Gastrointestinal (GI) disorders represent a significant global health burden, contributing to millions of outpatient visits, hospitalizations, and premature deaths annually. The Global Burden of Disease Study (1) reported that digestive diseases were responsible for over 8 million deaths worldwide in 2020, with colorectal cancer ranking among the top three causes of cancer mortality.

Furthermore, chronic inflammatory conditions like inflammatory bowel disease (IBD) affect more than 10 million people globally, showing a rising incidence in newly industrialized countries (2). Other major GI disorders, such as peptic ulcers, celiac disease, gastroesophageal reflux disease (GERD), small bowel tumors, and obscure gastrointestinal bleeding, necessitate timely and accurate diagnostics to reduce morbidity and prevent life-threatening complications (3, 4).

In this context, early detection and precise localization of GI pathology are critical for guiding therapy and improving patient outcomes. Conventional endoscopy, particularly esophagogastroduodenoscopy (EGD) and colonoscopy, has long been the diagnostic mainstay. These techniques facilitate direct mucosal visualization, biopsy acquisition, and a range of therapeutic interventions, including polypectomy, variceal banding, and hemostasis (5).

Despite their proven effectiveness, conventional methods are invasive, require sedation, and can be associated with patient discomfort, adverse events, and limited accessibility, particularly in under-resourced or rural settings (6, 7). These challenges frequently reduce adherence to recommended screenings, especially among elderly and pediatric patient populations.

To address these limitations, capsule endoscopy (CE) was introduced in the early 2000s as a minimally invasive diagnostic tool primarily for small bowel evaluation (8). This capsule, roughly the size of a large vitamin pill, contains a miniature camera, a light source, a battery, and a wireless transmitter. This sophisticated design allows it to capture up to 100,000 images as it naturally passes through the digestive tract (9).

Initially used to investigate obscure GI bleeding, CE’s indications have expanded to include Crohn’s disease, celiac disease, small bowel neoplasms, and more (10, 11). Unlike traditional endoscopy, CE requires no sedation or hospital admission, making it an ideal modality for ambulatory, pediatric, and fragile patient populations (12).

However, it lacks the ability to perform biopsies, deliver therapies, or be actively steered, and it carries risks such as capsule retention, particularly in patients with strictures (13).

In recent years, technological innovations have significantly expanded the capabilities of both conventional and capsule endoscopy. CE has evolved through the integration of artificial intelligence (AI) for image interpretation, magnetically guided navigation, self-propulsion mechanisms, and tactile sensors.

These advancements have transformed CE from a passive camera into a semi-intelligent diagnostic system (14-16). Concurrently, conventional endoscopic platforms now incorporate high-definition video, narrow-band imaging (NBI), confocal laser endomicroscopy, and augmented guidance systems, which collectively improve diagnostic accuracy and procedural safety (17).

These parallel developments—one driving towards non-invasive smart diagnostics and the other towards advanced therapeutic precision—necessitate a structured comparison. As healthcare transitions toward patient-centered and precision-based approaches, clinicians must carefully weigh factors such as diagnostic yield, patient comfort, cost-effectiveness, and accessibility when selecting between these modalities.

This review presents a comprehensive comparative analysis of capsule and conventional endoscopy technologies, evaluating their mechanisms, clinical applications, limitations, and future trajectories. Special attention is given to their distinct roles in small bowel bleeding, colorectal cancer screening, IBD diagnosis, and upper GI evaluation, all within the evolving context of digital gastroenterology.

Conventional Endoscopy – History, Modalities, Clinical Roles, and Limitations

Conventional endoscopy remains the cornerstone of modern gastrointestinal (GI) diagnostics and therapeutics, offering unparalleled access for direct visualization, targeted tissue sampling, and real-time intervention. Its development over the past century parallels some of the most transformative advancements in internal medicine.

This section outlines the historical evolution, procedural taxonomy, technical innovations, clinical utility, and inherent procedural risks, with particular attention to geriatric vulnerability and sedation-related concerns.

Historical Development and Scope

The evolution of GI endoscopy began with rigid esophagoscopes in the early 20th century, progressing rapidly after the introduction of fiberoptic technology in the 1950s. The invention of the video endoscope in the 1980s marked a critical inflection point, enabling real-time imaging, comprehensive documentation, and post-procedure analysis (18). These developments not only revolutionized mucosal visualization but also significantly expanded indications from mere diagnosis to minimally invasive interventions.

Over time, the scope of conventional endoscopy broadened to include several advanced submodalities, each targeting specific anatomical or pathological niches. These now form an integrated procedural spectrum vital to various medical specialties, including gastroenterology, hepatology, oncology, cardiology, and pancreatobiliary medicine.

Taxonomy of Conventional Endoscopic Modalities

Table 1: Conventional Endoscopic Modalities

Procedure	Target Area	Primary Applications
EGD	Esophagus, stomach, duodenum	Ulcers, varices, dysphagia, malignancy
Colonoscopy	Entire colon, terminal ileum	Cancer screening, IBD, bleeding
ERCP	Biliary and pancreatic ducts	Obstruction, stones, strictures
EUS	GI wall, pancreas, lymph nodes	Tumor staging, FNA, cyst drainage
TNE	Nasal approach to proximal upper GI	Tolerated diagnostics in frail patients
TEE	Posterior heart via esophagus	Valve disease, atrial thrombus, endocarditis
DBE/Push Enteroscopy	Mid–small bowel	Obscure bleeding, biopsy, therapy

Esophagogastroduodenoscopy (EGD)

EGD is a first-line diagnostic and therapeutic procedure for evaluating upper GI symptoms such as dyspepsia, upper GI bleeding, and dysphagia. It facilitates biopsy of suspicious lesions, treatment of bleeding ulcers or varices, foreign body retrieval, and percutaneous endoscopic gastrostomy (PEG) tube placement. Biopsies are also routinely performed for conditions like gastritis, Barrett’s esophagus, and Helicobacter pylori infection (5).

Colonoscopy

As the primary tool for colorectal cancer screening, colonoscopy allows for real-time detection and removal of polyps, assessment of inflammatory bowel disease (IBD), and stricture dilation. It remains the sole modality validated for both diagnosis and definitive therapy in colon-based pathology (6).

Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP utilizes a side-viewing duodenoscope combined with fluoroscopy to visualize and treat biliary or pancreatic ductal disorders, including choledocholithiasis, strictures, and bile leaks. While magnetic resonance cholangiopancreatography (MRCP) has largely superseded diagnostic ERCP, therapeutic ERCP remains essential for stone removal, sphincterotomy, and stent placement (5).

Endoscopic Ultrasound (EUS)

EUS combines high-frequency ultrasound with endoscopy, enabling submucosal and extramural evaluation of GI and hepatopancreatic structures. It is particularly valuable for tumor staging, lymph node biopsy, and pancreatic cyst characterization. EUS-guided fine-needle aspiration (FNA) facilitates cytological diagnosis of malignancy with minimal invasiveness (19).

Transnasal Endoscopy (TNE)

TNE offers unsedated access to the upper GI tract via a narrower transnasal scope. Although image quality and suction capacity are comparatively lower, it is ideal for elderly or anticoagulated patients where sedation poses an increased risk (7).

Transesophageal Echocardiography (TEE)

Though primarily a cardiology procedure, TEE involves endoscopic ultrasound via the esophagus to visualize posterior cardiac anatomy—especially the atria, valves, and aortic arch—with high resolution. It is critical in the diagnosis of infective endocarditis, atrial thrombi, and valvular disorders (19).

Deep Enteroscopy (Push or Balloon-Assisted)

These methods extend diagnostic and therapeutic reach into the jejunum and ileum, regions largely inaccessible by conventional EGD or colonoscopy. While more invasive than capsule endoscopy, they enable biopsy and therapy, making them indispensable in select cases of obscure GI bleeding (10).

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Anesthesia and Risk in Geriatric Patients

Conventional endoscopic procedures typically employ conscious sedation (e.g., midazolam, fentanyl) or monitored anesthesia care (MAC). For advanced procedures like ERCP or TEE, or in patients with low pain tolerance, deep sedation or general anesthesia may be necessary.

However, sedation-related complications are significantly more frequent in geriatric populations. The aging process affects drug metabolism, and comorbidities such as cardiac insufficiency, chronic obstructive pulmonary disease (COPD), or cognitive impairment inherently increase procedural risk. For instance, Mahmud et al. (2021) reported that patients over 75 years experienced a 3.6-fold increase in sedation-related adverse events, including hypoxia, bradycardia, and delayed recovery (20).

Therefore, appropriate risk stratification is vital. In frail elderly patients, especially those undergoing screening rather than urgent intervention, capsule endoscopy may offer a lower-risk alternative (7, 12).

Clinical Applications: Diagnostic and Therapeutic Excellence

Conventional endoscopy offers both diagnostic precision and therapeutic versatility unmatched by non-invasive imaging.

Common Indications:

• GI bleeding (variceal or non-variceal)
• Inflammatory bowel disease (IBD) surveillance
• Barrett’s esophagus screening
• Colorectal cancer prevention
• Evaluation of dysphagia, dyspepsia, and chronic diarrhea
• Biliary/pancreatic duct evaluation (ERCP)
• Tumor staging (EUS)

Therapeutic Functions:

• Polypectomy and mucosal resection
• Clip or thermal coagulation for bleeding
• Stent placement in obstructive lesions
• Dilation of benign strictures
• Percutaneous endoscopic gastrostomy (PEG) and cyst drainage

Limitations of Conventional Endoscopy

Despite its critical diagnostic and therapeutic utility, conventional endoscopy has notable limitations. One of the foremost challenges is its invasive nature, often necessitating intravenous sedation or general anesthesia. This carries an increased risk of cardiopulmonary complications, particularly among older adults and patients with multiple comorbidities (20). Sedation also requires post-procedure monitoring, extended recovery time, and substantial resource allocation.

Another significant constraint is limited access to the mid-small intestine, a region beyond the reach of both EGD and colonoscopy. This creates a diagnostic “blind spot” in evaluating conditions such as obscure gastrointestinal bleeding, mid-jejunal tumors, and isolated Crohn’s disease of the small bowel (10). While techniques like double-balloon enteroscopy can address this gap, they are technically demanding, time-consuming, and not widely available.

Psychological factors also contribute to reduced patient compliance, particularly in colorectal cancer screening. Fear of discomfort, anxiety about sedation, and embarrassment regarding the procedure can deter participation, especially among younger, asymptomatic individuals or those from culturally conservative backgrounds (6).

Additionally, conventional endoscopy is operator-dependent, with diagnostic yield and safety closely tied to the endoscopist’s skill, experience, and equipment quality. This variability can lead to missed lesions, particularly subtle or flat neoplasms.

While complication rates are relatively low, colonoscopy carries a 0.1–0.3% risk of perforation, and post-polypectomy bleeding remains a concern. For EGD, serious complications are rare but include aspiration, bleeding, and cardiac arrhythmias, especially in high-risk patients (7).

Finally, healthcare infrastructure disparities further limit access in low- and middle-income countries or rural regions, where trained personnel, high-end imaging platforms, and reprocessing systems may be lacking (2). These systemic limitations highlight the need for less invasive, scalable diagnostic alternatives, such as capsule endoscopy, in selected clinical settings.

Limitations of Conventional Endoscopy

Despite its strengths, conventional endoscopy has key limitations:

• Invasiveness and sedation risks, particularly in older or comorbid patients.
• Incomplete access to the mid-small bowel (a gap between EGD and colonoscopy).
• Psychological barriers to screening (e.g., fear, anxiety, embarrassment).
• Dependency on highly trained operators, leading to potential variability in diagnostic yield.
• Procedure-related complications (e.g., perforation rate: ~0.1–0.3% for colonoscopy; rare for EGD but include aspiration, bleeding, and cardiac arrhythmias).
• Limited accessibility in low-resource settings or rural hospitals (2).

Table 2: Comparison of Capsule Endoscopy vs. Conventional Endoscopy

Feature	Capsule Endoscopy (CE)	Conventional Endoscopy (C-EGD, Colonoscopy, etc.)
Invasiveness	Non-invasive (swallowed capsule)	Invasive (scope insertion via mouth or rectum)
Anesthesia/Sedation	Not required	Often required (IV sedation or MAC)
Diagnostic Reach	Small intestine, colon (with specific capsules), esophagus (via magnet guidance)	Upper GI (EGD), colon, duodenum; limited small bowel access
Therapeutic Capability	None (diagnostic only)	Full therapeutic tools (biopsy, polypectomy, dilation, stenting)
Visualization Quality	High-res images (frame-by-frame)	Real-time, dynamic high-res video with control
Procedure Control	Passive (natural peristalsis)	Active operator-controlled navigation
Risk Profile	Capsule retention (1–2%); incomplete transit	Sedation risks, perforation (0.1–0.3%), bleeding
Patient Comfort	Very high; no discomfort or prep (except for bowel cleansing)	Variable; discomfort, gas, sedation recovery time
Clinical Indications	Obscure GI bleeding, Crohn’s disease, celiac disease, small bowel tumors, pediatric/frail patients	Bleeding, ulcers, IBD, cancer screening, strictures, polyp management
Accessibility	Portable; outpatient-friendly; suitable for rural/limited settings	Requires specialized units, trained personnel, infrastructure
Time to Review	Requires extensive video analysis (30–60 min per case)	Real-time assessment and decision-making
Cost & Resource Use	Lower setup cost; higher interpretive time	Higher procedural cost but immediate intervention

Capsule Endoscopy – Technology, Workflow, Modalities, and Limitations

Capsule endoscopy (CE) represents one of the most significant innovations in gastrointestinal diagnostics over the last two decades. First introduced by Iddan et al. in 2000, this minimally invasive technique has enabled clinicians to visualize regions of the gastrointestinal tract that were historically difficult to access, particularly the small intestine (8).

Its development was primarily driven by the need to evaluate obscure gastrointestinal bleeding and small bowel diseases in patients for whom conventional endoscopy provided insufficient visualization or posed undue procedural risk.

Technological Design and Components

The capsule endoscope is a self-contained, swallowable device typically measuring approximately 11×26 mm and weighing under 5 grams. It incorporates a miniature complementary metal-oxide semiconductor (CMOS) camera, a set of light-emitting diodes (LEDs) for illumination, a wireless transmitter, an antenna, and a battery capable of continuous function for 8–12 hours (9). Modern designs may include:

• Dual-lens systems for bi-directional viewing.
• Adaptive frame rate to conserve battery life.
• Onboard data storage or real-time transmission to external recorders.
• Position-tracking and motion sensors for orientation.

These components enable CE to acquire 50,000–100,000 images per procedure, which are then transmitted to a data recorder worn externally by the patient. After capsule excretion (typically within 24–48 hours), the stored video is downloaded and reviewed by a trained physician using specialized software.

Workflow and Procedural Steps of Capsule Endoscopy

The CE process follows a standardized workflow:

• Pre-procedure preparation involves overnight fasting and, in some cases, bowel preparation using polyethylene glycol. This step is particularly important for colon capsule endoscopy.
• Capsule ingestion occurs in a clinical setting. No sedation is required, making CE highly suitable for elderly, pediatric, or medically fragile patients.
• Transit and image acquisition rely entirely on natural peristalsis. The capsule traverses the GI tract passively, capturing images of the mucosa.
• Data retrieval and interpretation happen post-procedure. The data recorder is returned, and the physician reviews the footage, often utilizing AI-assisted software to highlight potential abnormalities (21).

This approach facilitates remote, ambulatory diagnostics while avoiding the risks associated with sedation and scope insertion.

Types and Clinical Applications of Capsule Endoscopy

CE is available in several clinically specialized variants, each designed for specific anatomical regions and diagnostic purposes.

Small Bowel Capsule Endoscopy (SBCE)

SBCE remains the most established and widely used CE platform. It is particularly valuable for evaluating:

• Obscure gastrointestinal bleeding
• Crohn’s disease
• Small bowel tumors
• Celiac disease
• Iron-deficiency anemia

Studies report a diagnostic yield between 38% and 83%, with variations depending on the indication, preparation quality, and clinical setting (11).

Colon Capsule Endoscopy (CCE)

Colon capsules are larger, feature dual cameras, and possess wider visual fields. They are primarily used in:

• Colorectal cancer screening, particularly for patients who decline or cannot tolerate conventional colonoscopy.
• Cases of incomplete colonoscopies due to anatomical or procedural limitations.

Meta-analyses report 75–90% sensitivity for polyps ≥6 mm, with higher accuracy achieved in well-prepped colons (22).

Esophageal Capsule Endoscopy (ECE)

ECE enables rapid, high-resolution imaging of the esophagus and is primarily used to screen or monitor:

• Barrett’s esophagus
• Esophageal varices
• Reflux esophagitis

ECE can be paired with magnetically guided navigation systems to overcome the limitations of passive motion and enhance targeted visualization (14).

Technological Innovations

Ongoing developments are transforming CE into a more dynamic and intelligent platform, including:

• Magnetically guided capsule endoscopy: This technology uses external magnetic fields to control capsule position, enabling targeted examination of the stomach and esophagus (14).
• Self-propelling robotic capsules: These capsules employ piezoelectric motors, shape memory alloys, or vibratory propulsion for enhanced mobility and prolonged gastric visualization (15).
• Artificial Intelligence (AI): Algorithms powered by deep learning now assist in detecting ulcers, polyps, angioectasias, and inflammatory lesions, significantly reducing review time and increasing diagnostic yield (16).
• Smart sensors: Newer prototypes include tactile and biosensor arrays capable of measuring pH, temperature, pressure, and various chemical signatures (17).

These enhancements aim to eventually allow for biopsy acquisition, therapeutic delivery, and real-time manipulation, thereby extending CE’s capabilities far beyond its current diagnostic-only paradigm.

Limitations and Challenges of Capsule Endoscopy

While capsule endoscopy (CE) offers numerous advantages in patient comfort, accessibility, and non-invasiveness, it remains fundamentally limited by its diagnostic-only nature, inherent technological constraints, and associated procedural risks. Recognizing these limitations is critical for determining its appropriate clinical application and when considering it as an alternative or adjunct to conventional endoscopy.

Lack of Therapeutic Capability

The most significant constraint of CE is its inability to perform real-time therapeutic interventions. Unlike conventional endoscopes, capsule platforms are currently incapable of:

• Performing biopsies for histopathological diagnosis.
• Executing hemostasis in gastrointestinal bleeding.
• Removing polyps or foreign bodies.
• Delivering localized drug therapy or placing stents.

Consequently, capsule endoscopy often functions as a first-line screening or visualization tool. Positive findings frequently necessitate follow-up conventional endoscopy for definitive treatment or confirmation (11).

Capsule Retention

Capsule retention, defined as the capsule remaining in the GI tract for over two weeks or failing to exit naturally, occurs in approximately 1–2% of cases. However, rates can significantly increase in patients with:

• Known or suspected Crohn’s disease.
• NSAID-induced strictures.
• Small bowel tumors or adhesions.

Retention may lead to bowel obstruction and, in rare instances, requires surgical retrieval. The use of a patency capsule (biodegradable or dissolvable) is often recommended before CE in high-risk patients (13).

Incomplete Examination and Transit Failure

Successful capsule endoscopy depends on the capsule completing its transit through the area of interest—typically the entire small bowel—within its battery life. However, failure to reach the colon before battery depletion may result in incomplete studies, particularly in:

• Patients with gastroparesis.
• Those with delayed small bowel transit.
• Cases where intestinal motility is impaired.

Incomplete visualization can compromise diagnostic yield, leading to false negatives or indeterminate studies that require repetition (11).

Limited Image Control and Field of View

Unlike conventional endoscopy, where the endoscopist can:

• Steer and orient the scope.
• Irrigate, aspirate, and insufflate.
• Manipulate mucosal folds.

Capsule endoscopy is a passive modality, entirely dependent on natural peristalsis and gravity for movement and positioning. This can result in:

• Missed lesions due to rapid transit.
• Poor visualization from retained debris.
• Difficulty precisely localizing pathology.

Although magnetically guided systems improve control in the esophagus and stomach, this technology is not yet universally available or standardized (14).

Interpretive Time and Reader Variability

A single capsule study generates up to 100,000 images, requiring:

• 30–60 minutes of detailed video review by a trained reader.
• Significant reader fatigue and inter-observer variability, particularly for subtle findings like angioectasias or mucosal breaks.

Recent developments in AI-assisted image triage have reduced this burden, but a final diagnosis still requires human validation (21).

Cost, Access, and Reimbursement

While CE avoids the infrastructure and sedation-related costs of traditional endoscopy, it presents other financial barriers:

• High device cost (capsule plus recording system).
• Software licensing and data storage expenses.
• Lack of universal insurance coverage in many countries.
• Limited availability in rural or low-resource regions.

These issues can limit its adoption, especially outside tertiary care centers or in healthcare systems with fee-for-service reimbursement models.

Table 4. Summary of Key Limitations

Category	Limitation	Implication
Clinical	No therapeutic capability	Requires follow-up endoscopy
Safety	Capsule retention (1–2%)	Risk of obstruction; potential surgical retrieval
Diagnostic	Incomplete transit, poor localization	False negatives; missed pathology
Technical	No active steering or suction	Passive image capture limits precision
Logistical	Prolonged review time	Reader fatigue; interpretive variability
Economic	High capsule cost; limited reimbursement	Barriers to widespread adoption

Capsule endoscopy represents a major advance in GI diagnostics, particularly for small bowel pathology, non-invasive screening, and its utility in vulnerable patient populations. It provides a safe, comfortable, and effective method for internal visualization without the need for sedation or operator-dependent discomfort.

However, current limitations—including the absence of therapeutic functionality, the risk of capsule retention, and incomplete transit—restrict its universal application as a primary diagnostic modality. Thus, CE is best viewed as a complementary strategy that extends the reach of endoscopy into areas previously inaccessible or unsafe for conventional tools.

Table 4: Clinical Applications – Capsule vs Conventional Endoscopy

Clinical Indication	Capsule Endoscopy (CE)	Conventional Endoscopy (EGD / Colonoscopy / ERCP / EUS)
Obscure GI bleeding	✅ First-line for small bowel evaluation	✅ EGD + Colonoscopy first; DBE for follow-up
Crohn’s disease	✅ Early mucosal detection in small bowel	✅ Required for biopsy, disease staging
Celiac disease	✅ Villous atrophy visualization (if biopsy refused)	✅ Duodenal biopsy essential for diagnosis
Iron-deficiency anemia	✅ Non-invasive screening if scopes are negative	✅ EGD + Colonoscopy first-line
Small bowel tumors	✅ Sensitive for mass detection	✅ Required for tissue sampling (via DBE or EUS)
Colorectal cancer screening	✅ Alternative for low-risk or refusal cases	✅ Colonoscopy = gold standard
Barrett’s esophagus / GERD	⚠️ Possible with esophageal capsule + magnetic guidance	✅ EGD with biopsy is standard
Esophageal varices	⚠️ Detected by ECE in cirrhotics	✅ EGD allows surveillance and banding
Polyp removal	❌ Not possible	✅ Colonoscopy enables resection
GI bleeding (active)	❌ Cannot intervene	✅ EGD or colonoscopy allows immediate therapy
Pancreatobiliary evaluation	❌ Not accessible	✅ ERCP/EUS required for ducts, stones, strictures
Tumor staging	❌ Not accurate	✅ EUS and biopsy essential
Stricture evaluation	⚠️ Risk of capsule retention	✅ Dilatation and biopsy via endoscope
Pediatric & frail patients	✅ Ideal for non-invasive imaging	⚠️ Sedation risk; limited tolerance

Future Directions and Innovations in Endoscopic Technology

Over the past two decades, gastrointestinal endoscopy has transitioned from a purely diagnostic tool to a technologically dynamic and increasingly patient-centered field. While conventional endoscopy continues to evolve with enhanced imaging and therapeutic capabilities, capsule endoscopy (CE) is on a parallel trajectory, increasingly bridging its diagnostic limitations through integration with robotics, artificial intelligence (AI), and sensor technology.

These developments suggest a future where the boundary between diagnostic and interventional platforms may become increasingly blurred, with profound implications for patient care, access, and global screening strategies.

AI-Assisted Image Interpretation

Artificial intelligence, particularly deep learning, is playing an increasingly central role in both conventional and capsule endoscopy. Convolutional neural networks (CNNs) have demonstrated accuracy rates approaching or even exceeding those of expert endoscopists for detecting various gastrointestinal lesions, including:

• Colonic polyps
• Ulcers and erosions
• Angioectasias
• Bleeding stigmata

In capsule endoscopy, AI-based systems now enable automated frame triage, prioritizing frames with suspected pathology. This can reduce review time from 30–60 minutes to under 10 minutes in some cases (21). For conventional endoscopy, real-time AI overlays can assist during live procedures by alerting endoscopists to missed lesions or guiding biopsy targeting (23).

These capabilities not only improve diagnostic efficiency but also enhance standardization, thereby reducing inter-observer variability—a critical goal in population-level screening programs.

Robotic and Magnetically Controlled Capsules

One of the key limitations of CE—the lack of control over navigation—is being actively addressed through magnetically guided systems and self-propelled capsules. Magnet-controlled capsule endoscopy (MCE), already in clinical use for gastric and esophageal evaluation, utilizes an external magnetic field to orient and steer the capsule with sub-centimeter precision (14). These advanced systems enable:

• Extended imaging in the stomach, which typically lacks peristalsis-driven transit.
• Targeted positioning for suspected lesions.
• Potential for real-time video guidance instead of passive imaging.

Additionally, research into self-propelling capsules employs mechanisms such as:

• Vibratory motors
• Shape-memory alloys
• Electromagnetic or fluidic actuation

These innovative devices promise controlled locomotion, retrograde movement, and the ability to “hover” in areas of interest, enabling future platforms to pause, re-image, or even biopsy specific lesions (15).

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Toward Therapeutic Capsule Endoscopy

Though still in prototype stages, the development of interventional capsule platforms is gaining significant momentum. These advancements include:

• Biopsy-enabled capsules featuring micro-serrated cutting arms or spring-loaded needles.
• Drug-delivery capsules capable of releasing medication at specific pH zones or based on chemical sensors.
• Cautery-enabled microtools for treating angiodysplasia.
• Tissue sampling via microneedles, guided by onboard AI or a remote operator interface.

Such advancements could position capsule endoscopy not just as a diagnostic tool, but as an autonomous or teleoperated intervention system, particularly in settings with limited access to conventional endoscopy.

Multi-sensor and Smart Diagnostic Capsules

Beyond visual imaging, future CE platforms are integrating biosensors capable of measuring:

• pH
• Temperature
• Pressure
• Glucose, lactate, or other metabolites
• Microbiome and gut enzyme activity

These capabilities could expand CE’s role into functional GI diagnostics, such as evaluating gastroparesis, intestinal transit disorders, and even mucosal immune responses (17). When combined with AI-driven analysis, CE could provide not just anatomical, but also physiological and biochemical information, paving the way for multi-dimensional diagnostics.

Remote, Wireless, and Decentralized Screening

One of CE’s greatest untapped potentials lies in its ability to decentralize endoscopy—shifting diagnostics from hospitals to homes, rural clinics, or mobile care units. This trend is particularly significant in the context of:

• Global colorectal cancer screening programs.
• IBD surveillance in underserved regions.
• Post-COVID-19 adaptations favoring non-contact diagnostics.

As wireless transmission improves and cloud-based review systems mature, capsule endoscopy may integrate into tele-endoscopy frameworks, enabling image upload, AI triage, and remote physician oversight. This could potentially close access gaps in low-resource regions.

Ethical and Regulatory Considerations

As capsule systems become more autonomous and AI-driven, new regulatory challenges are emerging. Key issues include:

• Diagnostic liability concerning AI-based interpretation.
• Data privacy and cybersecurity of wireless transmissions.
• Ethical concerns surrounding overdiagnosis, incidental findings, and patient consent for algorithm-based decisions.

It is essential that innovation is accompanied by robust governance frameworks, ongoing validation trials, and integration into established clinical guidelines to ensure both safety and effectiveness.

The future of endoscopy is increasingly hybrid, intelligent, and decentralized. Capsule endoscopy is evolving beyond static imaging into an ecosystem of smart, responsive, and potentially interventional devices, augmented by robotic locomotion, biosensing, and artificial intelligence.

Concurrently, conventional endoscopy is incorporating real-time diagnostic augmentation and robotic tools for enhanced therapeutic precision. Together, these convergent paths point toward an era of adaptive, patient-personalized, and data-rich gastrointestinal care—one that may soon redefine the meaning of endoscopy itself.

Table 5. Technological Innovations and AI Applications in Endoscopic Platforms

Innovation Area	Capsule Endoscopy (CE)	Conventional Endoscopy (C-EGD, Colonoscopy)	Clinical Value
Artificial Intelligence (AI)	✅ Deep learning for image triage, bleeding/polyp detection (e.g., CNNs)	✅ Real-time AI overlay for polyp detection and characterization	Reduces missed lesions, speeds interpretation, improves interobserver consistency
Magnetic Navigation	✅ Magnetically controlled capsule for gastric and esophageal control	❌ Not applicable	Allows non-invasive control of capsule positioning in upper GI
Self-propelling Capsules	✅ Vibration motors, shape-memory alloys, piezoelectrics in development	❌ Not required	Enables capsule steering, pausing, retrograde motion
Biopsy & Therapeutic Capsules	🚧 Prototypes in development (e.g., microneedles, biopsy arms)	✅ Fully established functionality	May bring CE closer to therapeutic parity
Edge Computing / Onboard AI	✅ AI processing inside capsule (e.g., lesion scoring, compression)	🚧 Under development for scope-assisted cloud AI	Improves latency, enables offline diagnosis, field deployability
Biosensor Integration	✅ pH, pressure, temperature, chemical and microbiome sensors in prototypes	❌ Rarely used; some pH monitoring exists (e.g., Bravo capsule)	Expands diagnostic capability to functional and biochemical GI disorders
3D Mucosal Reconstruction	🚧 Capsule-based stereo imaging under investigation	✅ Enhanced scopes with NBI, chromoendoscopy, 3D imaging	Improves precision of lesion characterization and localization
Remote Diagnostics / Telemedicine	✅ Cloud upload and asynchronous AI review possible	✅ Possible with connected hospital platforms	Enables decentralized diagnostics in remote/rural areas

References

1. GBD 2020 Gastrointestinal Disease Collaborators. (2021). The global burden of gastrointestinal disorders. The Lancet Gastroenterology & Hepatology, 6(3), 162–174. https://doi.org/10.1016/S2468-1253(20)30245-3
2. Kaplan, G. G., & Windsor, J. W. (2021). The global emergence of inflammatory bowel disease: The evolution of epidemiology. Gastroenterology, 160(1), 39–51.e2. https://doi.org/10.1053/j.gastro.2020.06.063
3. Sung, J. J., Kuipers, E. J., & El-Serag, H. B. (2009). Systematic review: The global incidence and prevalence of peptic ulcer disease. Alimentary Pharmacology & Therapeutics, 29(9), 938–946. https://doi.org/10.1111/j.1365-2036.2009.03960.x
4. Mangipudi, U. K., Dhooria, B., Acharya, R., & Reddy, S. (2025). Endless bleeding: Elusive diagnosis via capsule imaging. Digestive Diseases and Sciences. https://doi.org/10.1007/s10620-025-09041-8
5. Cotton, P. B., & Williams, C. B. (2020). Practical gastrointestinal endoscopy: The fundamentals (7th ed.). Wiley-Blackwell.
6. Rex, D. K., & Imperiale, T. F. (2023). Patient experience in colonoscopy: Results of a national survey. American Journal of Gastroenterology, 118(4), 678–685. https://doi.org/10.14309/ajg.0000000000002183
7. Leung, W. K., & Chan, F. K. (2020). Endoscopy in the elderly: Balancing benefit and risk. Best Practice & Research Clinical Gastroenterology, 44-45, 101692. https://doi.org/10.1016/j.bpg.2020.101692
8. Iddan, G., Meron, G., Glukhovsky, A., & Swain, P. (2000). Wireless capsule endoscopy. Nature, 405(6785), 417. https://doi.org/10.1038/35013021
9. Pennazio, M., Rondonotti, E., & de Franchis, R. (2008). Capsule endoscopy in neoplastic lesions of the small bowel. World Journal of Gastroenterology, 14(33), 5245–5253. https://doi.org/10.3748/wjg.14.5245
10. Ejtehadi, F., Dadashpour, N., & Bordbar, M. (2025). Diagnostic yield of capsule vs balloon enteroscopy in small bowel disorders. SN Comprehensive Clinical Medicine. https://doi.org/10.1007/s42399-025-01889-1
11. Sidhu, R., Sanders, D. S., & McAlindon, M. E. (2012). The role of video capsule endoscopy in celiac disease. Gastrointestinal Endoscopy Clinics of North America, 22(4), 869–880. https://doi.org/10.1016/j.giec.2012.07.007
12. Barkin, J. S., & Friedman, S. (2002). Wireless capsule endoscopy: Patient acceptance and safety. Gastrointestinal Endoscopy, 56(4), 621–624. https://doi.org/10.1067/mge.2002.128967
13. Cave, D., Legnani, P., de Franchis, R., & Lewis, B. S. (2005). ICCE consensus for capsule retention. Endoscopy, 37(10), 1065–1067. https://doi.org/10.1055/s-2005-870071
14. Shiha, M., Finta, A., & Madácsy, L. (2025). Magnet-controlled capsule endoscopy versus esophagogastroduodenoscopy: Diagnostic accuracy for upper GI lesions. Gut, 74(Suppl 1), A8.2.
15. Yan, Y., Wang, Z., Tian, J., & Guo, R. (2025). Self-propelled capsule robot dynamics in the small intestine. Journal of Applied Mechanics, 92(2), 1–12. https://doi.org/10.1115/1.4063694
16. Krumb, H. J., & Mukhopadhyay, A. (2025). eNCApsulate: A neural cellular automata model for precision diagnosis on capsule endoscopy platforms. arXiv. https://arxiv.org/abs/2504.21562
17. Le Floch, M., Werner, J., & Wolf, F. (2025). Advancing video capsule endoscopy with edge AI: Integration and future perspectives. Thieme Connect. https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0045-1805505
18. Feldman, M., Friedman, L. S., & Brandt, L. J. (2010). Sleisenger and Fordtran’s gastrointestinal and liver disease (9th ed.). Saunders.
19. Hahn, R. T., & Abraham, T. (2014). Transesophageal echocardiography in clinical practice. Journal of the American College of Cardiology, 63(19), 1951–1964. https://doi.org/10.1016/j.jacc.2014.02.540
20. Mahmud, N., Cohen, J., Tsourides, K., & Berzin, T. M. (2021). Risk of sedation-related complications in older adults undergoing GI endoscopy. Clinical Gastroenterology and Hepatology, 19(7), 1357–1365.e2.
21. da Costa, A. M. M. P., Saraiva, M. M., Cardoso, P., et al. (2025). AI-driven capsule endoscopy in IBD. Gastrointestinal Endoscopy. https://doi.org/10.1016/j.gie.2025.03.006
22. Spada, C., Pasha, S. F., Gross, S. A., et al. (2021). Accuracy of capsule colonoscopy in polyp detection: A meta-analysis. Gastrointestinal Endoscopy, 93(5), 1105–1114.e3. https://doi.org/10.1016/j.gie.2020.08.045
23. Urban, G., Tripathi, P., Alkayali, T., et al. (2018). Deep learning localizes and identifies polyps in real time with 96% accuracy in screening colonoscopy. Gastroenterology, 155(4), 1069–1078.e8. https://doi.org/10.1053/j.gastro.2018.06.037