MODIFICATION TO GIVEN DIAGNOSTIC SYSTEM

K040248 · Given Imaging , Ltd. · NEZ · Feb 17, 2004 · Gastroenterology, Urology

Device Facts

• Record ID: K040248
• Device Name: MODIFICATION TO GIVEN DIAGNOSTIC SYSTEM
• Applicant: Given Imaging , Ltd.
• Product Code: NEZ · Gastroenterology, Urology
• Decision Date: Feb 17, 2004
• Decision: SESE
• Submission Type: Special
• Regulation: 21 CFR 876.1300
• Device Class: Class 2
• Attributes: Pediatric

Intended Use

The Given® Diagnostic System is intended for visualization of the small bowel mucosa. It may be used as a tool in the detection of abnormalities of the small bowel in adults and children from 10 years of age and up. The Suspected Blood Indicator (SBI) feature is intended to mark frames of the video suspected of containing blood or red areas.

Device Story

System consists of M2A® capsule, data recorder, and RAPID® workstation. Disposable wireless capsule travels via peristalsis through digestive tract; transmits digital images to external receiving antennas worn by patient. Data recorder stores images; downloaded to workstation post-procedure. Physician reviews video on workstation to identify abnormalities. Suspected Blood Indicator (SBI) feature automatically marks video frames containing potential blood or red areas to assist physician review. Used in clinical settings; operated by healthcare professionals. Benefits include non-invasive visualization of small bowel mucosa.

Clinical Evidence

No clinical data provided; substantial equivalence based on technological characteristics and intended use identical to predicate devices.

Technological Characteristics

Ingestible telemetric capsule imaging system. Components: M2A® capsule, data recorder, RAPID® workstation. Wireless data transmission via external antennas. Class II device per 21 CFR 876.1300. Complies with Class II Special Controls Guidance Document for Ingestible Telemetric Gastrointestinal Capsule Imaging Systems.

Indications for Use

Indicated for visualization of small bowel mucosa and detection of small bowel abnormalities in adults and pediatric patients aged 10 years and older.

Regulatory Classification

Identification

An ingestible telemetric gastrointestinal capsule imaging system is used for visualization of the small bowel mucosa as an adjunctive tool in the detection of abnormalities of the small bowel. The device captures images of the small bowel with a wireless camera contained in a capsule. This device includes an ingestible capsule (containing a light source, camera, transmitter, and battery), an antenna array, a receiving/recording unit, a data storage device, computer software to process the images, and accessories.

Special Controls

*Classification.* Class II (special controls). The special control is FDA's guidance, “Class II Special Controls Guidance Document: Ingestible Telemetric Gastrointestinal Capsule Imaging Systems; Final Guidance for Industry and FDA.”

Predicate Devices

• Given® Diagnostic System (K010312)
• Given® Diagnostic System (K020341)
• Given® Diagnostic System (K022362)
• Given® Diagnostic System (K022980)
• Given® Diagnostic System (K031033)
• Given® Diagnostic System (K032405)

Submission Summary (Full Text)

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# FEB 1 7 2004

#### 510(K) SUMMARY

# Given® Diagnostic System 510(k) Number K 04 0 248

## Applicant's Name:

Given Imaging Ltd. 13 Hayetzira St. P.O. Box 258 New Industrial Zone Yokneam 20692, Israel Tel.: [phone] Fax: [phone]

## Contact Person:

Shosh Friedman, RAC Corporate V.P. Regulatory & Medical Affairs Tel: [phone] Fax: [phone] Email: [e-mail]

#### Trade Name:

Given® Diagnostic System

# Classification Name:

Ingestible Telemetric Gastrointestinal Capsule Imaging System

#### Classification:

FDA has classified Ingestible Telemetric Gastrointestinal Capsule Imaging System as class II devices (product code 78NZE) and they are reviewed by the Gastroenterology Panel.

#### Predicate Device:

· Given® Diagnostic System (K010312, K020341, K022362, K022980, K031033, K032405)

#### Performance Standards and Special Controls:

The Given® Diagnostic System complies with the requirements presented in "Class II Special Controls Guidance Document; Ingestible Telemetric Gastrointestinal Capsule Imaging System: Final Guidance for Industry and FDA" issued on November 28,2001

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#### Intended Use:

The Given® Diagnostic System is intended for visualization of the small bowel mucosa. It may be used as a tool in the detection of abnormalities of the small bowel in adults and children from 10 years of age and up.

The Suspected Blood Indicator (SBI) feature is intended to mark frames of the video suspected of containing blood or red areas.

#### Device Description:

The Given® Diagnostic System is comprised of three subsystems M2A® Capsule, Data Recorder Set, and RAPID® Workstation.

The M2A® Capsule is a wireless, disposable capsule designed to glide smoothly through the digestive system by the peristaltic activity of the intestinal muscles and is excreted naturally. During its passage, the capsule transmits digital data that is captured by receiving antennas attached to the patient's body. The images are stored in the DataRecorder that is connected to the receiving antennas and is worn on a belt around the waist of the patient. When the test is over, the antennas and recorder are removed from the patient's body. The images from the recorder are downloaded to the RAPID® Workstation for processing and viewing by the physician. A Pediatric Accessory Kit for use of the system on pediatric (age 10 and up) population has been added .

#### Substantial Equivalence:

Given Imaging Ltd. believes that, based on the information provided in this submission, the Given® Diagnostic System with Pediatric Accessory Kit is substantially equivalent to the Given® Diagnostic System cleared under K010312, K020341, K022362, K022980, K031033 and K032405 without raising any new safety and/or efficacy issue.

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Image /page/2/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo features a stylized depiction of a human figure with outstretched arms, overlaid with three horizontal bars. The words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" are arranged in a circular pattern around the figure.

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

FEB 1 7 2004

Shosh Friedman, RAC Corporate V.P. Regulatory & Medical Affairs Given Imaging Ltd. 13 Havestzira St. New Industrial Park YOONEAM ISRAEL 20692

Re: K040248

Trade/Device Name: Given® Diagnostic System - Pediatric Accessory Kit Regulation Number: 21 CFR §876.1300 Regulation Name: Ingestible telemetric gastrointestinal capsule imaging system Regulatory Class: II Product Code: 78 NEZ Dated: January 30, 2004 Received: February 3, 2004

Dear Ms. Friedman:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food. Drug. and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register,

Please be advised that I'DA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as sct forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (sections 531-542 of the Act); 21 CFR 1000-1050.

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This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Office of Compliance at one of the following numbers, based on the regulation number at the top of the letter:

| 8xx. 1xxx | [phone] |
|----------------------------------|----------------|
| 876.2xxx, 3xxx, 4xxx, 5xxx | [phone] |
| 884.2xxx, 3xxx, 4xxx, 5xxx, 6xxx | [phone] |
| 892.2xxx, 3xxx, 4xxx, 5xxx | [phone] |
| Other | [phone] |

Additionally, for questions on the promotion and advertising of your device, please contact the Office of Compliance at [phone]. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97) you may obtain. Other general information on your responsibilities under the Act may be obtained from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/cdrfv/dsma/dsmamain.html.

Sincerely yours,

Nancy C. Brogdon

Nancy C. Brogdon Director, Division of Reproductive, Abdominal and Radiological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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## INDICATIONS FOR USE STATEMENT

510(k) Number (if known):_KO4 O24 O

Device Name:

Given® Diagnostic System

Indications for Use:

The Given® Diagnostic System is intended for visualization of the small bowel mucosa. It may be used as a tool in the detection of abnormalities of the small bowel in adults and children from 10 years of age and up.

The Suspected Blood Indicator (SBI) feature is intended to mark frames of the video suspected of containing blood or red areas

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510(k) Number K040248

Prescription Use (Per 21 CFR 801.109)

Ernst A. Lyonn

Division of Reproductive. and Radiological Device 510(k) Number

OR

Over the Counter Use__________________________________________________________________________________________________________________________________________________________

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