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Atlas of Capsule Endoscopy

Editors: Marisa Halpern, M.D. and Harold Jacob, M.D.

Atlas of Capsule EndoscopyWireless capsule endoscopy allows painless endoscopic imaging of the entire small bowel. In addition the examination of the intestine takes place in the physiological state. Artifact induction does not occur as in push enteroscopy as there is no need to push the device. These differences between wireless endoscopy and push endoscopy are the major factors governing the physiological and bio-optical principles of image acquisition, resulting in clear and detailed visualization of intestinal structures.

Atlas of Capsule EndoscopyFirst EditionMarisa Halpern, M.D.Senior Pathologist Director of Gastrointestinal Pathology Unit Rabin Medical Center, Golda Campus Petach Tiqva, Israel

Harold Jacob, M.D.

Director of Medical Affairs Given Imaging Ltd. Yoqneam, Israel

PrefaceWe are proud to present this first Atlas of Capsule Endoscopy. With the rapid adoption of Capsule Endoscopy by practicing gastroenterologists, a new spectrum of pathological images are being generated. New dimensions of the common diseases we treat are coming to light. In response to the intense interest and growth in the area of Capsule Endoscopy, we have produced the first Atlas of Capsule Endoscopy. By placing these images in your hand, we know that it will enhance your ability to diagnose and treat patients with gastrointestinal disorders. In this book we present the spectrum of disease that has been seen to date by Capsule Endoscopy. Where possible, we have correlated the M2A Capsule images with other diagnostic modalities including endoscopy, radiology and histopathology findings. This first edition of the Atlas of Capsule Endoscopy also contains information on normal capsule endoscopic anatomy, how to perform Capsule Endoscopy and principles of physiological image acquisition. Some consideration is also given to Capsule Endoscopy findings in other parts of the GI tract as well. The companion CD to the Atlas will enable you to load the M2A Capsule images onto your computer for easy reference in your practice. With the increased use and expanding indications of Capsule Endoscopy, we know that the Atlas of Capsule Endoscopy will continue to develop and grow. We hope this Atlas will be a useful tool for physicians who care for patients with gastrointestinal disease.

Harold Jacob, M.D. Marisa Halpern, M.D.

AcknowledgmentsWe would like to thank all the worldwide contributors to the "Atlas of Capsule Endoscopy" for their devoted efforts (see Contributors list). We would like to thank Sharon Besser for her immense devotion to this publication. Without her dedication, this project would not be completed. Dr Halpern would like to acknowledge her colleagues at the Department of Pathology and especially Professor Rivka Gal who understood the meaning of this project. Finally, we would like to thank our families for their understanding, moral support and patience during this period of long hours and hard work.

Given Imaging Inc. Oakbrook Technology Center 5555 Oakbrook Parkway #355 Norcross, GA, 30093, USA

Managing Editor and Production...............Sharon S. Besser

This first edition of the Atlas of Capsule Endoscopy does not integrate Capsule Endoscopy Standard Terminology. For comments or suggestions, please contact terminology@givenimaging.com

Copyright 2002 Given Imaging, Ltd. All rights reserved. Given,M2A, RAPID and/or other products and/or services referenced herein are either registered trademarks, trademarks or service marks of Given Imaging, Ltd. All other names are or may be registered trademarks or trademarks of their respective owners. This publication and its content are for your personal and non-commercial use. You may not modify, copy, distribute, transmit, display, perform, reproduce, publish, license, create derivative works from, transfer or sell any part of this publication and/or its content, without prior written permission from Given Imaging, Ltd. Given Imaging Ltd. Is not and will not be responsible or liable for any damage or loss caused or alleged to be caused due to inaccuracies or typographical errors in this publication, or for any action taken in reliance thereon. Contents are subject to change without notification. Please send all inquiries to sbesser@givenimaging.com Graphic Design......... Studio Rosinger Ltd., Haifa, Israel Printing ................... Rahash Offset Printing Ltd., Haifa, Israel

Expanding the scope of GI

Table of contents

Development of the Swallowable Video Capsule (G. Meron, Ph.D.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Notes from the Inventor (G. J. Iddan, D.Sc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Chapter 1 - Physiological Endoscopy (A. Glukhovsky, D.Sc., H. Jacob, M.D., P. Halpern, B.Sc.) . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 2 - Performance of the Capsule Endoscopy (B. Lewis, M.D., C. J. Gostout, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . 15 Chapter 3 - Normal M2A Anatomy (P. Swain, M.D., M. Appleyard, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Chapter 4 - Inflammatory Diseases of the Small Intestine (A. L. Buchman, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Chapter 5 - Neoplastic Diseases (F.P. Rossini, M.D., M. Pennazio, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Chapter 6 - Iatrogenic Diseases (D. Cave, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Chapter 7 - Vascular Abnormalities (M. Hahne, M.D., J. F. Riemann, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Chapter 8 - Malabsorption (G. Gay, M.D., I. Fassler, M.D., Ch. Florent, M.D., M. Delvaux, M.D.) . . . . . . . . . . . . . . . . . . . . . . . 83 Chapter 9 - Pediatrics (E. Seidman, M.D., G. L. de Angelis, M.D., Ana Maria Sant Anna, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . 103 Chapter 10 - Transplantation (R. de Franchis, M.D., E. Rondonotti, M.D., C. Abbiati, M.D., G. Beccari, M.D., E. Villa, M.D., A. Merighi, M.D., A. Pinna, M.D.) . . 111 Chapter 11 - Non Small Bowel Pathology (S. Adler, M.D., S. Kadish, M.D.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Contributors List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Development of the Swallowable Video CapsuleGavriel Meron, Ph.D.

It was in 1981 while on a sabbatical leave from his regular position as Senior Engineer at the Electro-Optical Design Section of Rafael, the R&D group of the Israeli Ministry of Defense, that Dr. Gavriel Iddan, a talented mechanical engineer, started his long term interest in medical imaging. The idea started as a seed of an invention in the midst of defense projects, particularly the development of electro-optical imaging devices for missiles. During the sabbatical, Dr. Iddan relocated to Boston to perform research for another Israeli company, Elscint Inc., doing x-ray and ultrasound medical imaging R&D. In Boston, Dr. Gavriel Iddan befriended Professor Eitan Scapa, an Israeli gastroenterologist, who was, at that time, at the local medical center. They had many mutual interests and discussions, which made Dr. Iddan wonder how he could "help" gastroenterologists. It was then that he dreamed up the idea of a miniature "missile" that could be easily swallowed and passed through the GI tract, transmitting images along the way. Dr. Iddan was specifically interested in "opening up a new frontier" by enabling direct imaging of the small intestine, which was until then, terra incognito, due to the inability of the other imaging methods to reach the small intestine. Dr. Iddan and a team of engineers and technicians in Rafael worked on the development of an initial prototype in the

laboratories, and performed some feasibility trials of imaging and transmission through animal tissue developing some of the basic technologies. Based on the initial research performed in the Rafael laboratories, the first of a number of patents were written up and submitted by Rafael in January 1994. At the same time and totally unbeknownst to Dr. Iddan, in the United States, Dr. Paul Swain presented the possibility of wireless endoscopy during the Los Angeles World Congress of Gastroenterology, in an invited talk entitled Microwaves in Gastroenterology in September 1994. In London, Dr. Swain had made some progress in making several (rather large) prototype wireless endoscopy devices from commercially available components in 1995 and 1996. It was in 1996 that his team achieved the first live transmissions from the stomach of a pig. The first two abstracts published by Swain's team on this topic were: Wireless transmission of a color television moving image from the stomach using a miniature CCD camera, light source and microwave transmitter. Swain CP, Gong F, Mills TN. Gut 1996;39:A26

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Development of the Swallowable Video Capsule

The Evolution of the Capsule. (from top to bottom). Components of the prototype capsule in a container. In the center, the prototype capsule is shown. Finally, the existing M2A Capsule.

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Development of the Swallowable Video Capsule Wireless transmission of a color television moving image from the stomach using a miniature CCD camera, light source and microwave transmitter. Swain CP, Gong F, Mills TN. Gastrointest Endosc 1997;45:AB40. Meanwhile, back in Israel, Dr. Iddan knew that if