As a doctor in the community, recent times have made the  practice of gastroenterology challenging.  Most patients do not want (and in most cases should not) come in to the office for a visit or procedure.  

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This change has made telemedicine the "new normal" (at least for the time being). Although good history taking is still important and easily obtained, telemedicine is limited as physical exam, which is so important for any medical diagnosis, can not fully be performed. 

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Currently elective procedures, specifically endoscopy and colonoscopy which are the main tools in the gastroenterologist's diagnostic and therapeutic armamentarium,  are not being.   Fear of infecting patients by sitting in waiting rooms, infecting doctors through aerosolized sputum and feces as well a risk of a rare complications which may require a ventilators needed to combat the ongoing pandemic have put performance of all but emergent egd and colonosocpy on hold. 

 

Although there are other diagnostic options, I have found that many of my patients do not want to go to radiology centers for imaging or labs for blood work secondary to other people which poses a risk of exposure to infectious pathogens

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As in many other GI practices in the US, I have adopted new technology which allows me to communicate with patients via video and audio over the internet.  Physical exam is done in the best way possible through indirect patient observation.  In most cases I use empiric medications (acid suppression, antibiotic, anti-diarrheals and anti-spasmotics) to treat presumed diagnosis and symptoms.

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What happens when this does not work?   What can a Gastroenterologist do when symptoms are not improving? Are there any other options?

 

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Many academic centers are currently doing clinical trials or using capsule endoscopy "off label" to view the stomach so that they can minimize the use of endoscopy for gi bleeding.  Although capsule has historically been a follow up to egd/colon for diarrhea or bleeding to look at the small bowel, many gastroenterologists are  now using it as a first line diagnostic modality. 

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In my practice, I have moved this idea into the outpatient setting and am using capsocam for epigastric pain (which is not responding to conservative management), diarrhea and gi bleeding (both occult and overt.) As I have learned from my inpatient colleagues, in this time of the Covid pandemic, capsule is an important first line test as it can help to avoid the need for more invasive studies.

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Before considering capsule endoscopy, I screen patients for signs of dysphagia during telemedicine consultation and subsequently have Capsovision mail the capsule to the patient's house by overnight Fedex. 

 

I obtain verbal consent for the procedure during the consultation and document the discussion.  A written consent form is sent to the patient with the capsule and mailed back to me at the time of ingestion. 

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I have a second telemedicine visit with the patient at the time of ingestion.  Directions are reviewed and the patient the ingestion is observed to decrease risk of aspiration. 

 

After the capsule is excreted, the patient  mails it back to Capsovision in an addressed envelope which is provided.  When the capsule reaches the lab, the company processes (downloads) the video and within a few days I can watch the video off of the cloud.  Results and subsequent treatment plan are discussed during follow up tele-isit.

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This process is what I have been doing in my practice over the past month, on select patients on a case-by-case basis.  In some scenarios such as using capsule as a primary modality to view the stomach or colon, it is clearly an off label use.  I would suggest that other physicians will need to determine if it is appropriate for their practice and patient population.

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The Capsovision company has been excellent at providing me with options which can minimize the financial risk to my practice so that I will not be left with undue expense if the capsules are not reimbursed by insurance companies when the pandemic has ended.

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I have had an amazing experience practicing in this way and patient response with this format has been nothing short of spectacular. 

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In the future, l fear that capsule systems with recorders and belts will be a major issue, as patient will (and  should) have a fear of contamination of these items with virus from prior patients.  I think that all medical equipment which is not single use and/or is made of material which is difficult to clean will pose an issue.  Although it may be possible to Dry-cleaning/ sterilize monitor holsters and lead belts after each, this will likely be cost prohibitive.

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To all GI physicians: please stay safe.  I hope the ideas presented help your patients and practice in this difficult time.  Feel free to contact me if you have any questions about how I use telecapsule endoscopy in my practice.

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Truly,

Dr. Ian Storch

Readmycapsule.com