Minimally Invasive Gastroenterology: Who Needs An Endoscopy?

Written by Prof Owen Epstein; Consultant Gastroenterologist, Royal Free London & Hadley Wood Hospital

The 6-meter digestive tract is dark as a dungeon and the fibre-optic endoscope was developed to illuminate and image the inner lining of the upper and lower gastrointestinal tract. Think of the word “gastroenterology” and for most, the image of an endoscope immediately springs to mind. For those who have travelled the GI pathways, the term “minimally invasive endoscopy” seems to be a fantasy.

Neither upper nor lower endoscopy are gentle investigations. Upper endoscopy is performed using “conscious sedation”, and following the procedure, patients often recount a sense of intense discomfort as the bundle of light is pushed through the pharynx into the oesophagus and on to the stomach, pylorus and duodenum. At the other end, the endoscopist is challenged to insert a 1.6-meter fibre-optic bundle through the rectum and manually advance the scope the wrong way up a winding one-way street to the caecum. To accomplish this, intravenous sedation and analgesia are administered prior to the procedure, numbing the experience for both the patient and endoscopist.

In the mid-1990s, digestive tract imaging was transformed by the Israeli inventor Gavriel Iddan who, together with British gastroenterologist, Paul Swain, pioneered the idea of wireless capsule endoscopy. Iddan was able to squeeze a TV studio into a capsule measuring 11 mm by 26 mm and weighing 3.7 grams, and in 2001, the invention was officially released. The first capsule was designed to video 5 meters of small intestine, a bowel segment well out of reach of traditional push endoscopy. The capsule is swallowed with a sip of water and transmits a wireless video sequence, as natural peristalsis painlessly powers its passage through an illuminated small bowel. The signal is captured by a small receiver worn by the patient and the capsule is expelled from the rectum never to be seen again.

Over the past two decades, the capsule has become smarter and video images brighter and sharper. Improved optics, a camera at each end, and extended battery power has led to the development of a colon capsule capable of scanning the colon from caecum to toilet. Together with the small bowel and upper GI capsule, colon capsule completes a pain free trio capable of imaging whichever segment is suspect and offering patients a gentler healthcare experience.

While most patients referred to gastroenterologists undergo an upper and/or lower endoscopy, only around 20% have mucosal pathology to account for symptoms and in most of these patients, the abnormality is benign and biopsy unnecessary. Conversely the discovery of a mucosal abnormality requiring intervention allows for a targeted and planned intervention with a traditional upper or lower endoscope. Capsule endoscopy is minimally invasive and, during the Covid-19 pandemic, can be performed as an outpatient procedure with social distancing. The device is administered by a nurse specialist and reported by a trained capsule endoscopist.

The Royal Free Private Patient Unit has one of the country’s leading capsule units, and the team, led by Professor Owen Epstein, has been at the forefront of UK training and practice of upper GI, small bowel and colon capsule endoscopy.

This gentler investigation scans the mucosa and both asks and answers the question “who needs an endoscopy?”.  Light at the end of the tunnel!