Orally peppermint oil in small bowel capsule endoscopy: Novel approach to improve completion rates in patients at risk of delayed gastric transit

Abstract

Background and study aims

Small bowel capsule endoscopy (SBCE) is crucial in diagnosing small bowel diseases, yet incomplete examinations often result from prolonged gastric transit time. This study aimed to assess the efficacy of orally administered peppermint oil solution as a prokinetic agent to improve SBCE completion rates in patients with delayed gastric transit risk factors.

Patients and methods

Conducted as a single-center, prospective, open-label, non-inferiority trial, the study involved 132 patients identified as at risk for delayed gastric transit. Participants were divided into three groups: peppermint oil solution group (n = 57), real-time monitoring and intravenous prokinetics group (n = 75), and control group without risk factors (n = 193). Primary outcomes included SBCE completion rates, gastric transit time (GTT), small bowel transit time (SBTT), diagnostic yield, and bowel preparation quality.

Results

Completion rates were high and comparable among groups, with 94.7% in the peppermint group, 90.7% in the real-time monitoring group, and 95.3% in the control group. The peppermint group exhibited a significantly shorter mean GTT of 42.3 minutes compared with 57.0 minutes in the real-time monitoring group (P = 0.0423). However, SBTT was longer in the peppermint group at 246 minutes versus 193 minutes in the real-time monitoring group (P = 0.0081), although similar to the control group at 228.3 minutes (P = 0.2612). Diagnostic yield and bowel preparation quality were consistent across all groups.

Conclusions

Oral peppermint oil solution is a safe and effective alternative to traditional prokinetics, enhancing SBCE completion rates while reducing time and resource use in the endoscopy unit.

 

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Keywords

Endoscopy Small Bowel - Capsule endoscopy - Endoscopy Upper GI Tract - Diagnosis and imaging (inc chromoendoscopy, NBI, iSCAN, FICE, CLE)

Introduction

Small bowel capsule endoscopy (SBCE) has revolutionized diagnosis and management of small bowel diseases, offering a noninvasive and patient-friendly alternative to traditional methods. With its miniature camera housed in a swallowable capsule, SBCE provides high-resolution images of the small intestine, aiding in detection of various pathologies such as obscure gastrointestinal bleeding, Crohn's disease, and small bowel tumors [1].

However, despite its widespread use and diagnostic efficacy, SBCE is not without limitations. One crucial aspect influencing its utility is the completion rate – the percentage of examinations where the capsule traverses the entire small bowel and reaches the cecum, enabling comprehensive evaluation. Understanding completion rates is pivotal because incomplete examinations may lead to missed diagnoses and compromise clinical outcomes [2].

Incomplete study rates remain problematic for capsule endoscopy. The European Society of Gastrointestinal Endoscopy (ESGE) recently published performance measures for capsule endoscopy that suggest a minimum completion rate of 80%, with a target ≥ 95%. This performance indicator was based on data from 23 studies (18035 patient procedures) where the percentage of complete examinations was reported. The results of these studies were heterogeneous with completion rates ranging from 64% to 96% (median 80%) [3].

Incomplete SBCE results in further costs owing to repetition of SBCE and/or alternative investigations. In cases where the capsule did not reach the colon or the stoma within the duration of the recording and the patient does not confirm excretion within 2 weeks of ingestion, an abdominal radiograph will be needed to rule out capsule retention [4]. A completion rate < 80% may be associated with a higher risk of missing significant pathology; nevertheless, the true magnitude of this risk is unclear.

Two important measures, gastric transit time (GTT) and small bowel transit time (SBTT), provide key insights into the digestive process. GTT refers to the time the capsule spends in the stomach before entering the small intestine, whereas SBTT measures the time it takes for the capsule to pass through the small intestine. Standard references for these times can help identify abnormalities; normal GTT typically ranges from a few minutes to around 2 hours, whereas SBTT is generally between 4 and 6 hours. Deviations from these ranges may indicate motility issues, obstructions, or other pathologies that warrant further investigation. Performing capsule endoscopy within the optimal time frame is crucial for diagnostic accuracy because prolonged transit times can lead to incomplete exams, and potentially missing critical findings. Adhering to therapeutic timing ensures a comprehensive view of the small intestine.

The major cause of incomplete small bowel examination is prolonged GTT. Prokinetics have been used to aid capsule passage from the stomach to the small bowel. However, prokinetic use alone is ineffective at increasing SBCE completion rates [5] except in patients with risk factors for an incomplete SBCE study (i.e., those with previous history of abdominal surgery, delayed gastric emptying, diabetic neuropathy, severe hypothyroidism, or use of psychotropic drugs) who may benefit from administration of certain prokinetics (metoclopramide, domperidone or erythromycin) when the capsule remains in the stomach for more than 30 minutes [1].

A prospective study [6] from Japan comparing SBCE in 80 patients with or without active monitoring of capsule location with real-time viewing and prokinetic administration if the capsule did not reach the small bowel within 60 minutes reported a significantly higher completion rate in the active monitor compared with the control group (90% vs. 72.5%) [6]. Another Japanese study [7] recently compared the proportion of completed exams and positive findings among a group of patients studied before introduction of real-time viewing and a group in which capsule transit was regularly monitored and action was taken (e.g., administration of water or IV metoclopramide) if it was delayed. Using the real-time viewer increased SBCE completion rates from 66% to 86% (P = 0.002).

The downside to this approach is the necessity for the patient to be kept in the department to do real-time monitoring because automated response is not available for SBCE, which is inconvenient for the patient and a logistical problem for the unit.

Our group has also demonstrated similar findings, where the completion rates (90.2 % vs. 96.3 %) and rates of significant findings (37.7 % vs. 32.5 %) were similar in our population with risk factors for delayed gastric emptying who received prokinetics in comparison with a control group [8] [9]. There were no serious adverse events (AEs) in the prokinetic group, but four patients (7 %) reported side effects, including nausea, dizziness, and pain at the cannula site. A significant proportion (15 %) required a second prokinetic, increasing the potential for AEs, given that metoclopramide and erythromycin as prokinetics can pose a risk of adverse cardiac effects in an elderly cohort. Thus, alternative prokinetic interventions would be advantageous.

An ideal intervention in patients with risk factors for delayed gastric emptying, and thus, an incomplete capsule study would be safe, cost-effective, and convenient for both the endoscopy service and the patient. Several studies have examined chewing gum and ingestion of coffee as an aid to gastric transit [10] [11].

Peppermint is of herbal origin and has menthol as its main constituent. It is a naturally occurring carminative that causes relaxation of the gastrointestinal smooth muscle through blockade of Ca2+ channels [12]. It has been shown to be effective in treatment of irritable bowel syndrome symptoms in several meta-analyses [13] [14]. It has several proposed effects on the gastrointestinal tract, including intestinal smooth muscle relaxation, k-opioid receptor agonism modulation of transient receptor potential channel-mediated visceral nociception, 5-hydroxytryptamine antagonism, and antimicrobial and antifungal effects [13] [15] [16]. Antispasmodic properties have shown a reduction in gastric antral spasms and a dramatic opening of the pyloric ring in endoscopic studies [16] [17]. Peppermint oil has been shown to function as a prokinetic when administered orally and provides a possible alternative to medications administered intravenously [17]. Orally administered peppermint oil has been reported to aid gastric emptying and has a suitably safe side effect profile [13] [16].

A pilot study on use of peppermint as an alternative to standard prokinetic interventions by our group showed that in 143 patient procedures, peppermint (P) and metoclopramide (M) had similar completion rates of 83.3% vs 90.2%, respectively, when given 30 to 60 minutes post capsule ingestion in patients with risk factors for delayed gastric emptying. GTTs were 111 min (P) vs 97 min (M). There was no statistical difference between the two test groups (P = 0.1582). Interestingly SBTT was shorter in the peppermint test group 118 min vs 193 min for metoclopramide (P = 0.0005) [9].

This study aimed to assess efficacy of peppermint oil as a prokinetic in patients with risk factors for delayed gastric transit undergoing SBCE. The primary endpoint was completion rate. Secondary endpoints of GTT, SBTT, cleanliness score, and rates of significant findings were also assessed.

 

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Patients and methods

Study design and population

We performed a single-center, prospective, open-label, noninferiority trial comparing orally administered peppermint water solution vs real-time monitoring (current standard protocol) as an aid to completion of SBCE in patients with risk factors for delayed gastric transit. Ethical approval was obtained for the study from the St James’ Hospital/Tallaght University Hospital Joint Research Ethics Committee (Approval Date: November 21, 2022, Number: 2228)

All patients aged 18 years or older referred for SBCE without contraindications to administration of the study prokinetics were invited to participate over 6 months from January to June 2023. Contraindications included a history of cardiac arrhythmia, QT prolongation, and documented allergies to test prokinetics. Informed consent was obtained. Patients from January to March were recruited to the real-time monitoring group, whereas those from the remaining 3 months were recruited to the peppermint arm.

 

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Procedure

SBCE was carried out using the PillCam SB3 (Medtronic, Dublin, Ireland). Patients with risk factors for capsule retention (e.g., known Crohn’s Disease, prior surgery of the gastrointestinal tract, abdominal radiation, regular nonsteroidal anti-inflammatory drug use, previous capsule retention, obstructive symptoms) completed a capsule patency test before capsule endoscopy. No purgative agents were used before the procedure and patients fasted from 7 pm the evening before.

The real-time monitoring (RTM) group ingested the capsule with up to 200 mL of water. They remained in the department for capsule location check at 30 minutes post-ingestion using the real-time viewer. In the event of the capsule remaining in the stomach 30 minutes post-ingestion, all patients received 10 mg of IV metoclopramide. A further site check was performed at 60 minutes post ingestion where if the capsule remained in the stomach patients received 250 mg of erythromycin intravenously (IV).

The peppermint protocol (PP) group ingested the capsule with 200 mL of a peppermint water solution (containing 90 mg of peppermint). They were then free to leave the department to return the equipment the following day. No position check or further prokinetics were administered to this group.

A control group of age- and sex-matched patients who had no risk factors for delayed gastric emptying were included from our capsule database for comparison purposes.

All studies were read and reported by experienced readers and the final reports were reviewed at a departmental capsule review meeting before approval. The PillCam software automatically generated transit times following landmark identification by the reader. Image quality was based on reader overall impression of bowel preparation as per the Brotz score [18].

A nested case-control design was utilized. Basic demographics, completion rates, image quality, transit times, and diagnostic yield were compared between groups using student t-tests or chi-square tests as appropriate. AEs and complications were documented.

Results were compared among the three groups of patients. P < 0.05 was considered statistically significant. Analysis was performed on an intention-to-treat basis.

 

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Results

Over the study period, 449 small bowel capsules were performed. Of these, 132 (29.4%) had risk factors for delayed gastric transit and were randomized: 57 in the PP group and 75 in the RTM group. A control group of 193 patients with no risk factors for delayed transit was also included.

All patients in the peppermint group received peppermint water solution with capsule ingestion. One patient did not tolerate the solution and consumed only 25 mL. In the RTM group, 34 of 75 patients (45.1%) received metoclopramide; of these eight of 75 (8.0%) also received erythromycin.

Demographics were similar between the PP and RTM groups (60.1 vs 64.0 years (P = 0.2046); 42% vs 39% male (P = 0.7226) respectively) ([Table 1]).

Table 1 Demographics.

	PP		RTM		Control
PP, peppermint protocol; RTM, real-time monitoring; SD, standard deviation.
n	57		75		193
Male (n, %)	24	42.1%	29	38.7%	81	42.0%
Age (years)	60.1	(SD 19.0)	64.0	(SD 16.1)	59.0	(SD 16.0)
Risk factor for delayed gastric transit
Medication	15	26.3%	25	33.3%
DM	9	15.8%	16	21.3%
Hypothyroidism	12	21.1%	14	18.7%
More than one	21	36.8%	20	26.7%

A similar proportion from each group had risk factors for capsule retention and had a patency prior to capsule endoscopy ([Table 2]).

Table 2 Patency assessment performed.

	n	Patency assessment	%
PP, peppermint protocol; RTM, real-time monitoring.
PP	57	11	19.3%
RTM	75	11	14.7%	P = 0.645
Control	193	26	13.5%	P = 0.407

Indications for capsule endoscopy were similar in all three groups with suspected small bowel bleeding being the most common indication in all groups ([Table 3]).

Table 3 Indication for SBCE.

	Peppermint group		RTM group			Control group
P value compared against peppermint group. RTM, real-time monitoring; SBCE, small bowel capsule endoscopy.
n	57		75			193
Suspected small bowel Bleeding	28	49.1%	33	44.0%	P = 0.756	97	50.3%	P = 1.000
Suspected Crohn's disease	18	31.6%	25	33.3%	P = 1.000	72	37.3%	P = 0.65
Polyps	6	10.5%	4	5.3%		10	5.2%
Crohn’s assessment	4	7.0%	9	12.0%		14	7.3%
Radiological abnormality	1	1.8%	4	5.3%		0	0.0%

Completion rates

Completion rates overall were high and similar in the three groups: 94.7% (PP) vs 90.7% (RTM) vs 95.3% (C) ([Table 4]). There was no statistical difference in completion rates between the two study groups (P = 0.5135) or between the PP group and the control group (P = 0.7385).

Table 4 Completion rates.

	n	Complete	Completion rate
P values are measured compared with PP group. PP, peppermint protocol; RTM, real-time monitoring.
PP	57	54	94.7%
RTM	75	68	90.7%	P = 0.5135
Control	193	184	95.3%	P = 0.7385

In the PP group, 54 of 57 patients had a complete study. Of the three patients with incomplete studies, two had delayed gastric emptying, with the capsule remaining in the stomach for the entire study duration, and one patient had capsule retention at a small bowel stricture.

In the RTM group, 68 of 75 patients had a complete study. Three had delayed gastric emptying despite administration of both prokinetics with the capsule remaining in the stomach for the entirety of the study, whereas four had incomplete studies with the capsule not reaching the caecum. The control group of patients without identified risk factors for delayed gastric emptying had a completion rate of 184 of 193 (95.3%). There was also no statistical difference between the PP group and the C group (P = 0.7385).

All three groups met the ESGE minimum completion key performance indicator of 80%, with the peppermint and control groups meeting the higher target of ≥ 95% [4].

 

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Transit times

GTTs were 42.3 minutes (SD 34.2) (PP) vs 57.0 minutes (SD 45.1) (RTM). There was a statistical difference between the two test groups (P = 0.042). GTT in the control group was 34.4 minutes, which was not statistically different from the PP group (P = 0.184).

SBTT was 246.4 minutes in the PP group vs 193 minutes in the RTM group. There was a statistical difference between the two test groups (P = 0.012). The SBTT in the control group was 228.3 min, which was not significantly different compared with the PP group (P = 0.301) ([Table 5]).

Table 5 Capsule transit times.

	GTT (min)	SD	P value	SBTT (min)	SD	P value
P value compared against PP group. GTT, gastric transit time; PP, peppermint protocol; SBTT, small bowel transit time; SD, standard deviation.
PP	42.3	34.2		246.4	90.3
RTM	57.0	45.1	P = 0.042	193.0	127.5	P = 0.012
Control	34.4	40.0	P = 0.184	228.3	110.9	P = 0.301

 

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Diagnostic yield

Significant findings were identified in 24 of 56 (42.9%) in the peppermint group vs 28 of 75 (37.3%) of the standard group (P = 0.5895) and 63 of 193 (32.6%) in the control group (P = 0.2025 in comparison to peppermint group ([Table 6]).

Table 6 Diagnostic yield.

	Peppermint group		RTM group			Control group
P value compared against peppermint group. RTM, real-time monitoring.
n	56		75			193
Ileitis	6	10.5%	13	17.3%	P = 0.458	26	13.5%	P = 0.821
Angiodysplasia	3	5.3%	5	6.7%	P = 1.000	15	7.8%	P = 0.771
Blood	3	5.3%	6	8.0%		11	5.7%
Polyp/mass	2	3.5%	4	5.3%		11	5.7%
Normal	42	73.7%	47	62.7%		130	67.4%

 

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Bowel prep

Adequate bowel prep assessed by the Brotz score was similar in the three groups 98.2% (P) vs 93.2% (S) vs 95.3% (C) deemed adequate. There was no statistical difference in the comparison.

 

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Adverse events

No significant AEs were recorded. One patient in the PP group tolerated the peppermint solution poorly and only consumed 25 mL. In the RTM monitoring group, pain at the IV site was recorded in two patients and nausea in two other patients.

 

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Discussion

Diagnostic yield of SBCE is only limited by two confounders that hamper complete evaluation of small bowel mucosal features: 1) poor luminal visualization; and 2) slow gastric and/or SBTT, which can prevent the capsule from reaching the ileocecal valve/cecum within capsule battery life [19]. The current generation of small bowel capsules have battery life of between 12 and 15 hours [20].

Therefore, various techniques and interventions have been developed with the aim of improving clinical chances for total enteroscopy. Prokinetics have been used to aid capsule passage from the stomach to the small bowel. Prokinetic use alone is ineffective in increasing SBCE completion rates [5], possibly due to limited effect on the small bowel as well as other factors. However, patients with risk factors for an incomplete SBCE study may benefit from administration of certain prokinetics (metoclopramide, domperidone, or erythromycin) when the capsule remains in the stomach for more than 30 to 60 minutes. The ESGE recommends prokinetic usage/or endoscopically assisted capsule delivery into the duodenum in patients for whom delayed gastric emptying has been confirmed by RTM [2].

Erythromycin, a macrolide antibiotic with a favorable safety profile, works by activating motilin receptors on endocrine cells in the duodenum [21]. It is widely recognized for its prokinetic effects, producing strong gastric contractions that help move contents through the stomach. This action speeds up emptying of both liquids and solids, including indigestible particles [22]. However, its most frequent side effect is nausea, which can limit its use in SBCE [23].

Metoclopramide, a dopamine D2 receptor antagonist, works by relaxing the pyloric sphincter and enhancing coordination between the antrum and duodenum [24]. It is quickly absorbed when taken orally, reaching peak plasma levels within 1 hour and having a half-life of 5 hours [25]. However, its use has occasionally been associated with idiosyncratic side effects, such as tardive dyskinesia and other extrapyramidal or dystonic reactions.

Peppermint water, commonly used as a natural remedy for digestive discomfort, is made by diluting peppermint oil or extract in water and is taken orally [26]. Although generally safe when consumed in moderation, peppermint water can have some side effects. It may cause heartburn by relaxing the lower esophageal sphincter. Rarely, some individuals may experience allergic reactions, such as skin rashes, mouth irritation, or headaches. Peppermint may sometimes cause nausea or gastrointestinal upset [12].

This study shows that capsule ingestion with a peppermint water solution in patients with risk factors for delayed gastric emptying is well tolerated with minimal adverse effects.

The prokinetic effects are equivalent to the standard protocol for patients with delayed gastric emptying risk factors. Overall, completion rates were high and similar in the three groups: 94.7% (PP) vs 90.7% (RTM) vs 95.3% (C), with no effect on preparation quality or findings. GTT times were significantly shorter in the PP group than in the RTM group, likely due to timing of interventions: 42.3 minutes (PP) vs 57.0 minutes (RTM), P = 0.042). But this did not continue through to SBTT times, where an opposite result was recorded; 246.4 minutes (PP) vs. 193 minutes (RTM), P = 0.012).

Limitations of this study include it being a single-center study and the randomization method used resulting in slightly imbalanced study groups; however, demographics in both were similar. Although outcomes were very good with high completion rates in all groups, a much larger number of patients would be required to show a number needed to treat advantage. Dosing of peppermint was taken from a previous paper in which it was shown to be effective in aiding gastric emptying; however, the optimum dosing regimen is not clear from the limited published data [27].

Apart from recording AEs, no patient feedback was assessed. A cost-effectiveness study would help assess any potential financial savings.

 

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Conclusions

Peppermint water solution given at time of capsule ingestion in patients with risk factors for delayed gastric emptying is equivalent to the current standard protocol involving administration of prokinetics. Peppermint water solution also reduces patient time in the department because no position checks are required, reducing the workload for the capsule laboratory in repeated monitoring and administration of prokinetics before patients can leave the department.

 

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Pennazio M, Spada C, Eliakim R. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2015; 47: 352-376
• 2 Rondonotti E, Spada C, Adler S. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2018; 50: 423-446
• 3 Kastenberg D, Bertiger G, Brogadir S. Bowel preparation quality scales for colonoscopy. World J Gastroenterol 2018; 24: 2833-2843
• 4 Spada C, McNamara D, Despott EJ. et al. Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2019; 51: 574-598
• 5 Koulaouzidis A, Giannakou A, Yung DE. et al. Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis. Curr Med Res Opin 2013; 29: 1171-1185
• 6 Hosono K, Endo H, Sakai E. et al. Optimal approach for small bowel capsule endoscopy using polyethylene glycol and metoclopramide with the assistance of a real-time viewer. Digestion 2011; 84: 119-125
• 7 Shiotani A, Honda K, Kawakami M. et al. Use of an external real-time image viewer coupled with prespecified actions enhanced the complete examinations for capsule endoscopy. J Gastroenterol Hepatol 2011; 26: 1270-1274
• 8 O’Hara F, Seminov S, McNamara D. Audit of the use of prokinetics to improve completion rates of small bowel capsule endoscopy. Endoscopy 2021; 53: S130
• 9 O'Hara F. Orally administered peppermint oil as an aid to prevent delayed gastric emptying in capsule endoscopy. United Europ Gastroenterology J 2022; 2022: 10
• 10 Buijs MM, Kobaek-Larsen M, Kaalby L. et al. Can coffee or chewing gum decrease transit times in Colon capsule endoscopy? A randomized controlled trial. BMC Gastroenterology 2018; 18: 95
• 11 Huang L, Hu Y, Chen F. et al. Effectiveness of improved use of chewing gum during capsule endoscopy in decreasing gastric transit time: A prospective randomized controlled study. Front Med (Lausanne) 2021; 8: 605393
• 12 Chumpitazi BP, Kearns GL, Shulman RJ. Review article: the physiological effects and safety of peppermint oil and its efficacy in irritable bowel syndrome and other functional disorders. Aliment Pharmacol Ther 2018; 47: 738-752
• 13 Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol 2014; 48: 505-512
• 14 Ingrosso MR, Ianiro G, Nee J. et al. Systematic review and meta-analysis: efficacy of peppermint oil in irritable bowel syndrome. Aliment Pharmacol Ther 2022; 56: 932-941
• 15 Hills JM, Aaronson PI. The mechanism of action of peppermint oil on gastrointestinal smooth muscle. An analysis using patch clamp electrophysiology and isolated tissue pharmacology in rabbit and guinea pig. Gastroenterology 1991; 101: 55-65
• 16 Hiki N, Kurosaka H, Tatsutomi Y. et al. Peppermint oil reduces gastric spasm during upper endoscopy: a randomized, double-blind, double-dummy controlled trial. Gastrointestinal Endoscopy 2003; 57: 475-482
• 17 Inamori M, Akiyama T, Akimoto K. et al. Early effects of peppermint oil on gastric emptying: a crossover study using a continuous real-time 13C breath test (BreathID system). J Gastroenterol 2007; 42: 539-542
• 18 Brotz C, Nandi N, Conn M. et al. A validation study of 3 grading systems to evaluate small-bowel cleansing for wireless capsule endoscopy: a quantitative index, a qualitative evaluation, and an overall adequacy assessment. Gastrointest Endosc 2009; 69: 262-270 e261
• 19 Enns R. Transit times in capsule endoscopy: are all patients the same?. Dig Liver Dis 2007; 39: 581-583
• 20 Blanco-Velasco G, Hernández-Mondragón OV, Solórzano-Pineda OM. et al. Which model of small bowel capsule endoscopy has a better diagnostic yield? A systematic review and meta-analysis. Acta Gastroenterol Belg 2022; 85: 509-517
• 21 Caddy GR, Moran L, Chong AK. et al. The effect of erythromycin on video capsule endoscopy intestinal-transit time. Gastrointest Endosc 2006; 63: 262-266
• 22 Niv E, Bonger I, Barkay O. et al. Effect of erythromycin on image quality and transit time of capsule endoscopy: a two-center study. World J Gastroenterol 2008; 14: 2561-2565
• 23 Selby W. Complete small-bowel transit in patients undergoing capsule endoscopy: determining factors and improvement with metoclopramide. Gastrointest Endosc 2005; 61: 80-85
• 24 Schwarzberg MN. Pro-kinetic medications as aids in imaging the small bowel by video-capsule. Med Hypotheses 2005; 64: 602-607
• 25 Almeida N, Figueiredo P, Freire P. et al. The effect of metoclopramide in capsule enteroscopy. Dig Dis Sci 2010; 55: 153-157
• 26 Goerg KJ, Spilker T. Effect of peppermint oil and caraway oil on gastrointestinal motility in healthy volunteers: a pharmacodynamic study using simultaneous determination of gastric and gall-bladder emptying and orocaecal transit time. Aliment Pharmacol Ther 2003; 17: 445-451
• 27 Mahawongkajit P, Kanlerd A. A prospective randomized controlled trial comparing simethicone, N-acetylcysteine, sodium bicarbonate and peppermint for visualization in upper gastrointestinal endoscopy. Surg Endosc 2021; 35: 303-308

Publication History

Received: 14 June 2024

Accepted after revision: 11 November 2024

Accepted Manuscript online:
13 November 2024

Article published online:
14 March 2025