First Brazilian expert consensus for video capsule endoscopy and balloon-assisted enteroscopy

1 Afonso Celso da Silva Paredes 2 Alexandre de Souza Carlos 3 Américo de Oliveira Silvério 4 Arthur Adolfo Parada 5 Aureo Paoliello 6 Barbara Cathala Esberard 7 Caio Cesar Wanderley Salem 8 Carlos Saul 9 Cláudio Hashimoto 10 Clóvis Massato Kuwahara 11 Cristiane Kibune Nagasako da Cruz 12 Daniel de Alencar Macedo Dutra 13 Dorival Zito Filho 14 Edgard Rodrigo Pinheiro Cruz de Medeiros 15 Emília Pereira de Magalhães 16 Fabiana Sartore Guimarães 17 Fábio Gomes Teixeira 18 Fernanda Prata Borges Magalhães Martins 19 Fernando Pavinato Marson 20 Flávio Hayato Ejima 21 Flávio Heuta Ivano 22 Francisco das Chagas Gonçalves de Oliveira 23 Guilherme Francisco Gomes 24 Hélcio Pedrosa Brito 25 Isabel Fonseca Santos 26 José Renato Hauck 27 Juliano Coelho Ludvig 28 Laura Cotta Oernellas Halfeld 29 Lucidio Balduino Leitão 30 Luiz Henrique Mazzonetto Mestieri 31 Marcelo Vicente Toledo de Araújo 32 Mauro Gester 33 Mauro José Wagner Moreira Maia 34 Newton Teixeira dos Santos 35 Pablo Rodrigo de Siqueira 36 Roberto Chiumeo do Nascimento 37 Robson Kiyoshi Ishida 38 Thiago Alonso Domingos 39 Thiago Festa Secchi 40 Vitor Monteiro e Silva

Level of Evidence (LE)	Description
I (High)	High-quality evidence; Well-conducted Randomized Controlled Trials (RCTs) or meta-analyses of RCTs
II (Moderate)	Moderate-quality evidence; RCTs with limitations, high-quality cohort studies, or meta-analyses of such studies
III (Low)	Low-quality evidence; Case-control studies, case series, or lower-quality cohort studies
IV (Very Low)	Very low-quality evidence; Expert opinion, case reports, or unsystematic studies
Grade of Recommendation (GR)	Clinical Implication
A (Strong)	Strong recommendation. Benefits clearly outweigh risks. Based on LE I (High)
B (Moderate)	Moderate recommendation. Benefits likely outweigh risks. Based on LE II (Moderate)
C (Weak)	Weak recommendation. Benefits and risks are balanced or uncertain. Based on LE III (Low)
D (Opinion)	Expert opinion. Based on LE IV (Very Low)

	Statement	Topic	Agreement 1st Round	Agreement 2st Round	Agreement 3st Round
1	On the day before VCE, it is recommended that patients consume a low-fiber diet for breakfast and lunch, and only clear liquids in the afternoon to improve the quality of preparation.	VCE	86%	−	−
2	Osmotic laxatives may enhance the quality of small bowel visualization, and their use is at the discretion of the medical team and the availability of the product.	VCE	56%	93%	−
3	Antifoaming agents are beneficial in preparing for VCE because it improves the small bowel visualization quality and should be used routinely.	VCE	75%	89%	−
4	The routine use of prokinetics is not recommended in VCE, as they do not significantly improve completion rates.	VCE	89%	−	−
5	Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) should be suspended, if possible, for at least 4 weeks before VCE.	VCE	77%	100%	−
6	Orally administered iron-based drugs should be withheld at least 7-days prior to VCE.	VCE	98%		−
7	In patients with swallowing disorders, the video capsule should be positioned directly into the duodenum, with the aid of endoscopy. For children under 8-years of age, the ability of swallowing or the need for endoscopic positioning should be evaluated case-by-case.	VCE	94%	−	−
8	The use of cardiac pacemakers, Implantable Cardioverter Defibrillators (ICDs) and Left Ventricular Assist Devices (LVADs) do not represent a contraindication to VCE examination.	VCE	78%	97%	−
9	The use of VCE during pregnancy is not recommended. The paucity of data from the literature does not allow any specific recommendation, however it's use could be considered in life-threatening situations, such as massive bleeding.	VCE	92%	−	−
10	In situations where there is a need to assess the patency of the small intestine prior to VCE, enteroresonance, enterotomography and patency capsule are advised options, and the choice should depend on the context, expertise and availability of the method.	VCE	97%	−	−
11	The patient should be monitored with real-time image visualization (real-time viewer) during the first hour of the examination until the video capsule passes into the duodenum.	VCE	71%	80%	−
12	It is recommended that the patient remain fasting, with the intake of clear liquids permitted after real-time visualization of video capsule passage into the duodenum using the real-time viewer, and light food intake allowed 4 h after the start of the examination.	VCE	77%	94%	−
13	It is recommended that the examination be concluded only after confirming the passage of the video capsule into the colon through real time visualization (real-time viewer), capsule evacuation or depletion of the recorder's battery.	VCE	97%	−	−
14	In patients where the video capsule has not reached the cecum during the recording period, and it has not been evacuated after 14-days; an imaging study should be performed to confirm its retention.	VCE	94%	−	−
15	The preferred approach for video capsule retrieval should be endoscopic, reserving surgical intervention only in cases of failure or when surgical indication is warranted due to the original pathology.	VCE	100%	−	−
16	It is suggested to read the images at an average speed of 10 frames per second, with the screen display mode as a single image (Single View), reducing the speed when evaluating the proximal small intestine. Digital chromoscopy is not routinely recommended throughout the recording reading, as it does not appear to improve the detection or characterization of lesions.	VCE	68%	96%	−
17	The indication for BAE should be well-founded to ensure greater diagnostic positivity, thus reflecting on the quality of the procedure.	BAE	100%	−	−
18	BAE should be performed in a hospital environment or in clinics with infrastructure for performing advanced anesthetic procedures.	BAE	70%	77%	85%
19	It is recommended to carry out a pre-procedure evaluation to know the clinical history (comorbidities, previous surgeries, allergies), to identify high-risk patients and plan the initial route.	BAE	100%	−	−
20	For anterograde BAE, it is only necessary to fast for 8‒12 h. For the retrograde route, bowel preparation is required, similarly to colonoscopy.	BAE	92%	−	−
21	The choice of BAE route should be made based on previous imaging tests or VCE results.	BAE	92%	−	−
22	In cases of non-definition by imaging or endoscopic exams or failure to perform them, the clinical picture should guide the choice of the access route; if melena: oral route, if enterorrhagia: anal route.	BAE	69%	75%	80%
23	General anesthesia is recommended for BAE in pediatric patients, the elderly and those with comorbidities, as well as in therapeutic procedures.	BAE	92%	−	−
24	Ideally, Carbon Dioxide Insufflation (CO₂) should be used, especially in cases where there is an intention to use both routes (greater success in deep intubation and complete enteroscopy).	BAE	96%	−	−
25	Fluoroscopy as an adjunct to BAE is useful in special situations, such as altered anatomy, dilation of stenosis, ERCP and placement of self-expanding metal stents.	BAE	100%	−	−
26	In case of perforation during BAE, closure of the mucosa with metal clips may be initially considered. If this is not possible, the patient should be referred for surgical treatment.	BAE	100%	−	−
27	After BAE, medical reevaluation is essential before the patient is discharged, especially in therapeutic cases such as polypectomies, ERCP, hemostatic procedures, and stent placement.	BAE	100%	−	−
28	VCE can be used in the diagnostic evaluation of iron deficiency, with or without anemia, after negative clinical, laboratory, radiologic, and endoscopic investigations using upper gastrointestinal endoscopy and colonoscopy.	VCE	94%	−	−
29	It is recommended that, in the investigation of overt mid-gastrointestinal bleeding, VCE should be the first-line small bowel endoscopic examination, provided it is available, due to its safety profile and diagnostic accuracy. It should be performed as early as possible, preferably within 48-hours.	VCE	97%	−	−
30	Patients with mid-gastrointestinal bleeding, where VCE identifies lesions amenable to endoscopic treatment, should be referred for therapeutic BAE. However, in the absence of VCE, BAE can be performed as the initial diagnostic procedure.	BAE	78%	92%	−
31	In cases of overt bleeding, in patients with hemodynamic stability, it is recommended to perform BAE within 72-hours.	BAE	79%	100%	−
32	In cases of bleeding with a negative VCE and persistence or recurrence of bleeding, it is recommended to repeat this procedure or perform BAE.	BAE	88%	−	−
33	In cases of active bleeding in the emergency setting, with normal upper and lower gastrointestinal endoscopy, VCE or even diagnostic and therapeutic BAE may be performed, depending on availability and expertise.	BAE	78%	92%	−
34	In the suspicion of active and severe hemorrhage in the small bowel, cross-sectional imaging (angiotomography) is a diagnostic option prior to endoscopic exams.	BAE	75%	91%	−
35	VCE is indicated in diagnostic and topographic investigations of Crohn's disease of the small bowel, when there is strong clinical suspicion in the absence of conventional endoscopic and radiological findings.	VCE	98%	−	−
36	VCE can be used to study the small bowel to evaluate the response to treatment of Crohn's disease.	VCE	89%	−	−
37	In patients with obstructive symptoms and signs, or known stenosis, cross- sectional imaging examination should be performed before BAE.	BAE	92%	−	−
38	In inflammatory bowel disease, BAE is indicated for diagnostic confirmation, establishment of differential diagnoses and therapy (dilation and removal of foreign bodies).	BAE	96%	−	−
39	VCE can be used in the evaluation of the small bowel in patients with refractory celiac disease, in patients with alarm signs such as anemia, bleeding or weight loss, for differential diagnosis with other enteropathies and possible tumors.	VCE	100%	−	−
40	VCE can be used to assess the extent of small bowel polyp involvement.	VCE	97%	−	−
41	In patients with polyposis, BAE is recommended for polypectomies to avoid complications such as bleeding, obstruction, intussusception, malignancy, in addition to multiple surgical resections with the risk of short bowel.	BAE	100%	−	−
42	VCE can be used in cases of strong diagnostic suspicion of small bowel tumors not identified in imaging tests, especially in cases of suspected neuroendocrine tumor and metastatic melanoma.	VCE	97%	−	−
43	If a tumor lesion is suspected, BAE is indicated for performing biopsies, assessing tumor location and extent, and for therapeutic intervention such as placement of self-expanding metal stents.	BAE	79%	96%	−
44	In patients with diarrhea, protein-losing enteropathy, or small bowel wall thickening, BAE should be indicated to perform biopsies for differential diagnosis of infectious diseases.	BAE	92%	−	−
45	In patients with altered anatomy, BAE is the endoscopic method of choice for diagnostic and/or therapeutic evaluation.	BAE	71%	77%	84%

	Statement	Level of evidence	Grade of recommendation
VCE Pre-procedure
1	On the day before VCE, it is recommended that patients consume a low-fiber diet for breakfast and lunch, and only clear liquids in the afternoon to improve the quality of preparation	III (Low)	C
2	Osmotic laxatives may enhance the quality of small bowel visualization, and their use is at the discretion of the medical team and the availability of the product.	I (High)	B
3	Antifoaming agents are beneficial in preparing for VCE because it improves the small bowel visualization quality and should be used routinely.	I (High)	A
4	The routine use of prokinetics is not recommended in VCE, as they do not significantly improve completion rates.	I (High)	A
5	Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) should be suspended, if possible, for at least 4 weeks before VCE.	III (Low)	C
6	Orally administered iron-based drugs should be withheld at least 7-days prior to VCE.	III (Low)	C
VCE Procedure
7	In patients with swallowing disorders, the video capsule should be positioned directly into the duodenum, with the aid of endoscopy. For children under 8-years of age, the ability of swallowing or the need for endoscopic positioning should be evaluated case-by-case.	III (Low)	C
8	The use of cardiac pacemakers, Implantable Cardioverter Defibrillators (ICDs) and Left Ventricular Assist Devices (LVADs) do not represent a contraindication to VCE examination.	II (Moderate)	B
9	The use of VCE during pregnancy is not recommended. The paucity of data from the literature does not allow any specific recommendation, however it's use could be considered in life-threatening situations, such as massive bleeding.	IV (Very low)	D
10	In situations where there is a need to assess the patency of the small intestine prior to VCE, enteroresonance, enterotomography and patency capsule are advised options, and the choice should depend on the context, expertise and availability of the method.	II (Moderate)	B
11	The patient should be monitored with real-time image visualization (real-time viewer) during the first hour of the examination until the video capsule passes into the duodenum.	II (Moderate)	B
12	It is recommended that the patient remain fasting, with the intake of clear liquids permitted after real-time visualization of video capsule passage into the duodenum using the real-time viewer, and light food intake allowed 4-hours after the start of the examination.	IV (Very Low)	D
13	It is recommended that the examination be concluded only after confirming the passage of the video capsule into the colon through real-time visualization (real-time viewer), capsule evacuation or depletion of the recorder's battery	III (Low)	C
VCE Post-procedure
14	In patients where the video capsule has not reached the cecum during the recording period, and it has not been evacuated after 14-days; an imaging study should be performed to confirm its retention.	III (Low)	C
15	The preferred approach for video capsule retrieval should be endoscopic, reserving surgical intervention only in cases of failure or when surgical indication is warranted due to the original pathology.	III (Low)	C
16	It is suggested to read the images at an average speed of 10-frames per second, with the screen display mode as a single image (Single View), reducing the speed when evaluating the proximal small intestine. Digital chromoscopy is not routinely recommended throughout the recording reading, as it does not appear to improve the detection or characterization of lesions.	II (Moderate)	B
BAE Pre-procedure
17	The indication for BAE should be well-founded to ensure greater diagnostic positivity, thus reflecting on the quality of the procedure	III (Low)	C
18	BAE should be performed in a hospital environment or in clinics with an infrastructure for performing advanced anesthetic procedures	III (Low)	C
19	It is recommended to carry out a pre-procedure evaluation to know the clinical history (comorbidities, previous surgeries, allergies), to identify high-risk patients and plan the initial route.	IV (Very Low)	D
20	For anterograde BAE, it is only necessary to fast for 8‒12 h. For the retrograde route, bowel preparation is required, similar to colonoscopy.	IV (Very Low)	D
21	The choice of BAE route should be made based on previous imaging tests or VCE results.	II (Moderate)	B
22	In cases of non-definition by imaging or endoscopic exams or failure to perform them, the clinical picture should guide the choice of the access route; if melena: oral route, if enterorrhagia: anal route.	IV (Very Low)	D
BAE Procedure
23	General anesthesia is recommended for BAE in pediatric patients, the elderly and those with comorbidities, as well as in therapeutic procedures	III (Low)	C
24	Ideally, Carbon Dioxide (CO₂) insufflation should be used, especially in cases where there is an intention to use both routes (greater success in deep intubation and complete enteroscopy)	I (High)	A
25	Fluoroscopy as an adjunct to BAE is useful in special situations, such as altered anatomy, dilation of stenosis, ERCP and placement of self-expanding metal stents.	III (Low)	C
26	In case of perforation during BAE, closure of the mucosa with metal clips may be initially considered. If this is not possible, the patient should be referred for surgical treatment.	IV (Very Low)	D
BAE Post-Procedure
27	After BAE, medical reevaluation is essential before the patient is discharged, especially in therapeutic cases such as polypectomies, ERCP, hemostatic procedures, and stent placement.	IV (Very Low)	D
Indications
Mid-GI Bleeding
28	VCE can be used in the diagnostic evaluation of iron deficiency, with or without anemia, after negative clinical, laboratory, radiologic, and endoscopic investigations using upper gastrointestinal endoscopy and colonoscopy.	II (Moderate)	B
29	It is recommended that, in the investigation of overt mid-gastrointestinal bleeding, VCE should be the first-line small bowel endoscopic examination, provided it is available, due to its safety profile and diagnostic accuracy. It should be performed as early as possible, preferably within 48 h.	I (High)	A
30	Patients with mid-gastrointestinal bleeding, where VCE identifies lesions amenable to endoscopic treatment, should be referred for therapeutic BAE. However, in the absence of VCE, BAE can be performed as the initial diagnostic procedure.	II (Moderate)	B
31	In cases of overt bleeding, in patients with hemodynamic stability, it is recommended to perform BAE within 72-hours.	III (Low)	C
32	In cases of bleeding with a negative VCE and persistence or recurrence of bleeding, it is recommended to repeat this procedure or perform BAE.	II (Moderate)	B
33	In cases of active bleeding in the emergency setting, with normal upper and lower gastrointestinal endoscopy, VCE or even diagnostic and therapeutic BAE may be performed, depending on availability and expertise.	II (Moderate)	B
34	In the suspicion of active and severe hemorrhage in the small bowel, cross- sectional imaging (angiotomography) is a diagnostic option prior to endoscopic exams.	II (Moderate)	B
Crohn’s Disease
35	VCE is indicated in diagnostic and topographic investigations of Crohn's disease of the small bowel, when there is strong clinical suspicion in the absence of conventional endoscopic and radiological findings.	II (Moderate)	B
36	VCE can be used to study the small bowel to evaluate the response to treatment of Crohn's disease.	II (Moderate)	B
37	In patients with obstructive symptoms and signs or known stenosis, cross- sectional imaging examination should be performed before BAE.	II (Moderate)	B
38	In inflammatory bowel disease, BAE is indicated for diagnostic confirmation, establishment of differential diagnoses and therapy (dilation and removal of foreign bodies).	III (Low)	C
Celiac Disease
39	VCE can be used in the evaluation of the small bowel in patients with refractory celiac disease, in patients with alarm signs such as anemia, bleeding or weight loss, for differential diagnosis with other enteropathies and possible tumors.	II (Moderate)	B
Polypoid Syndromes
40	VCE can be used to assess the extent of small bowel polyp involvement.	III (Moderate)	C
41	In patients with polyposis, BAE is recommended for polypectomies to avoid complications such as bleeding, obstruction, intussusception, malignancy, in addition to multiple surgical resections with the risk of short bowel.	III (Low)	C
Tumors
42	VCE can be used in cases of strong diagnostic suspicion of small bowel tumors not identified in imaging tests, especially in cases of suspected neuroendocrine tumor and metastatic melanoma.	II (Moderate)	B
43	If a tumor lesion is suspected, BAE is indicated for performing biopsies, assessing tumor location and extent, and for therapeutic intervention such as placement of self-expanding metal stents.	III (Low)	C
Infectious Diseases
44	In patients with diarrhea, protein-losing enteropathy, or small bowel wall thickening, BAE should be indicated to perform biopsies for differential diagnosis of infectious diseases.	III (Low)	C
Altered Anatomy
45	In patients with altered anatomy, BAE is the endoscopic method of choice for diagnostic and/or therapeutic evaluation.	III (Low)	C

1	Afonso Celso da Silva Paredes
2	Alexandre de Souza Carlos
3	Américo de Oliveira Silvério
4	Arthur Adolfo Parada
5	Aureo Paoliello
6	Barbara Cathala Esberard
7	Caio Cesar Wanderley Salem
8	Carlos Saul
9	Cláudio Hashimoto
10	Clóvis Massato Kuwahara
11	Cristiane Kibune Nagasako da Cruz
12	Daniel de Alencar Macedo Dutra
13	Dorival Zito Filho
14	Edgard Rodrigo Pinheiro Cruz de Medeiros
15	Emília Pereira de Magalhães
16	Fabiana Sartore Guimarães
17	Fábio Gomes Teixeira
18	Fernanda Prata Borges Magalhães Martins
19	Fernando Pavinato Marson
20	Flávio Hayato Ejima
21	Flávio Heuta Ivano
22	Francisco das Chagas Gonçalves de Oliveira
23	Guilherme Francisco Gomes
24	Hélcio Pedrosa Brito
25	Isabel Fonseca Santos
26	José Renato Hauck
27	Juliano Coelho Ludvig
28	Laura Cotta Oernellas Halfeld
29	Lucidio Balduino Leitão
30	Luiz Henrique Mazzonetto Mestieri
31	Marcelo Vicente Toledo de Araújo
32	Mauro Gester
33	Mauro José Wagner Moreira Maia
34	Newton Teixeira dos Santos
35	Pablo Rodrigo de Siqueira
36	Roberto Chiumeo do Nascimento
37	Robson Kiyoshi Ishida
38	Thiago Alonso Domingos
39	Thiago Festa Secchi
40	Vitor Monteiro e Silva

First Brazilian expert consensus for video capsule endoscopy and balloon-assisted enteroscopy☆

First Brazilian expert consensus for video capsule endoscopy and balloon-assisted enteroscopy^☆