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Abstract
Background:
The use of purging for bowel cleansing prior to small-bowel capsule endoscopy (SBCE) has now been established in clinical practice. Despite that, the number of incomplete SBCEs is still around 15–20%. To date, the use of prokinetics in SBCE – aiming to improve completion rate (CR) – remains a contentious issue resulting in lack of consensus among capsule experts.
Methods:
Extensive medical literature searches were conducted (to November 2012), using suitable MeSH terms and keywords, in search of studies that compared capsule ingestion with prokinetic agents vs. controls or placebo. We examined the effects of prokinetic administration on SBCE CR (primary end point), as well as on the following secondary end points: diagnostic yield (DY), gastric transit time (GTT) and small-bowel transit time (SBTT) by meta-analysis of all relevant studies.
Results:
A total of 17 eligible studies (14 prospective, 3 retrospective) were identified, including 1028 individuals who ingested the capsule with no prokinetic vs. 876 who received a prokinetic. Overall, there was a higher CR in patients who ingested the capsule with prokinetics vs. controls (OR [95% CI]: 1.96 [1.38–2.78]). Of the two most readily available prokinetics, metoclopramide was associated with superior SBCE CR vs. control (OR [95% CI]: 2.8 [1.35–3.21]), while erythromycin showed no benefit (OR [95% CI]: 1.36 [0.61–3.03]). Where prokinetics were used alone, neither metoclopramide nor erythromycin showed any benefit on CR. There was no benefit of prokinetics (over controls) on DY. However, metoclopramide had a significant effect on GTT and SBTT.
Limitations:
The majority of the included studies were heterogeneous, and the effect of prokinetics on image quality and mucosal visualization was not examined.
Conclusion:
Our pooled data shows that the use of prokinetics for capsule ingestion improves CR in SBCE. This effect appears to be particularly evident with metoclopramide, when used concurrently with purging and/or use of real-time monitoring. In a small number of studies, erythromycin showed – through its gastrokinetic effect – marginal benefit. No prokinetic has a beneficial effect on SBCE DY.
Transparency
Declaration of funding
This study was not funded by any grant and represents the authors’ own work.
Specific author contributions: A.K. conceived and drafted this study, extracted the data and participated in the statistical analysis; A.G. and A.K. performed the literature searches. K.J.D. and D.E.Y. participated in data collection/extraction. A.G. performed the statistical analysis. The initial manuscript was prepared by A.K. and A.G. Significant editing and major revision was performed by J.N.P. Editing and final draft revisions were provided by all co-authors. A.K. is guarantor of the article.
Declaration of financial/other relationships
A.K. has received research grant support from Given Imaging Ltd, Germany (Given Imaging – ESGE Research Grant 2011), and material support for capsule endoscopy research from SYNMED, unrelated to present work. He has also received lecture honoraria from Dr Falk Pharma UK. A.G., D.E.Y., K.J.D., and J.N.P. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.
CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships.
Acknowledgements
The authors thank Professor Peter C. Hayes and Dr Emanuele Rondonotti for their invaluable suggestions during the preparation of the present manuscript. We thank Dr A. Karargyris for his help with . The authors also feel indebted to all investigators for kindly providing us with relevant articles.