 mL of water	90 mL oral sulfate solution mixed in 150 mL of water + 1000 mL of water
	2 hours later - alert “3”	10 mg bisacodyl suppository	10 mg bisacodyl suppository
	2 hours later - alert “4”	A light meal	A light meal
Total liquid volume		4240 mL	6720 mL

PCE: Pan-enteric capsule endoscopy; PEG: Polyethylene glycol.

Table 2 Four-point Likert scale for bowel preparation assessment

Score	Description	Definition of adequacy
1	Excellent	Adequate
2	Good	Adequate
3	Fair	Inadequate
4	Poor	Inadequate

Table 3 Clinical and demographic characteristics, n (%)

	LVP (n = 55)	HVP (n = 12)	P value
Age (years)1	35.7 (19.3-90.1)	34.2 (23-58.4)	0.423
Male sex	22 (40.0)	6 (50.0)	0.538
Any GI surgery	5 (9.1)	1 (8.3)	1.000
BMI (kg/m2)1	24.8 (18.2-37)	23.6 (15.9-24.9)	0.235
Smoking
Never	21 (56.8)	10 (90.9)	0.095
Current	7 (18.9)	1 (9.1)
Past	9 (24.3)	0 (0.0)
Medications associated with bowel ulcers
NSAIDS	2 (3.6)	0 (0.0)	0.502
Micropirin	3 (5.5)	0 (0.0)	0.408

¹Continues variables are presented as median (range).

LVP: Low-volume protocol; HVP: High-volume protocol; GI: Gastrointestinal; BMI: Body mass index; NSAIDS: Non-steroidal anti-inflammatory drugs.

Table 4 Crohn’s disease characteristics, n (%)

	LVP	HVP	P value
Disease duration, years, median (range)1	6.3 (0.03-17.6)	4.6 (0.3-16.4)	0.492
Age at diagnosis, years, median (range)1	25 (16-86)	22 (17-58)	0.422
Montreal classification1
Age at diagnosis
> 16	2 (4.8)	0 (0.0)	0.728
17-40	30 (73.2)	6 (85.7)
> 40	9 (22.0)	1 (14.3)
Location
L1	24 (57.1)	4 (50.0)	0.608
L2	3 (7.1)	0 (0.0)
L3	15 (35.8)	4 (50.0)
L4	0 (0.0)	0 (0.0)
Behavior
Inflammatory	32 (76.2)	6 (75.0)	0.660
Structuring	7 (16.7)	2 (25.0)
Penetrate	3 (7.1)	0 (0.0)
Peri-anal disease	10 (23.8)	0 (0.0)	0.184
Symptoms2
Abdominal pain	26 (47.3)	8 (66.7)	0.340
Diarrhea	20 (36.4)	6 (50.0)	0.515
Rectal bleeding	5 (9.1)	1 (8.3)	1.000
Extra-intestinal manifestation	12 (21.8)	4 (33.3)	0.444
Asymptomatic	19 (34.5)	4 (33.3)	1.000
Current treatment2
No treatment	18 (32.7)	3 (25.0)	0.740
5-ASA	8 (14.5)	2 (16.7)	1.000
Thiopurines	6 (10.9)	1 (8.3)	1.000
Methotrexate	0 (0.0)	1 (8.3)	0.179
Biologic	21 (38.2)	3 (25.0)	0.515
Steroids	2 (3.6)	1 (8.3)	0.452
Elevated CRP2	27 (49.0)	9 (75.0)	0.152
Elevated fecal calprotectin2	19 (34.5)	4 (33.3)	1.000
Anemia2	10 (18.1)	3 (25.0)	0.633

¹Data was analyzed only among patients with established Crohn’s disease (low-volume protocol, n = 42; high-volume protocol, n = 8).

²Data was analyzed for the entire cohort (low-volume protocol, n = 55; high-volume protocol, n = 12).

LVP: Low-volume protocol; HVP: High-volume protocol; 5-ASA: 5-aminosalicylic acid; CRP: C-reactive protein.

Table 5 Characteristics of three historical cohorts using the high-volume preparation protocol

Ref.	CD status	n	Sex	VCE completion rate	Location at the end of the incomplete study (n)	True retention	SB adequate preparation rate	Colonic adequate preparation rate
Leighton et al[24], 2017	Active CD	721	Male 306%; female 611%; unknown 8.3%	91.7%	SB (5); stomach (1)	0	87.9%	39.4%-62.9%
Bruining et al[27], 2020	Active CD	119	Male 40%; female 60%	85.6%	Requested removal (1); SB (1); colon (16)	13	79%-90%	64%
Eliakim et al[26], 2020	CD in remission	542	Male 500%; female 259%; unknown 24.1%	92.6%	SB (2); colon (1)	0	94.4	75%

¹In the original study, 6/72 patients were excluded due to incomplete pan-enteric capsule endoscopy.

²There were 54 pan-enteric capsule endoscopies performed in 41 patients.

³1 patient - capsule was retrieved by dilation of the small bowel stricture through ileo-colonoscopy.

PCE: Pan-enteric capsule endoscopy; CD: Crohn’s disease; SB: Small bowel; VCE: Video capsule endoscopy.

Table 6 Clinical and demographic characteristics of the individual participant data meta-analysis, n (%)

	LVP (n = 55)	Combined HVP (n = 257)	P value
Sex
Male	22/55 (40.0)	103/257 (40.1)	0.104
Female	33/55 (60.0)	135/257 (52.5)
Unknown	0/55 (0.0)	19/257 (7.4)
CD status1
Active CD	23 (41.8)	195 (75.9)	< 0.001b
CD in remission	19 (34.5)	58 (22.6)
Suspected CD	13 (23.6)	4 (1.6)
Montreal classification1
Age at diagnosis
> 16	2/41 (4.9)	10/126 (7.9)	0.513
17-40	30/41 (73.2)	97/126 (77.0)
> 40	9/41 (22.0)	19/126 (15.1)
Location
L1	24/42 (57.1)	73/168 (43.5)	0.269
L2	3/42 (7.1)	19/168 (11.3)
L3	15/42 (35.7)	76/168 (45.2)
L4	0/42 (0.0)	0/168 (0.0)
Behavior1
Inflammatory	32/42 (76.2)	121/168 (72.0)	0.840
Structuring	7/42 (16.7)	31/168 (18.5)
Penetrating	3/42 (7.1)	16/168 (9.0)
Current treatment1
5-ASA	8/55 (14.5)	21/172 (12.2)	0.651
Immunomodulatory	6/55 (10.9)	44/172 (25.6)	0.025a
Biologic	21/55 (38.2)	98/172 (57.0)	0.020a

^aP < 0.05.

^bP < 0.01.

¹Data was analyzed only among patients with established Crohn’s disease.

LVP: Low-volume protocol; HVP: High-volume protocol; 5-ASA: 5-aminosalicylic acid; CD: Crohn’s disease.