Original article Clinical endoscopy| Volume 96, ISSUE 5, P822-828.e1, November 2022

Clinical utility of purgative bowel preparation before capsule endoscopy: a multicenter, blinded, randomized controlled trial

      Background and Aims

      Optimal bowel preparation before capsule endoscopy (CE) is currently unknown. In this multicenter, blinded, randomized controlled trial, we assessed clinical effectiveness of 2 types of purgative regimen and a control arm of clear fluid only.


      Patients with suspected small intestinal bleeding were randomized into 3 arms: arm A, clear fluids only for 18 hours before CE and simethicone 200 mg in 150 mL water immediately before CE; arm B, same as A + 2 L of polyethylene glycol (PEG) 12 hours before CE; and arm C, same as A + 1 L PEG + sodium ascorbate 3 hours before CE. To assess diagnostic yield, lesions were classified either as highly relevant (P2) or less relevant (P0 or P1) lesions. Small-bowel visualization quality (SBVQ) was assessed using the Brotz score. Patient tolerability was assessed using the visual analog scale (0-10, with lower scores indicating better tolerability).


      Two hundred twenty-nine patients completed the study. The mean age was 58.7 years (95% confidence interval, 29.3-87.9), and 47.2% were men. There was no significant difference in diagnosis of P2 lesions in arms A, B, and C (48.7%, 48.0%, and 45.9%, respectively; P = .94). Overall SBVQ and distal SBVQ were similar across the 3 arms (P = .94 and P = .68, respectively). Patients reported better tolerability in arm A (mean score, 1.5) compared with arms B and C (mean score, 3.5 and 2.6, respectively; P < .001).


      The use of a purgative bowel preparation before CE does not improve diagnostic yield or small-bowel visualization and is associated with lower patient tolerance. (Clinical trial registration number: ACTRN 12614000883617.)


      CE (capsule endoscopy), PEG (polyethylene glycol), RCT (randomized controlled trial), SBTT (small-bowel transit time), SBVQ (small-bowel visualization quality), VAS (visual analog scale)
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        • Appleyard M.
        • Fireman Z.
        • Glukhovsky A.
        • et al.
        A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions.
        Gastroenterology. 2000; 119: 1431-1438
        • Appleyard M.
        • Glukhovsky A.
        • Swain P.
        Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding.
        N Engl J Med. 2001; 344: 232-233
        • Pennazio M.
        • Spada C.
        • Eliakim R.
        • et al.
        Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
        Endoscopy. 2015; 47: 352-376
        • Postgate A.
        • Tekkis P.
        • Patterson N.
        • et al.
        Are bowel purgatives and prokinetics useful for small-bowel capsule endoscopy? A prospective randomized controlled study.
        Gastrointest Endosc. 2009; 69: 1120-1128
        • Wi J.H.
        • Moon J.S.
        • Choi M.G.
        • et al.
        Bowel preparation for capsule endoscopy: a prospective randomized multicenter study.
        Gut Liver. 2009; 3: 180-185
        • Pons Beltran V.
        • Gonzalez Suarez B.
        • Gonzalez Asanza C.
        • et al.
        Evaluation of different bowel preparations for small bowel capsule endoscopy: a prospective, randomized, controlled study.
        Dig Dis Sci. 2011; 56: 2900-2905
        • Park S.C.
        • Keum B.
        • Seo Y.S.
        • et al.
        Effect of bowel preparation with polyethylene glycol on quality of capsule endoscopy.
        Dig Dis Sci. 2011; 56: 1769-1775
        • Ninomiya K.
        • Yao K.
        • Matsui T.
        • et al.
        Effectiveness of magnesium citrate as preparation for capsule endoscopy: a randomized, prospective, open-label, inter-group trial.
        Digestion. 2012; 86: 27-33
        • Rosa B.J.
        • Barbosa M.
        • Magalhaes J.
        • et al.
        Oral purgative and simethicone before small bowel capsule endoscopy.
        World J Gastrointest Endosc. 2013; 5: 67-73
        • Oliva S.
        • Cucchiara S.
        • Spada C.
        • et al.
        Small bowel cleansing for capsule endoscopy in paediatric patients: a prospective randomized single-blind study.
        Dig Liver Dis. 2014; 46: 51-55
        • Hookey L.
        • Louw J.
        • Wiepjes M.
        • et al.
        Lack of benefit of active preparation compared with a clear fluid-only diet in small-bowel visualization for video capsule endoscopy: results of a randomized, blinded, controlled trial.
        Gastrointest Endosc. 2017; 85: 187-193
        • Viazis N.
        • Sgouros S.
        • Papaxoinis K.
        • et al.
        Bowel preparation increases the diagnostic yield of capsule endoscopy: a prospective, randomized, controlled study.
        Gastrointest Endosc. 2004; 60: 534-538
        • van Tuyl S.A.
        • den Ouden H.
        • Stolk M.F.
        • et al.
        Optimal preparation for video capsule endoscopy: a prospective, randomized, single-blind study.
        Endoscopy. 2007; 39: 1037-1040
        • Franke A.
        • Hummel F.
        • Knebel P.
        • et al.
        Prospective evaluation of small bowel preparation with bisacodyl and sodium phosphate for capsule endoscopy.
        World J Gastroenterol. 2008; 14: 2061-2064
        • Lapalus M.G.
        • Ben Soussan E.
        • Saurin J.C.
        • et al.
        Capsule endoscopy and bowel preparation with oral sodium phosphate: a prospective randomized controlled trial.
        Gastrointest Endosc. 2008; 67: 1091-1096
        • Wei W.
        • Ge Z.Z.
        • Lu H.
        • et al.
        Purgative bowel cleansing combined with simethicone improves capsule endoscopy imaging.
        Am J Gastroenterol. 2008; 103: 77-82
        • Niv Y.
        Efficiency of bowel preparation for capsule endoscopy examination: a meta-analysis.
        World J Gastroenterol. 2008; 14: 1313-1317
        • Rokkas T.
        • Papaxoinis K.
        • Triantafyllou K.
        • et al.
        Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy? A meta-analysis.
        Am J Gastroenterol. 2009; 104: 219-227
        • Belsey J.
        • Crosta C.
        • Epstein O.
        • et al.
        Meta-analysis: efficacy of small bowel preparation for small bowel video capsule endoscopy.
        Curr Med Res Opin. 2012; 28: 1883-1890
        • Kotwal V.S.
        • Attar B.M.
        • Gupta S.
        • et al.
        Should bowel preparation, antifoaming agents, or prokinetics be used before video capsule endoscopy? A systematic review and meta-analysis.
        Eur J Gastroenterol Hepatol. 2014; 26: 137-145
        • Wu S.
        • Gao Y.J.
        • Ge Z.Z.
        Optimal use of polyethylene glycol for preparation of small bowel video capsule endoscopy: a network meta-analysis.
        Curr Med Res Opin. 2017; 33: 1149-1154
        • Yung D.E.
        • Rondonotti E.
        • Sykes C.
        • et al.
        Systematic review and meta-analysis: Is bowel preparation still necessary in small bowel capsule endoscopy?.
        Expert Rev Gastroenterol Hepatol. 2017; 11: 979-993
        • Gkolfakis P.
        • Tziatzios G.
        • Dimitriadis G.D.
        • et al.
        Meta-analysis of randomized controlled trials challenging the usefulness of purgative preparation before small-bowel video capsule endoscopy.
        Endoscopy. 2018; 50: 671-683
        • McLachlan S.A.
        • Clements A.
        • Austoker J.
        Patients' experiences and reported barriers to colonoscopy in the screening context—a systematic review of the literature.
        Patient Educ Couns. 2012; 86: 137-146
        • Rapier R.
        • Houston C.
        A prospective study to assess the efficacy and patient tolerance of three bowel preparations for colonoscopy.
        Gastroenterol Nurs. 2006; 29: 305-308
        • Saurin J.C.
        • Delvaux M.
        • Gaudin J.L.
        • et al.
        Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy.
        Endoscopy. 2003; 35: 576-584
        • Saurin J.C.
        • Delvaux M.
        • Vahedi K.
        • et al.
        Clinical impact of capsule endoscopy compared to push enteroscopy: 1-year follow-up study.
        Endoscopy. 2005; 37: 318-323
        • Brotz C.
        • Nandi N.
        • Conn M.
        • et al.
        A validation study of 3 grading systems to evaluate small-bowel cleansing for wireless capsule endoscopy: a quantitative index, a qualitative evaluation, and an overall adequacy assessment.
        Gastrointest Endosc. 2009; 69: 262-270
        • Enns R.A.
        • Hookey L.
        • Armstrong D.
        • et al.
        Clinical practice guidelines for the use of video capsule endoscopy.
        Gastroenterology. 2017; 152: 497-514
        • Rondonotti E.
        • Spada C.
        • Adler S.
        • et al.
        Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) technical review.
        Endoscopy. 2018; 50: 423-446
        • Spada C.
        • McNamara D.
        • Despott E.J.
        • et al.
        Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.
        United Eur Gastroenterol J. 2019; 7: 614-641
        • Shiotani A.
        • Opekun A.R.
        • Graham D.Y.
        Visualization of the small intestine using capsule endoscopy in healthy subjects.
        Dig Dis Sci. 2007; 52: 1019-1025