Capsule Endoscopy

HOW TO PREPARE FOR CAPSULE ENDOSCOPY

What is a Capsule Endoscopy?

I think that there might be a problem with your small bowel and therefore recommend that you have a procedure to examine these areas so that I can decide if you need any treatment.

During Capsule Endoscopy, you will swallow a capsule camera about the size of a large vitamin tablet while wearing an external recorder that hangs around your neck for about 12 hours. You will eventually pass the capsule camera when you go to the toilet. 

In the past the batteries last about 8 hours and therefore only capture the small bowel images, the newer devices last up to 12 hours and therefore are able to visualize the colon as well. This however means patients would benefit the most when they perform full bowel preparation like a colonoscopy.

Where do I go on the day of the procedure?

You will go directly to the endoscopy unit.

I already had a colonoscopy, how do I prepare for the procedure?

Capsule endoscopy is usually performed on the same day or the very next day after a colonoscopy. You can only take clear fluids after the colonoscopy. If your Capsule Endoscopy is scheduled on the same day, you do not need additional bowel preparation. If it is the next day, you will be given 1 litre of Fortrans on the day of procedure. 

I did not have a colonoscopy, how do I prepare for the procedure?

Capsule endoscopy is usually performed on the same day or the very next day after a colonoscopy. 

In order to achieve the best results, the preparation for Capsule Endoscopy Starts 3 days before the procedure and is divided into 4 steps. 

• STEP 1 – 3 DAYS BEFORE PROCEDURE
  • You start taking Low Residue Diet – avoid vegetable, fruits and nuts

• STEP 2 – 1 DAY BEFORE PROCEDURE
  • Take clear liquids or semi liquids like clear apple or orange juice, jelly or clear chicken soup.

• STEP 3 – BOWEL PREPARATION
  • You will be given 3 sachets of Fortrans which is a medication that causes diarrhoea to clear your colon. 
  • Each sachet of Fortrans should be diluted in 1 liter of water and consumed within 1 hour. You can add some orange or lychee cordial for taste. 
  • The timing of your Bowel Preparation depends on the time of your Capsule Endoscopy.

MORNING Capsule Endoscopy
DAY BEFORE PROCEDURE		DAY OF PROCEDURE
6 pm	8 pm	5 am	8 am
1 sachet Fortrans in 1 litre of water	1 sachet Fortrans in 1 litre of water	1 sachet Fortrans in 1 litre of water	Capsule Endoscopy

EVENING Capsule Endoscopy
DAY OF PROCEDURE
6 am	8 am	10 am	2 pm
1 sachet Fortrans in 1 litre of water	1 sachet Fortrans in 1 litre of water	1 sachet Fortrans in 1 litre of water	Capsule Endoscopy

• STEP 4 – FASTING
  • Your last drink must be 2 hours before the procedure in order to make sure your stomach is empty during endoscopy.
  • An empty stomach is important to prevent the contents of your stomach from entering into your lungs while you are sedated during the procedure.

Why is it important that I prepare my bowels before the procedure?

You must prepare your bowels for 3 days for the best results during capsule endoscopy. Many researches have proven that a clear colon increases detection of polyps that can become cancer. While Fair bowel preparation can cause small polyps to be missed, Inadequate bowel preparation can cause large polyps and cancer to be missed. In most instances the Capsule Endoscopy will have to be repeated on another day with repeat bowel preparation unless you refuse. 

Image from Park et al.¹

As seen in the picture, a colon full of feces/stool cannot be examined completely. 

If I cannot drink or eat, can I take my medications?

You can take your medications with sips of water at 5 AM on the day of the procedure or 4 hours AFTER you swallow the capsule camera.

I am a Heart Patient, I am restricted to only 1 litre of liquid per day.

Fortrans in 1 litre of water will enter your mouth and come out through your anus as diarrhoea in order to clear your colon, it will not be absorbed into your body. This will not count towards your 1 litre of fluid restriction. Fortrans is the safest and the only bowel preparation approved for heart patients. 

I am a Kidney Patient on Dialysis, I am restricted to only 500ml of liquid per day.

Again, Fortrans in 1 litre of water will enter your mouth and come out through your anus as diarrhoea in order to clear your colon, it will not be absorbed into your body. This will not count towards your 500ml of fluid restriction and does not need to be extracted during dialysis. Fortrans is the safest and the only bowel preparation approved for kidney patients. 

I am a Heart Patient, should I stop my blood thinners?

Please remind me and the nurse that you are taking blood thinners. Please bring the name, photo or the medication with you. However, please continue taking your blood thinners such as Aspirin, Clopidogrel, Prasugrel, Apixaban, Dabigatran, Rivaroxaban and Warfarin. DO NOT STOP unless I instruct you. 

I am a Diabetic, what do I do with my tablets?

If you are on the newer drugs called SGLT-2 inhibitors such as Empaglifon (Jardiance), Dapaglifozin (Forxiga) and Canaglifozin (Invokana), you must stop it 3 days before the endoscopy.² These medications cannot be used when you’re fasting. 

All your other diabetes tablets should be taken AFTER endoscopy as you will be fasting overnight. 

I am a Diabetic, what do I do with my Insulin?

Please reduce the night dose of your insulin by 20%.² The morning dose of your insulin can be injected AFTER your endoscopy.

I have got High Blood Pressure, should I eat my medications?

Please take your Blood Pressure medications with sips of water BEFORE coming to the hospital.

If you are on GLP-1 (Wegovy, Saxenda, Ozempic, Mounjaro) for Obesity?

GLP-1 agonists should be withheld for 1 week before capsule endoscopy and you should consume only clear liquids during the 24 hours before the procedure.³ This is to reduce the risks of your stomach contents entering your lungs during the procedure as these medications slow the movements of food in your stomach. 

What about my Vitamins and Supplements, should I stop?

Yes. Please stop all vitamins and supplements 1 week before endoscopy as it interferes with the examination, especially iron tablets and iron containing supplements.  

Drug Allergies.

It is very important to inform me or the nurse if you have any drug allergies.  

Valuables

Please DO NOT bring any valuables on the day of the procedure such as jewelleries. You will be asked to remove it as metal items can interfere with our equipment.

Consent Form

A consent form should be signed before the test after being given all the important information as this allows you the opportunity to ask questions. This may be signed by yourself or may require to be signed by someone on your behalf. You can withdraw your consent anytime before the procedure. 

CONSENT

About the Condition

I would have explained the purpose for Capsule Endoscopy such as investigation for bleeding in your gastrointestinal tract, to investigate inflammatory bowel disease or to check for cancer. 

Investigation Options and Alternatives

Capsule Endoscopy enables me to see the abnormality but I would not be able to take biopsies.  If abnormalities are found, you require a procedure called Enteroscopy (endoscopy of the small bowel ) in order to take biopsies or to determine and/or treat the problem. 

Other options such as Barium Swallow and CT scan involve both radiation and contrast, but it would not be able to visualise the inside of the bowels and determine the nature of the problem. 

Treatment Options

Treatment options will depend on the nature of the problem.

Benefits

To diagnose conditions involving the small bowel and colon.

Risks, Possible Adverse Effects or Complications

Risks include capsule retention and aspiration occur in less than 2% of examinations, but might require surgery to remove the capsule. Incomplete small bowel examinations occur in 15% of examinations.⁴

Residual Effects

None.

Likely Results If Treatment Not Undertaken

Possibility to miss polyps, ulcers or cancers. 

Minors⁵

It is important to note that for the purposes of the Regulations, a patient who is unmarried and below 18 years of age does not have the capacity to give valid consent to any medical procedure or surgery in Malaysia.

Patients Who Are Incapable of, or Impaired with, Decision-Making Ability.⁵

Some patients might not be able to give consent such as those with dementia. When there is a relative, next-of-kin or legal guardian available, and the relationship well established or confirmed, the consent may be obtained from such a person if an elective or non-emergency operation is necessary according to the doctor.

Additional Procedures

Any abnormalities found at Capsule Endoscopy would usually require a follow-up procedure called Small Bowel Enteroscopy which involves Endoscopy examination of your small bowels.. 

You can choose to perform diagnosis at first endoscopy and perform any treatment at a separate session but this costs more. Please inform me or the nurse if you wish to do so. 

Change of Mind

It is perfectly ok to change your mind even after you have signed the consent form. You can always inform me or the nurse if you no longer wish to have the procedure. Alternatively you can discuss your concerns with me such as pain and medication side effects.

WHAT TO EXPECT ON DAY OF PROCEDURE

Registration

On arrival, please take a number at the Registration Counter where you will be registered by the Counter Staff. You will then proceed to the Endoscopy Unit Counter where a nurse will perform a Safety Screening using a Checklist. 

Screening

The nurse will measure your blood pressure, heart rate, temperature, oxygen level and blood sugars if you are a diabetic. The nurse will also ask a series of questions regarding your health. Please inform the nurse if you are on blood thinners or if you have any concerns. 

Change of Clothes

You are not required to change clothes, but please wear loose fitting comfortable clothes. 

Preparation for Procedure

No preparation is required. 

Waiting

You will need to wait for your turn, this usually is not very long. 

WHAT TO EXPECT DURING PROCEDURE 

Chaperone

All female patients will have a female nurse chaperoning them at all times during the procedure.

Procedure

The nurse will let you wear the recording device around your neck so that it can receive the data from the Capsule. The nurse then will give you a pill to swallow with some water. PLEASE DO NOT REMOVE THE RECORDING DEVICE . 

WHAT TO EXPECT AFTER PROCEDURE

After Swallowing The Capsule

You need to fast for another 2 hours after swallowing the Capsule. You can drink clear fluids such as water, Sprite or 100 Plus AFTER 2 hours but you cannot eat food.

After 4 hours, you can have a light snack like bread or buns but do not eat vegetables. 

While Recording Is In Progress

DO NOT REMOVE THE RECORDING DEVICE and DO NOT SHOWER. 

Capsule Retention

Please let us know if you do not pass the capsule during a bowel movement in the next 3-5 days. 

After Endoscopy

The results of your capsule endoscopy usually will be ready in 2-3 days. You will be given a clinic appointment for follow-up.

REFERENCES

1. Fig. 1. Aronchick bowel preparation scale. ResearchGate. Accessed January 9, 2025. https://www.researchgate.net/figure/Aronchick-bowel-preparation-scale_fig1_318765331

2. Dogra P, Anastasopoulou C, Jialal I. Diabetic Perioperative Management. In: StatPearls. StatPearls Publishing; 2024. Accessed December 4, 2024. http://www.ncbi.nlm.nih.gov/books/NBK540965/

3. GLP-1 Agonists and Retained Gastric Contents at Endoscopy: An Update. Accessed December 4, 2024. https://www.jwatch.org/na57481/2024/05/14/glp-1-agonists-and-retained-gastric-contents-endoscopy

4. Ho KK, Joyce AM. Complications of capsule endoscopy. Gastrointest Endosc Clin N Am. 2007;17(1):169-178, viii-ix. doi:10.1016/j.giec.2006.11.001

5. Consent_Guideline_21062016.pdf. Accessed December 4, 2024. https://mmc.gov.my/wp-content/uploads/2019/11/Consent_Guideline_21062016.pdf