COLONIC CLEANSING BEFORE COLON CAPSULE ENDOSCOPY (CCE) – TOLERABLE AND EFFECTIVE? Gábor Balogh MD, András Székely MD, László Madácsy MD PhD Endoscopy Unit, Fejér Megyei Szent György County Hospital, Székesfehérvár, Hungary 1. Neither of the published colonoscopy preparation protocols can guarantee 100% efficacy and adaptability for all patients. 2. Inadequate colonic cleanliness decreases the sensitivity of CCE. 3. The rate of suboptimal colonic cleanliness reaches % during CCE. Nevertheless, the sensitivity of the CCE is % comparing to colonoscopy. 4. Since the clinical introduction of CCE, the development had been particularly aimed to progress the technical features of the capsule (field of view, longer lifetime of the battery). 5. Application of the same colon preparation protocol has different individual effect on colonic cleanliness, which could not be explained by only the poor compliance of the patients. 6. Measurement of colonic cleanliness by bowel preparation scales is a subjective and ambiguous method depending on the current observer, therefore not adequate for sufficient scientific conclusions. A quantitative measurement of colonic cleanliness could therefore be essential in the efficacy evaluation of certain bowel preparation protocols. Hypothesis Decreased patient compliance. Different efficacy of the laxative (Fleet phospho soda). Organic disease (stricture, tumor…) Medicine intake, which influence the bowel function. Transit time of the colon? ( Frequency, regularity of defecation, stool consistency…) Individual factors that might affect the efficiency of the colonic preparation To estimate the influence of individual defecation habits on the efficacy of bowel preparation. To compare a semi-quantitative and a new quantitative method of colonic cleanliness- evaluation during colonic capsule endoscopy (CCE). Study aim The Rapid software was used for evaluation of the capsule’s recording, and it has a color bar (CB) which is generated from the sum of spectral images captured by the capsule (Figure 3). This CB is composed of several consecutive and well separated color sections depending on the color-compound of the colonic segment just being presented by the capsule. Each part of the gastro- intestinal tract has its own color compound idiosyncratically. The spectral predominance of the green color of the CB indicated those colonic segments with poor preparation and visibility. Therefore, the assessment of the CB’s green color compound could inform quantitatively about the colonic cleanliness alluding to the efficacy of preparation. The projection of the colon and the rectum on the CB was cut out from the rapid software and pasted into another color evaluating program. Quantitative color evaluation was carried out by a histogram analysis with a newly developed and validated program called “Colors”. The quantitative values of the cleanliness were correlated with our semi- quantitative analysis (BBPS) calculated from the cleanliness values of the four colonic regions. CCE cases GenderAverage of age Question naire2211 femal e 17male pts fielded a standardized questionnaire A. 7 Several times per day, and during night B. 6 Several times per day, but not at night C. 5 Every day D. 4 Every second-third day E. 3 Twice a week F. 2 Once a week G. 1 Less than once a week Frequency of stool. 3 NeverA. 3 Never B. 2 SometimesB. 2 Sometimes C. 1 OftenC. 1 Often D. 0 AlwaysD. 0 Always To exert oneself during a bowel movement, difficult to empty the stool? A. 2 Recently I have diarrhoea B. 1 Recently diaorrhea and constipation alterated. C. 0 Recently I have constipation Last couple of weeks, months been any change in the order of bowel movements A. 2 Yes, regulary, every day B. 1 Sometimes C. 0 Never Do you use any laxative? Questionnaire and grading (table 1.) Bowel preparation protocol (table 2.) Patients and methods 22 patients filled a standardized questionnaire, which aimed to grade the defecation habits of our patients (detailed on table 1). After CCE assessment the colonic cleanliness was graded by using the modified Boston Bowel preparation scale (BBPS) (figure 1). Four colonic regions were graded by the BBPS (figure 2). The summarized BBPS values of the four colonic regions were correlated by the defecation habits graded by the questionnaire. 0. Poor preparation: Unprepared colon segments with most of the mucosa are not visible because of staining and large amount of residual stool peaces and/or opaque liquid. 1. Incomplete preparation: Portion of the mucosa is visible, but other areas of the colon segment are not well seen because of staining and residual small amount of stool pieces and/or opaque liquid. 2. Good preparation: Most of the mucosa can be seen well of the colonic segment with minor amount of residual staining and/or opaque liquid, but without stool pieces. 3. Excellent preparation: Entire mucosa of the colon segment can be seen well, clear fluid and or only minimal residual staining. Modified BBPS (Boston Bowel preparation scale) (Figure 1) Grading of the four colonic segment from 0 to 3 and the average values of different sections (figure 2) The maximum value of the BBPS was 12 Evaluation of the color green compound in the color bar (figure 3) The spectral proportion of color green is increased on those pictures with large amount of residual pieces of stool indicating poor preparation of the colonic segment. In this regard, the histogram evaluation of green color could be usefull in the quantitative assessment of colonic cleanliness. Results Each patient was able to swallow the capsule and there was no capsule retention. Significant correlation could be presented between the defecation habits and the colonic cleanliness (figure 4). Significant correlation could be demonstrated between the semi- quantitative BBPS and the computer based quantitative analysis of colonic visualization G/R+G+B.(p=0.02, r=-0,72689). Sufficient colonic mucosal visualization is achieved under 0.32 cut-off value.(figure 5). Correlation between BBPS and the defecation habits (figure 4) Correlation between the BBPS and color green hystogram of CB (figure 5) 1.The defecation habits obviously influence the individual efficacy of certain bowel preparation protocols. 2. Our study highlights that individual preparation models might be created by using a standardized questionnaire, which evaluates the defecation habits. It would be practical to find and generally apply those preparation model, with which one might guarantee the optimal colonic cleanliness for those patients who are difficult to preparate. 3. Further studies needed to search those factors, which principally influence the individual adaptability for different bowel preparation protocols. 4. The quantitative analysis of the CB’s color green histogram is an adequate method to evaluate the efficacy of the bowel preparation compared to BBPS. Further studies are needed to determine the cut-off values. 5. Our new computer based quantitative analysis is suitable method to measure the efficacy of colonic cleansing and also to compare different future preparation protocols. Conclusions