Professor El-Omar has selected Dr Ulrik Deding from the Department of Surgery, Odense University Hospital and the Department of Clinical Research, University of Southern Denmark, Odense, Denmark, to do the next #GUTBlog. Dr Deding is the senior author on this paper, on behalf of the CareForColon2015 study group.
The #GUTBlog focusses on the paper entitled “Choice of colon capsule or colonoscopy versus default colonoscopy in FIT positive patients in the Danish screening programme: a parallel group randomised controlled trial” which was published in paper copy in GUT in October 2025.
Dr Deding writes:
“We can trust colon capsule endoscopy as a diagnostic test?
The first video capsule swallowed by a human occurred in 1999 [1]. Capsules targeting the large bowel was presented less than a decade later. Twenty-five years have passed since and yet the question of the colon specific capsules’ accuracy in detecting advanced adenomas and cancers was left unanswered. While the literature comparing the detection rates for polyps and adenomas between colon capsule endoscopy (CCE) and colonoscopy is quite vast, a direct comparison of advanced adenomas and cancers would require a huge trial with associated great costs.
Does this mean we would now recommend CCE to be introduced as a standard in colorectal cancer screening programs using faecal immunochemical tests? The short answer is no. Unsurprisingly, the re-investigation rate following CCE is much too high in this population with approximately 70% being referred for colonoscopy following CCE. However, the demonstrated diagnostic accuracy of CCE is also valid for other populations, and CCE could provide a good alternative to primary colonoscopy screening or to non-participants of FIT-based screening.
In order for CCE to be a viable and cost-efficient alternative to colonoscopy we need to reduce the re-investigation rate. That can directly be done by bringing down the rate of incomplete capsule transits, while improving the rate of acceptable bowel cleanliness. Nevertheless, by doing so we would still expect a relatively high rate of re-investigations, due to CCE’s sensitivity to adenomas. If we are able to accurately predict which patients would have a good chance of a complete CCE investigation with a low risk of pathology, even before the bowel preparation, we would be able to triage patients into the best individually suited diagnostic pathway. This may be possible using AI algorithms. Going even further than that, the development of AI for both detecting and characterizing adenomas in situ could enable us to lower the re-investigation rate even further and leave patients be without a need for therapeutic actions based on that prediction. This would ultimately reduce the overall discomfort to patients and the number of polypectomy-related complications.
We propose a patient pathway (the AICE pathway, www.aiceproject.eu) in which AI is used to:
• Determine which patients should undergo CCE
• Assess whether the capsule transit was complete
• Assess the bowel cleanliness
• Detect and localise cancers and adenomas, and
• Characterise the findings in terms of risk
By doing so, it may be possible to avoid a high number of double investigations, to reduce the current pressure experienced in many colonoscopy units globally, to reduce the quantity of labor needed related to reading capsule videos, while also offering more patients an investigation associated with limited discomforts and risk of complications.
References
[1] Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature 2000; 405(6785): 417.
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Dr Ulrik Deding @UlrikDeding