Factors associated with diagnosis of obscure gastrointestinal bleeding by video capsule enteroscopy

Could Capsule Endoscopy Be Useful in Detection of Suspected Small Bowel Bleeding and IBD-10 Years of Single Center Experience

A retrospective study in patients who underwent video capsule endoscopy (VCE) between 2006 and 2016 was conducted in the Clinic for gastroenterology and Hepatology, University Clinical Center of Serbia. A total of 245 patients underwent VCE. In 198 patients the indication was obscure gastrointestinal bleeding (OGIB), with 92 patients having overt and the other 106 occult bleeding. The remaining 47 patients underwent VCE due to suspected small bowel (SB) disease (i.e., Von Hippel-Lindau syndrome, familial adenomatous polyposis, Peutz Jeghers syndrome, Crohn's disease, prolonged diarrhea, abdominal pain, congenital lymphangiectasia, protein-losing enteropathy, tumors, refractory celiac disease, etc.). VCE identified a source of bleeding in 38.9% of patients (in the obscure overt group in 48.9% of patients, and in the obscure occult group in 30.2% of patients). The most common findings were angiodysplasias, tumors, Meckel's diverticulum and Crohn's disease. In the smaller group of patients with an indication other than OGIB, 38.3% of patients had positive VCE findings. The most common indication is OGIB, and the best candidates are patients with overt bleeding; patients with IBD should be evaluated in this setting.

Video capsule endoscopy in overt and occult obscure gastrointestinal bleeding: Insights from a single-center, observational study in Japan

Objective

This study aimed to evaluate the use of video capsule endoscopy (VCE) in patients with obscure gastrointestinal bleeding (OGIB), compare cases of overt and occult OGIB, assess the rates of balloon-assisted enteroscopy (BAE) interventions and rebleeding, and identify predictive markers of positive VCE findings.

Methods

Medical records of 430 patients who underwent VCE for OGIB between 2004 and 2022 were analyzed. Occult OGIB was defined as IDA or positive fecal occult blood, whereas overt OGIB was defined as clinically imperceptible bleeding. We retrospectively analyzed demographics, VCE findings based on Saurin classification (P0, P1, and P2), outcome of BAE interventions, and rebleeding rates.

Results

A total of 253 patients with overt OGIB and 177 with occult OGIB were included. P1 findings were predominant in both groups, with a similar distribution. The percentage of patients receiving conservative therapy was higher in P1 than in P2 for both overt and occult OGIB. BAE was more frequently performed in P2 than in P1 VCE (83.0% vs. 35.3% in overt OGIB, 84.4% vs. 24.4% in occult OGIB). The percentage of positive findings and intervention in total BAE performed patients were comparable in P1 and P2 of overt OGIB, whereas these percentages in P2 were more than P1 of occult OGIB.

Conclusion

VCE effectively identified OGIB lesions requiring intervention, particularly occult OGIB lesions, potentially reducing unnecessary BAE. Rebleeding rates varied according to the VCE findings, emphasizing the importance of follow-up in high-risk patients.

Artificial intelligence in endoscopy: Overview, applications, and future directions

Since the emergence of artificial intelligence (AI) in medicine, endoscopy applications in gastroenterology have been at the forefront of innovations. The ever-increasing number of studies necessitates the need to organize and classify applications in a useful way. Separating AI capabilities by computer aided detection (CADe), diagnosis (CADx), and quality assessment (CADq) allows for a systematic evaluation of each application. CADe studies have shown promise in accurate detection of esophageal, gastric and colonic neoplasia as well as identifying sources of bleeding and Crohn's disease in the small bowel. While more advanced CADx applications employ optical biopsies to give further information to characterize neoplasia and grade inflammatory disease, diverse CADq applications ensure quality and increase the efficiency of procedures. Future applications show promise in advanced therapeutic modalities and integrated systems that provide multimodal capabilities. AI is set to revolutionize clinical decision making and performance of endoscopy.

Predictive Model for Positive Video Capsule Endoscopy in Iron Deficiency Anemia

BACKGROUND AND AIMS

Bleeding from the gastrointestinal tract can contribute to the development of iron deficiency anemia (IDA) among individuals without another obvious source of bleeding. In order to identify patients most likely to benefit from examination of the small bowel, our aim was to create a risk score for positive video capsule endoscopy (VCE) in IDA utilizing a multicenter collection of studies.

METHODS

We performed a retrospective multicenter study utilizing VCE studies performed for an indication of IDA between 1/1/2005 and 7/31/2018. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. Data were analyzed with Student's t test for continuous variables and the Fisher's exact test for categorical variables. Logistic regression was used to identify independent associations with positive VCE.

RESULTS

In total, 765 VCE procedures were included with 355 (46.5%) male subjects and a median age of 63.2 (SD 15.3) years. One hundred ninety studies (24.8%) were positive (P2) for small bowel bleeding. Four variables associated with positive VCE which were incorporated into a point scoring system: (+) 1 for age ≥ 66 years, active smoking and cardiac arrythmia and (-) 1 for preceding hemoglobin level ≥ 8.5. The risk probabilities for positive VCE-assigned scores - 1, 0, 1, and 2 + were 12.3% (95% CI 7.3-17.3%), 20% (14.9-25.1%), 34.8% (28.6-41%), and 39% (30-47.8%).

CONCLUSION

In order to improve the diagnostic yield of capsule examinations, risk factors should be applied to clinical decision-making. We created a risk score for positive VCE in IDA, including the risk factors of age, smoking, history of cardiac arrythmia, and preceding hemoglobin level.

Diagnosis and management of small-bowel bleeding

Small-bowel (SB) bleeding is a challenging problem for the clinician, presenting many pitfalls in both diagnosis and subsequent treatment. Videocapsule endoscopy (VCE) and device-assisted enteroscopy (DAE) have revolutionized the approach to the patient with SB bleeding, allowing for the endoscopic diagnosis and management of what was previously only a surgical matter. The patients' assessment in SB bleeding is of foremost importance, as treatment success relies on a detailed evaluation of clinical history, suspicion for underlying lesions, and a careful selection and timing of diagnostic and therapeutic tools. This review will summarize current state-of-the-art evidence and practice points, to provide the clinician with a comprehensive guide towards the management of SB bleeding.

Small bowel capsule endoscopy in obscure gastrointestinal bleeding: A matched cohort comparison of patients with normal vs surgically altered gastric anatomy

BACKGROUND

Little is known about small bowel capsule endoscopy (SBCE) outcomes in patients with surgically altered anatomy.

AIMS

To assess the feasibility and diagnostic yield of orally ingested SBCE to investigate obscure gastrointestinal bleeding (OGIB) in patients with surgically altered gastric anatomy, compared to native gastric anatomy.

METHODS

207 patients with OGIB were selected from an open, multicenter, retrospective cohort (SAGA study) and match-paired according to age, gender and bleeding type (overt/occult) to 207 control patients from a randomized controlled trial (PREPINTEST). Primary outcomes were the diagnostic yield (P1 or P2 findings), completion rate, adverse events rate, and small bowel transit time (SBTT).

RESULTS

The diagnostic yield was not statistically different between groups (44.9% in SAGA vs 42.5% in control patients). Inflammatory/ulcerated lesions were significantly more frequent in patients with SAGA (43.0% vs 29.3%). The median SBTT was significantly longer in the SAGA group than in control patients (283 vs 206 minutes), with a significantly lower completion rate (82.6% vs 89.9%); Adverse events were scarce (0.5% vs 0.0%).

CONCLUSION

Patients with surgically altered gastric anatomy should benefit from SBCE investigation for OGIB as much as non-operated patients.

Impact of Early Video Capsule Endoscopy on Hospitalization and Post-hospitalization Outcomes: A Propensity Score-Matching Analysis

INTRODUCTION

Video capsule endoscopy (VCE) has become the accepted evaluation of choice for patients with suspected small bowel bleeding. Our aim was to evaluate the impact of early as compared to delayed inpatient VCE on post-index hospitalization readmission rates.

METHODS

We performed a retrospective study using medical claims from the IBM® Marketscan® Commercial Database from January 1, 2004, through September 30, 2018, including adult patients that underwent an inpatient VCE. Early VCE was defined as occurring on days 0, 1, or 2 of the index hospitalizations, whereas delayed VCE was performed on days 3-7. Propensity matching was performed to create an analytic cohort, and outcomes were assessed using logistic regression.

RESULTS

Following propensity score matching, 607 patients undergoing early VCE were matched 1:1 with 607 patients undergoing delayed VCE. The median patient age was 65 (IQR: 56-78) years, and 560 (37.9%) of the included patients were female. The mean time to VCE was 1.6 (± 0.6) days for the early VCE group and 4.0 (± 1.2) days from admission for delayed VCE. In unadjusted comparisons, we found no significant difference between early VCE and delayed VCE with respect to 90-day all-cause readmission (18.6% vs. 17.0%, P = 0.5) or 90-day rebleeding risk (10.5% vs. 8.7%, P = 0.331). Patients undergoing an early VCE had a shorter hospital LOS and less total hospitalization charges.

CONCLUSION

Early as compared to delayed inpatient VCE was associated with a reduction in index hospitalization resource utilization. No differences were found with respect to reductions in readmissions or rebleeding events.

Diagnostic yield of small bowel capsule endoscopy in obscure gastrointestinal bleeding: a real-world prospective study

Small bowel capsule endoscopy (SBCE) visualizes the small bowel (SB) mucosa. Gastrointestinal (GI) bleeding from SB accounts for the majority of SBCE indications. We aimed to assess, in a "real-world" prospective study, the diagnostic yield of SBCE in a cohort of consecutive patients with obscure gastrointestinal bleeding (OGIB). Secondary end point was to assess the frequency of adverse events and the role of SBCE in determining the diagnostic work-up and clinical outcome. From 2016 to 2018, all patients referred for SBCE examination were enrolled. Indication for SBCE was re-assessed by 2 dedicated gastroenterologists. Inclusion criteria: (1) age ≥ 18 and ≤ 85 years; (2) diagnosis of OGIB; 3) non-diagnostic standard bidirectional endoscopy; (4) informed consent. Exclusion criteria: (1) deglutition impairment; (2) SBCE contraindications; (3) pregnancy. The cohort included 50 patients [males 18 (36%), age 68 (27-83)]. SBCE indication: patients with ongoing overt OGIB (Group A) (n = 11; 22%), previous overt OGIB (Group B) (n = 14; 28%), occult bleeding (with Iron Deficiency Anaemia) (Group C) (n = 25; 50%). SBCE detected clinically relevant lesions in 46 (92%) cases. Clinically relevant lesions were more frequent in Group C (24/25; 96%), followed by Group A (10/11; 91%) and Group B (12/14; 85.5%). After SBCE, treatment was medical (60%); endoscopic (14%), surgical (36%) or conservative (18%). Clinical follow-up showed complete resolution in 63.2%, partial/absent resolution in 18.4% of cases. In a prospective study, the high diagnostic yield of SBCE supports its role as first-line investigation in patients with OGIB. However, this achievement requires an accurate and timely assessment by dedicated gastroenterologists.

Video Capsule Endoscopy and Device-Assisted Enteroscopy

Mark Hanscom Courtney Stead Harris Feldman Neil B. Marya David Cave.

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn's disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.

Scoring systems in clinical small-bowel capsule endoscopy: all you need to know!

Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.

Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.

Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

Role of Video Capsule Endoscopy as a Prelude to Deep Enteroscopy

Video capsule endoscopy and device-assisted enteroscopy are complementary technologies. Capsule endoscopy is a highly acceptable technology with high diagnostic yield that can guide a subsequent enteroscopy approach. This article aims to focus on the role of video capsule endoscopy as a prelude to deep enteroscopy with a focus on the strengths and limitations of either approach.

Timing and Use of Capsule Endoscopy in the Acute Care Setting

Video capsule endoscopy (VCE) is a crucial adjunct to conventional endoscopy in small intestinal bleeding, with a high positive and negative predictive value. Timing is critical in VCE, with earlier deployment associated with improved diagnostic yield. VCE is also useful as a first-line diagnostic modality in the evaluation of acute gastrointestinal bleeding, with accumulating evidence demonstrating expedited VCE can increase diagnostic yield, reduce unneeded admissions, and overall improve patient care. In resource-limited settings, first-line VCE also can reduce unneeded procedures and protect staff from dangerous exposures.

The Use of Capsule Endoscopy For Diagnosis of Iron Deficiency Anemia: A Retrospective Analysis

BACKGROUND

There was some ambiguity in the recent guidelines on the use of capsule endoscopy (CE) in cases of iron deficiency anemia (IDA).

GOAL

We aimed to examine the yield of CE in diagnosing the cause of IDA and to define clinical parameters that predict higher diagnostic yields.

MATERIALS AND METHODS

A total of 1351 individuals underwent CE in Winnipeg between 2005 and 2016. All studies were reported by 1 reading physician. Data included demographics and requested information on medication use, prior imaging studies, and hemoglobin and ferritin levels. In a total of 620 (46%) patients, CE was indicated for occult gastrointestinal bleeding or IDA. Positive findings on CE were separated into "definite" and "possible." Multinomial regression analysis was used to determine the variables correlated with definite CE findings. A survey analysis was then used to assess how the study results impacted further management.

RESULTS

With regard to the 620 patients, the mean age was 62.9 years, mean hemoglobin level was 89 g/L, and median ferritin level was 9 μg/L. A total of 210 (33.9%) patients had positive findings (definite: 23%, possible: 10.8%). Vascular ectasias were the majority of definite findings (47.5%). Predictors of definite findings were age (relative risk ratio: 1.04; 95% confidence interval: 1.02-1.06) and male sex (relative risk ratio: 1.88; 95% confidence interval: 1.25-2.83). An overall 12.7% of positive studies required therapeutic intervention, with 65.8% undergoing further workup.

CONCLUSION

We report a 33.9% positive yield, with 65.8% of patients undergoing further workup as a result of CE and 12.7% requiring therapeutic intervention. We conclude that CE plays an important role in the investigation of IDA and occult gastrointestinal bleeding and has important implications on further management.

Emergent Double Balloon Enteroscopy in Overt Suspected Small Bowel Bleeding: Diagnosis and Therapy

Background

Double balloon enteroscopy (DBE) is a diagnosis and therapy method for suspected small bowel bleeding (SSBB). The data for emergent DBE is limited in overt SSBB cases. The aim of this study was to investigate the role of diagnosis and therapy of emergent DBE in patients with overt SSBB.

Material/Methods

The clinical and endoscopic data for patients with overt SSBB undergoing DBE in a single center from January 2010 to December 2017 were collected and analyzed. Emergent DBE was defined as DBE performed less than 3 days of last bleeding onset.

Results

A total of 265 DBEs in 265 patients with overt SSBB were enrolled (mean age, 44.7±17.3 years; 66.8% males). The patients were divided into 3 groups according to the timing of DBE: less than 3 days (n=32), more than 3 days and less than 7 days (n=146), and more than 7 days (n=87) (first group was the emergent group, the latter 2 groups were the non-emergent groups). The diagnosis yield for the emergent group was significantly higher than the non-emergent groups (84.4% versus 65.1% or 59.8%, respectively, P<0.05), but was not different between the 2 non-emergent groups (P>0.05). The top 3 diagnoses were angioectasias (19.6%), diverticulum (16.2%), and tumor (12.1%). For therapy yield, there was a remarkable reducing trend in the emergent group (<3 days), and the 2 non-emergent groups (3 to 7 days group and >7 days group: 78.1%, 58.2% and 39.1%, respectively, P<0.05. The top 3 endoscopic treatments were hemostatic clips (21.9%), argon plasma coagulation (15.8%), and epinephrine injection (14.0%).

Conclusions

The emergent DBE had the highest yields for diagnosis and therapy. The study finding showed a pivotal role of emergent DBE in overt SSBB.

A case of small bowel adenocarcinoma that caused intestinal obstruction after administration of patency capsule

An 80-year-old man was admitted to our hospital with iron deficiency anemia and exertional chest pain. Coronary artery angiography showed 90% stenosis in the middle left anterior descending branch; abdominal computed tomography (CT) showed enlarged mesenteric lymph nodes. Although his past medical history and results of imaging studies did not suggest intestinal stenosis, assessment of intestinal patency with the PillCam® patency capsule (tag-less PC) was performed. Thirty-three hours after administration, excretion of tag-less PC was not confirmed; an abdominal contrast-enhanced CT showed arrest of tag-less PC in the small bowel and thickening of the bowel wall, suggesting a small bowel tumor. Four days after administration of tag-less PC, he developed abdominal pain and vomiting. Intestinal obstruction was diagnosed by abdominal radiograph. A diagnosis of small bowel tumor with intestinal obstruction was made, and surgical resection was performed. The tumor was histologically an adenocarcinoma. It is necessary to carefully evaluate gastrointestinal patency before small intestine endoscopy especially in elderly people with reduced cardiopulmonary function and many underlying diseases.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.

Capsule endoscopy for small-intestinal disorders: Current status

Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. In this review article, we focus on the current status of SBCE. Several platforms for SBCE are available worldwide. Third-generation SBCE (PillCam^® SB3) has a high-resolution camera equipped with an adaptive frame rate system. Several software modes have been developed to reduce the reading time for capsule endoscopy and to minimize the possibility of missing lesions. The main complication of SBCE is capsule retention. Thus, the main contraindication for SBCE is known or suspected gastrointestinal obstruction unless intestinal patency is proven. Possible indications for SBCE are obscure gastrointestinal bleeding, Crohn's disease, small-intestinal polyps and tumors, and celiac disease. Colon capsule endoscopy (CCE) can observe inflamed colonic mucosa non-invasively, and allows for the continuous and non-invasive observation of the entire intestinal tract (pan-endoscopy). Recently, application of CCE as pan-enteric endoscopy for inflammatory bowel diseases (including Crohn's disease) has been reported. In the near future, reading for CE will be assisted by artificial intelligence, and reading CE videos for long periods will not be required.

History of malignancy and relevant symptoms may predict a positive computed tomography enterography in obscure gastrointestinal bleeds

BACKGROUND AND AIM

This study aimed to assess the clinical utility of computed tomography enterography (CTE) and identify factors associated with a diagnostic CTE for patients with obscure gastrointestinal bleeding (OGIB).

METHODS

A retrospective observational study was performed at a Canadian tertiary care center from 2005 to 2015. A total of 138 patients underwent a CTE for OGIB. Univariate and multivariate logistic regressions were performed to determine factors associated with a diagnostic CTE. A highly sensitive clinical rule was then developed to help identify OGIB patients for whom a CTE may be beneficial in their clinical work-up.

RESULTS

A possible bleeding source was identified in 30 (22%) cases. The presence of abdominal or constitutional symptoms as well as history of colorectal cancer was significantly associated with a positive CTE in univariate and multivariate analyses (P < 0.05). A positive CTE could be predicted based on the presence of abdominal or constitutional symptoms and history of colorectal cancer with 90% sensitivity (95% CI 74-98%) in our population.

CONCLUSION

CTE identified a possible source of OGIB in one in five cases. In patients with the presence of abdominal or constitutional symptoms and a personal history of colorectal cancer, CTE may contribute to their diagnostic work-up.

The Clinician's Guide to Suspected Small Bowel Bleeding

Small bowel bleeding accounts for 5-10% of gastrointestinal bleeding. With the advent of capsule endoscopy, device-assisted enteroscopy, and multiphase CT scanning, a small bowel source can now be found in many instances of what has previously been described as obscure gastrointestinal bleeding. We present a practical review on the evaluation and management of small bowel bleeding for the practicing clinician.

Risk factors for small bowel bleeding in an overt gastrointestinal bleeding presentation after negative upper and lower endoscopy

INTRODUCTION

A small bowel source is suspected when evaluation of overt gastrointestinal (GI) bleeding with upper and lower endoscopy is negative. Video capsule endoscopy (VCE) is the recommended next diagnostic test for small bowel bleeding sources. However, clinical or endoscopic predictive factors for small bowel bleeding in the setting of an overt bleeding presentation are unknown. We aimed to define predictive factors for positive VCE among individuals presenting with overt bleeding and a suspected small bowel source.

METHODS

We included consecutive inpatient VCE performed between September 1, 2012 to September 1, 2015 for melena or hematochezia at two tertiary centers. All patients had EGD and colonoscopy performed prior to VCE. Patient demographics, medication use, and endoscopic findings were retrospectively recorded. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. The secondary outcome of interest was the performance of a therapeutic intervention. Data were analyzed with the Fisher exact test for dichotomous variables and logistic regression.

RESULTS

Two hundred forty-three VCE were reviewed, and 117 were included in the final analysis. A positive VCE (P2) was identified in 35 (29.9%) cases. In univariate analysis, a positive VCE was inversely associated with presence of diverticula on preceding colonoscopy (OR: 0.44, 95% CI: 0.2-0.99), while identification of blood on terminal ileal examination was associated with a positive VCE (OR: 5.18, 95% CI: 1.51-17.76). In multivariate analysis, only blood identified on terminal ileal examination remained a significant risk factor for positive VCE (OR: 6.13, 95% CI: 1.57-23.81). Blood on terminal ileal examination was also predictive of therapeutic intervention in both univariate (OR: 4.46, 95% CI: 1.3-15.2) and multivariate analysis (OR: 5.04, 95% CI: 1.25-20.32).

CONCLUSION

Among patients presenting with overt bleeding but negative upper and lower endoscopy, the presence of blood on examination of the terminal ileum is strongly associated with a small bowel bleeding source as well as with small bowel therapeutic intervention. Presence of diverticula on colonoscopy is inversely associated with a positive VCE and therapeutic intervention in univariate analysis.

Antithrombotic Treatment Is Associated with Small-Bowel Video Capsule Endoscopy Positive Findings in Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

INTRODUCTION

The impact of antithrombotic treatment on the findings of small-bowel capsule endoscopy for patients with obscure gastrointestinal bleeding remains contentious. We aimed to determine the effect of these agents on small-bowel video capsule endoscopy positive findings.

METHODS

MEDLINE, Cochrane Library, and Google Scholar were searched for studies reporting on patients receiving concurrent antithrombotic treatment, while undergoing capsule endoscopy for obscure gastrointestinal bleeding (OGIB). Outcomes were the effect of antithrombotic therapy-overall and per type of antithrombotic agent-on the examination's positive findings and re-bleeding risk. The effect size of study outcomes is presented as odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Fourteen studies with 1023 patients were included. We detected significant heterogeneity with no evidence of publication bias. Compared to antithrombotic drug nonusers, antithrombotic treatment was associated with an increased prevalence of positive findings [OR 1.98 (95% CI 1.34-2.93); P = 0.0006]. This effect did not differ between antiplatelet and anticoagulant treatments [OR 2.22 (95% CI 1.28-3.84); P = 0.005 and 2.53 (95% CI 1.66-3.87); P < 0.0001, respectively]. Antithrombotic use over no use was not associated either with overt [OR 1.17 (95% CI 0.51-2.66); P = 0.71] or with occult [OR 0.86 (95% CI 0.38-1.95); P = 0.71] bleeding pattern. However, concurrent antithrombotic treatment was associated with higher odds for re-bleeding compared to no treatment [OR 2.53 (95% CI 1.46-4.37); P = 0.0009].

CONCLUSIONS

Antithrombotic treatment is associated with more positive findings in small-bowel video capsule endoscopy in OGIB as well as higher odds of re-bleeding.

Diagnostic and therapeutic yields of urgent balloon-assisted enteroscopy in overt obscure gastrointestinal bleeding

BACKGROUND AND AIMS

Balloon-assisted enteroscopy (BAE) is one of the diagnostic and therapeutic procedures in the algorithm for the evaluation of overt obscure gastrointestinal bleeding (OGIB). There is currently no consensus regarding the role of urgent BAE in overt OGIB. The aims of this study were to compare the diagnostic and therapeutic yields of urgent and nonurgent BAE in patients with overt OGIB.

PATIENTS AND METHODS

We conducted a retrospective, single-center study that included patients who underwent BAE for overt OGIB between January 2010 and December 2017. Urgent BAE was defined as an enteroscopy performed within 72 h of clinical presentation. Demographic, clinical, laboratory, and technical data were reviewed and the diagnostic and therapeutic yields evaluated and compared.

RESULTS

Seventy BAEs were performed in 57 patients with overt OGIB [29 (50.9%) females, mean age: 68.0±11.1 years]. The diagnostic yield of urgent BAE was significantly higher than nonurgent BAE (84.5 vs. 50.0%, P<0.01). The most common diagnosis were angiodysplasias (30%), tumors (15.7%), erosions/ulcers (4.3%), and diverticula (4.3%). Endoscopic therapy was more frequently performed in urgent BAE patients (57.7 vs. 31.8%, P=0.03). The most commonly used endoscopic therapies were argon plasma coagulation (30.0%), hemostatic clips (5.7%), epinephrine injection (5.7%), and polypectomy (2.9%). In terms of urgent BAE, the diagnostic yield was similar when enteroscopy was performed at less than or equal to 24, 48, or 72 h (P>0.05), but the therapeutic yield was higher the earlier the enteroscopy was performed (100, 76.9, and 57.7% at ≤24, ≤48, and ≤72 h respectively; P=0.03).

CONCLUSION

The diagnostic and therapeutic impact of BAE was higher in an urgent setting. These data support an important role for urgent BAE in overt OGIB.

Gastroduodenal lesions detected during small bowel capsule endoscopy: incidence, diagnostic and therapeutic impact

BACKGROUND

Capsule endoscopy was primarily designed for the investigation of the small bowel. However, it may also identify lesions in other segments of the gastrointestinal tract. The aim of the current study was to evaluate the incidence of gastroduodenal abnormalities during small bowel capsule endoscopy and its impact on patient diagnosis and management.

PATIENTS AND METHODS

This study is a retrospective analysis of data from 2,217 consecutive capsule endoscopy procedures performed at a single tertiary-care center between January 2008 and February 2016. Patient baseline characteristics, gastroduodenal lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was performed.

RESULTS

Two thousands and two hundred seventeen patients were finally included in the analysis. One thousand and seventy patients were male (48.2%) and the mean age was 56.1 ± 19.5 years (range: 12-93). Obscure gastrointestinal bleeding (52.3%) and inflammatory bowel disease (18.3%) were the main procedure indications. Gastroduodenal abnormalities were detected by capsule endoscopy in 696 (31.4%) of 2,217 patients. The most common types of missed gastric and duodenal lesions found were gastric erosions (35.4%), findings suggestive of chronic gastritis (22.9%), duodenal erosions (28.1%) and duodenal erythema (23.5%). This information had a clinical or diagnostic impact of 26.2% and a therapeutic impact of 15.5%.

CONCLUSION

Capsule endoscopy detects not only small bowel lesions but also some gastroduodenal lesions that may be overlooked during an initial gastroscopy. Therefore, all gastroduodenal images should be read during small bowel capsule endoscopy as it may provide relevant information that result in changes in patient management.

The etiology of potential small-bowel bleeding depending on patient's age and gender

Background

Whether the etiology of potential small-bowel bleeding depends on the age and gender of the patient is not yet fully understood.

Methods

A total of 1953 patients who underwent video capsule endoscopy (VCE) to evaluate potential small-bowel bleeding and were registered in the Capsule Endoscopy Nationwide Database Registry from 2003 to 2014 were eligible for this study. VCE findings and the etiology of small-bowel bleeding were analyzed by age and gender.

Results

The diagnostic yield of VCE was 48.4% (95% CI: 46.2%-50.6%) and the diagnosis rate of etiology of potential small-bowel bleeding was 61.4% (95% CI: 59.2%-63.6%). The etiology of potential small-bowel bleeding depends on the age and gender of the patient. Crohn's disease and small-bowel diverticular diseases were more prevalent etiology of potential small-bowel bleeding in the young adults group (< 40 years) whereas angiodysplasia was revealed to be a most common etiology in elderly group (≥ 60 years), reaching statistical significance (p<0.00152) by Bonferroni correction.

Conclusions

The etiology of potential small-bowel bleeding depends on the age of the patient. Thus, an individualized lesion-specific diagnostic approach based on age might be needed for patients with potential small-bowel bleeding.

Earlier use of capsule endoscopy in inpatients with melena or severe iron deficiency anemia reduces need for colonoscopy and shortens hospital stay

Background and study aims  Capsule endoscopy(CE) is a well-established investigation for iron deficiency anemia (IDA) and melena, usually following negative upper and lower endoscopy. We aimed to study the effect of earlier CE in the investigative pathway for inpatients with IDA or melena at a large tertiary referral centre. Patients and methods  We analyzed inpatients undergoing CE for IDA or melena from 2005 to 2017, without signs/symptoms suggesting lower gastrointestinal tract pathology. Patients underwent CE following negative upper and lower gastrointestinal endoscopy (Group 1), or negative upper gastrointestinal endoscopy (UGIE) only (Group 2). Results  One hundred and seventy inpatients underwent CE for IDA (n = 44) and melena (n = 126). In Group 1, 46/95 (48.4%) patients had small bowel (SB) findings. CE found 16/95 (16.8 %) gastric and 12/95 (12.6 %) colon findings. Three of 12 patients with colon findings required repeat colonoscopy. One hundred and three colon investigations were carried out for 95 admissions. In Group 2, 33/75 (44.0%) patients had SB findings. There were 12/75 (16.0 %) gastric and 11/75 (14.7 %) colon findings. In patients with positive CE, significant colonic findings led to colonoscopy in 10 of 39 patients (diagnostic yield 6/10). Thirty-six patients had negative CE; 15 underwent colonoscopy (diagnostic yield 9/15). The remaining 21 of 36 patients with no further colonoscopy did not develop adverse outcomes related to colonic pathology. Twenty-six colon investigations were carried out in 75 admissions. Patients in Group 2 had shorter mean times from admission to CE (5.08 ± 3.80 vs. 6.38 ± 3.80 days; P  = 0.02) and hospital stays (10.5 ± 9.58 vs. 12.5 ± 11.4 days; P  = 0.04) compared to Group 1. Conclusion  Earlier use of CE in inpatients with melena or IDA, no signs of lower gastrointestinal pathology and negative UGIE resulted in shortened hospital stays, significant DY from both small bowel and upper gastrointestinal tract, and two-thirds less unnecessary colon investigations without affecting clinical outcomes.

Current Status of Interpretation of Small Bowel Capsule Endoscopy

Capsule endoscopy (CE) has revolutionized direct small bowel imaging and is widely used in clinical practice. Remote visualization of bowel images enables painless, well-tolerated endoscopic examinations. Small bowel CE has a high diagnostic yield and the ability to examine the entire small bowel. The diagnostic yield of CE relies on lesion detection and interpretation. In this review, issues related to lesion detection and interpretation of CE have been addressed, and the current status of automated reading software development has been reviewed. Clinical significance of an external real-time image viewer has also been described.

Small bowel bleeding: cause and the role of endoscopy and medical therapy

PURPOSE OF REVIEW

The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias.

SUMMARY

SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.

Colonic lesions in patients undergoing small bowel capsule endoscopy: incidence, diagnostic and therapeutic impact

BACKGROUND

Nowadays, capsule endoscopy is the first-line procedure to assess the small bowel. During small bowel procedures, other segments of the gastrointestinal tract may be visualized. The aim of the current study was to evaluate the incidence of colonic abnormalities in patients undergoing small bowel capsule and its impact on patient management.

PATIENTS AND METHODS

This study is a retrospective analysis of data from 526 consecutive capsule endoscopy procedures performed at a single tertiary-care centre between 2008 and 2011. Patients with incomplete procedures were excluded from the analysis. Patient baseline characteristics, colonic lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was performed.

RESULTS

Four hundred and sixty four patients were finally included in the analysis. Two hundred and ninety three patients were male (57.3%) and the mean age was 61.3 ± 20.03 years (18-86). Obscure gastrointestinal bleeding (59%) and inflammatory bowel disease (19%) were the main indications for the procedure. Colonic abnormalities were detected by capsule endoscopy in 47 (9%) of 464 patients. The most common types of missed lesions were vascular lesions (34%) and colonic ulcers (32%). This information had a clinical or diagnostic impact of 7.55% and a therapeutic impact of 6.03%.

CONCLUSION

All images of the colon should be evaluated during small bowel capsule endoscopy as they may provide relevant information that may result in changes in patient management.

Impact of the timing of capsule endoscopy in overt obscure gastrointestinal bleeding on yield and rebleeding rate - is sooner than 14 d advisable?

AIM

To evaluate the impact of the timing of capsule endoscopy (CE) in overt-obscure gastrointestinal bleeding (OGIB).

METHODS

Retrospective, single-center study, including patients submitted to CE in the setting of overt-OGIB between January 2005 and August 2017. Patients were divided into 3 groups according to the timing of CE (≤ 48 h; 48 h-14 d; ≥ 14 d). The diagnostic and therapeutic yield (DY and TY), the rebleeding rate and the time to rebleed were calculated and compared between groups. The outcomes of patients in whom CE was performed before (≤ 48 h) and after 48 h (> 48 h), and before (< 14 d) and after 14 d (≥ 14 d), were also compared.

RESULTS

One hundred and fifteen patients underwent CE for overt-OGIB. The DY was 80%, TY-46.1% and rebleeding rate - 32.2%. At 1 year 17.8% of the patients had rebled. 33.9% of the patients performed CE in the first 48 h, 30.4% between 48h-14d and 35.7% after 14 d. The DY was similar between the 3 groups (P = 0.37). In the ≤ 48 h group, the TY was the highest (66.7% vs 40% vs 31.7%, P = 0.005) and the rebleeding rate was the lowest (15.4% vs 34.3% vs 46.3% P = 0.007). The time to rebleed was longer in the ≤ 48 h group when compared to the > 48 h groups (P = 0.03).

CONCLUSION

Performing CE within 48 h from overt-OGIB is associated to a higher TY and a lower rebleeding rate and longer time to rebleed.

Suspected Blood Indicator to Identify Active Gastrointestinal Bleeding: A Prospective Validation

Background

The suspected blood indicator (SBI) function in the RAPID Reader v8.3 program was designed to quickly identify the presence of blood in video capsule endoscopy. While previous retrospective studies have shown that the SBI function was accurate in detecting the presence of active bleeding in the small bowel, its specificity and sensitivity were poor.

Methods

An initial retrospective review (phase 1) compared 115 patients with active gastrointestinal bleeding seen on video capsule endoscopy (VCE) to 115 patients with no active bleeding seen on VCE to produce a highly accurate algorithm. A prospective study (phase 2) was then performed by applying the algorithm to 100 consecutive patients who received VCE for the following indications: obscure bleeding, iron deficiency anemia, melena, and hematochezia.

Results

The initial retrospective review found that eight contiguous SBI markers had a specificity of 100% in identifying active gastrointestinal bleeding regardless of the total number of SBI markers, while two or more contiguous SBI markers had a sensitivity of 96.5%. Using a cutoff of eight contiguous SBI markers, the prospective arm found that there was a 100% sensitivity and specificity in detecting active gastrointestinal bleeding (P < 0.001).

Conclusions

The SBI function can greatly facilitate the identification of active gastrointestinal bleeding on VCE by using eight contiguous SBI markers as a cutoff for active bleeding.

Does discontinuation of antithrombotics affect the diagnostic yield of small bowel capsule endoscopy in patients demonstrating obscure gastrointestinal bleeding?

A large proportion of patients demonstrating obscure gastrointestinal bleeding (OGIB) are antithrombotic users and need to undergo small bowel capsule endoscopy (SBCE). We examined the effect of discontinuation of antithrombotics on the diagnostic yield of SBCE. Additionally, we assessed predictive factors associated with positive SBCE findings. Our study included 130 patients using antithrombotics who underwent SBCE for overt OGIB. The primary endpoint was the difference in the rate of positive SBCE findings between patients who continued and those who discontinued antithrombotics. Secondary endpoints were to investigate the effect of discontinuation of antithrombotics using a propensity score analysis, and to assess predictive factors associated with a positive SBCE. Among the 73 patients who continued use of antithrombotics, 36 (49.3%) patients demonstrated positive findings, while among the 57 patients who discontinued antithrombotics, 35 (61.4%) patients showed positive findings. Rates of positive SBCE findings didn't differ between the two groups. After we performed propensity score matching, discontinuation didn't affect the rate of positive SBCE findings. The lowest hemoglobin level was the only independent predictive factor associated with positive SBCE findings. In conclusion, discontinuation of antithrombotic therapy didn't affect the diagnostic yield of SBCE in patients presenting with overt OGIB.

Laparoscopic Resection of a Jejunal Inflammatory Fibroid Polyp that Caused Occult Gastrointestinal Bleeding, Diagnosed via Capsule Endoscopy and Double-Balloon Enteroscopy: A Case Report

An inflammatory fibroid polyp (IFP) is a mesenchymal tumor of the gastrointestinal tract. IFPs in the small intestine are the most frequently detected with symptoms, such as abdominal pain and tarry stool due to intussusception. Accordingly, few studies have reported jejunal IFP as a cause of occult gastrointestinal bleeding (OGIB) diagnosed via both of capsule endoscopy (CE) and double-balloon enteroscopy (DBE). A 68-year-old woman presented with a progression of anemia and a positive fecal occult blood test result. Esophagogastroduodenoscopy and total colonoscopy findings were unremarkable. CE revealed a tumor with bleeding in the jejunum. DBE also revealed a jejunal polypoid tumor. Bleeding from the tumor seemed to have caused anemia. The patient underwent partial laparoscopic resection of the jejunum, including resection of the tumor. The tumor was histopathologically diagnosed as IFP. To our knowledge, this is the first reported case of laparoscopic resection of jejunal IFP with OGIB diagnosed via CE and DBE preoperatively.

ORBIT score: an useful predictor of small bowel rebleeding in patients under chronic anticoagulation

BACKGROUND AND STUDY AIMS

Available scoring systems to assess the risk for major bleeding in patients on chronic anticoagulation seem inadequate in predicting higher diagnostic yields of small bowel capsule endoscopy (SBCE) or higher rebleeding rates in patients with suspected small bowel bleeding. The aim of this study was to evaluate the ability of the new ORBIT score in predicting positive findings of SBCE or higher rebleeding rates in chronically anticoagulated patients with suspected small bowel bleeding.

PATIENTS AND METHODS

Retrospective analysis of 570 patients who consecutively underwent SBCE for the study of suspected small bowel bleeding. For each of the 67 patients who were on chronic anticoagulation, ORBIT score (Older age, Reduced hemoglobin/hematocrit, Bleeding history, Insufficient kidney function and Treatment with antiplatelets) was calculated. Patients were classified as high-risk (ORBIT score ≥4) or low/intermediate-risk (ORBIT score <4). Data on SBCE findings, diagnostic yield and rebleeding were compared between groups.

RESULTS

When ORBIT score was calculated, 41 and 26 patients were classified as low/intermediate-risk and high-risk, respectively. When low/intermediate-risk and high-risk groups were compared, no differences were found in the diagnostic yield of SBCE (39.0% vs. 23.1%; p = .176). However, in high-risk patients, rebleeding was significantly more common than in low/intermediate-risk patients (80.0% vs. 36.6%; p = .003).

CONCLUSIONS

In patients presenting with suspected small bowel bleeding and on chronic anticoagulation, the new ORBIT score seems promising in identifying those with a higher risk of rebleeding, in whom a closer follow-up and a more aggressive diagnostic and therapeutic strategy is advisable.

Fecal calprotectin and C-reactive protein are associated with positive findings in capsule endoscopy in suspected small bowel Crohn's disease

BACKGROUND AND AIM

Capsule endoscopy is an extended tool for the diagnosis of small bowel Crohn's disease. However, factors associated with positive findings of this technique have not been well established. Our aim is to asses which factors are associated with a better diagnostic yield of capsule endoscopy in suspected small bowel Crohn's disease.

MATERIAL AND METHODS

This was a retrospective study including patients under capsule endoscopy because of suspected small bowel Crohn's disease. Demographic data of these patients, as well as symptoms and laboratory data including hemoglobin levels, count of leucocytes and platelets, and levels of C-reactive protein, erythrocyte sedimentation rate and fecal calprotectin were collected. Capsule endoscopy studies were classified as negative (no lesions) or positive (lesions suggestive of Crohn's disease). Descriptive, univariate and multivariate analysis were done, as well as diagnostic yield tests of the different markers for predicting lesions in capsule studies.

RESULTS

One hundred and twenty-four patients were included (85 women and 39 men). The average age was 38.21 years. Levels of C-reactive protein and fecal calprotectin were the markers more frequently associated with positive findings in capsule endoscopy. Calprotectin presented the best sensitivity as isolated marker. The association of altered levels of C-reactive protein and calprotectin showed the best specificity and predictive values.

CONCLUSIONS

C-reactive protein and fecal calprotectin are appropriate biomarkers for selecting patients with suspected Crohn's disease of the small bowel for capsule endoscopy studies.

Clinical factors associated with positive capsule endoscopy findings in patients with obscure gastrointestinal bleeding: a single-center study

BACKGROUND

Capsule endoscopy (CE) is a useful tool for patients with obscure gastrointestinal bleeding (OGIB), but positive finding rate differs among trials, which may be attributable to the difference in patients' background.

OBJECTIVES

To evaluate the predictive factors associated with positive findings on CE.

METHODS

Consecutive patients with OGIB who underwent CE between March 2004 and May 2015 at a single university hospital were enrolled. Patients' clinical factors and CE data were reviewed retrospectively, and we evaluated the relationship between clinical factors and positive findings by univariate and multivariate logistic regression analyses.

RESULTS

Five hundred and seventy-eight patients were included in the analysis. Positive CE findings were obtained in 284 patients (49.1%). In multivariate analysis, low hemoglobin level (odds ratio (OR), 1.142 per 1 g/dL decrease; p < .001), Charlson comorbidity index (CCI) score (OR, 1.170 per 1 point increase; p = .002), and non-steroidal anti-inflammatory drug (NSAID) use (OR, 1.640; p = .044) were associated with an increased prevalence of positive findings. As for components of CCI, malignant tumor (OR, 1.839; p = .017) was associated with the positive findings.

CONCLUSIONS

OGIB patient with a low-hemoglobin level, complex and severe comorbidities, and NSAID use should receive CE.

Clinical Practice Guideline for Enteroscopy

Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.

Predictors and characteristics of angioectasias in patients with obscure gastrointestinal bleeding identified by video capsule endoscopy

Background

In obscure gastrointestinal bleeding, angioectasias are common findings in video capsule endoscopy (VCE).

Objective

The objective of this study was to identify predictors and characteristics of small bowel angioectasias.

Methods

Video capsule examinations between 1 July 2001 and 31 July 2011 were retrospectively reviewed. Patients with obscure gastrointestinal bleeding were identified, and those with small bowel angioectasia were compared with patients without a definite bleeding source. Univariate and multivariable statistical analyses for possible predictors of small bowel angioectasia were performed.

Results

From a total of 717 video capsule examinations, 512 patients with obscure gastrointestinal bleeding were identified. Positive findings were reported in 350 patients (68.4%) and angioectasias were documented in 153 of these patients (43.7%). These angioectasias were mostly located in the proximal small intestine (n = 86, 56.6%). Patients' age >65 years (odds ratio (OR) 2.15, 95% confidence interval (CI) 1.36-3.38, p = .001) and overt bleeding type (OR 1.89, 95% CI 1.22-2.94, p = .004) were identified as significant independent predictors of small bowel angioectasia.

Conclusion

Angioectasias are the most common finding in VCE in patients with obscure gastrointestinal bleeding. They are mostly located in the proximal small bowel and are associated with higher age and an overt bleeding type.

Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding

AIM

To define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.

METHODS

Small-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.

RESULTS

We retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 ± 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P < 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P < 0.001). Age and small-bowel transit time were correlated (P < 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).

CONCLUSION

In this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.

Video Capsule Endoscopy: Technology, Reading, and Troubleshooting

Video capsule endoscopy (VCE) has completed the endoscopic visualization of the entire luminal gastrointestinal tract. VCE can be performed in inpatients and outpatients, requires appropriate bowel preparation before the study, and can be administered via oral swallowing or endoscopic device placement into the small bowel based on outlined patient-dependent factors. Current commercially available VCE systems were reviewed and compared for individual features and attributes. This article focuses on preparation for VCE, currently available VCE technology, how to read a VCE study, and risks and contraindications to VCE.

Detection of suspected small bowel bleeding: challenges and controversies

Detection of small bowel (SB) bleeding remains a challenge to gastroenterologists, with a dearth of standardized recommendations regarding evaluation and management. Areas covered: A recursive literature search was performed using PubMed, Cochrane and Medline databases for original and review articles on SB and obscure gastrointestinal bleeding (OGIB). Based upon the available literature, this review outlines the main challenges and controversies, and provides a practical and cost-effective approach towards SB bleeding. Expert commentary: SB bleeding is suspected in patients with persistent or recurrent bleeding after negative bidirectional endoscopy, and unexplained iron deficiency anemia. Selection of test(s) should be individualized based upon patient presentation and suspicion for type of underlying lesion. Endoscopic or radiologic evaluation and treatment is the mainstay in the majority of patients, while pharmacologic agents may have a role in patients with refractory bleeding, and those unable to undergo evaluation.

Small Bowel Endoscopy

OPINION STATEMENT

The small bowel is a challenging area for endoscopic evaluation and therapy due to its length and angulated configuration. A small lumen diameter and segmental peristalsis made it a perfect fit for examination by a novel ingestible wireless camera in a capsule. The development of capsule endoscopy changed the diagnosis and management of bleeding lesions, ulcers, and tumors deep in the small bowel, allowing earlier diagnosis with excellent patient acceptance. Device-assisted enteroscopy revolutionized small bowel therapy, particularly management of bleeding, Peutz-Jeghers polyposis, and tumor marking for minimally invasive surgery. Small bowel stricture dilation in select patients is safe and effective. Tools for a spectrum of small bowel therapies are available but remain suboptimal to tackle lesions on angulated folds deep in the small bowel. Universal terminology to describe the endoscopic appearance of vascular lesions will facilitate studies of endoscopic and medical therapy. The future holds improvements in imaging, easier advancement through the small bowel, and therapeutic capacity. This review focuses on methods of small bowel endoscopy, therapy, and outcomes.

Comparison of Risk Factors Between Small Intestinal Ulcerative and Vascular Lesions in Occult Versus Overt Obscure Gastrointestinal Bleeding

BACKGROUND AND AIMS

The detailed risk factors such as bleeding pattern, comorbidities, and medication usage of patients with obscure gastrointestinal bleeding (OGIB) are largely unknown. We evaluated the risk factors related to ulcerative and vascular lesions of the small intestine diagnosed by capsule endoscopy or balloon-assisted endoscopy in OGIB cases.

METHODS

We retrospectively evaluated 390 OGIB cases (occult, n = 101; overt, n = 289) in our hospital between January 2005 and March 2011 using univariate and multivariate logistic regression analyses to determine the related risk factors.

RESULTS

In occult (n = 36) and overt (n = 120) OGIB cases, some lesions were detected in the small intestine. Ulcerative and vascular lesions were detected in both occult (n = 25, 69.4 %; n = 8, 22.2 %, respectively) and overt (n = 57, 47.5 %; n = 39, 32.5 %, respectively) cases. For ulcerative lesions, non-steroidal anti-inflammatory drugs were identified as a risk factor in overt cases [odds ratio (OR) 2.974, 95 % confidence interval (CI) 1.522-5.809, P = 0.001]. For vascular lesions, lowest hemoglobin level (OR 0.634, 95 % CI 0.422-0.953, P = 0.028) and hematologic disease (OR 8.575, 95 % CI 1.076-68.309, P = 0.042) were identified as risk factors in occult cases, whereas hemodialysis (OR 3.71, 95 % CI 1.315-10.467, P = 0.013) was identified in overt cases. Additionally, liver cirrhosis was noted as a risk factor in both occult (OR 7.453, 95 % CI 1.213-45.773, P = 0.013) and overt (OR 4.900, 95 % CI 2.099-11.443, P < 0.001) OGIB cases.

CONCLUSION

There are differences in risk factors related to ulcerative versus vascular lesions in the small intestine in occult and overt OGIB cases. Differences were seen in both medication usage and comorbidities.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

Obscure gastrointestinal bleeding: diagnosis and treatment

Small-bowel bleeding comprises a majority of obscure gastrointestinal bleeding, but is caused by various kinds of diseases. For its diagnosis, history-taking and physical examination is requisite, leading to a suspicion of what diseases are involved. Next, cross-sectional imaging such as computed tomography should be done, followed by the latest enteroscopy, videocapsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient conditions. After comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected.

Current status of capsule endoscopy through a whole digestive tract

More than a decade has passed since small-bowel capsule endoscopy (CE) was first reported. Small-bowel CE is a non-invasive tool that allows visualization of the entire small-intestinal mucosa and facilitates detection of small-intestinal abnormalities. Several studies have shown benefit of small-bowel CE for certain disorders. Because it is non-invasive, CE has been applied to other organs including the esophagus, stomach, and colon. The main indications for esophageal CE (ECE) are screening for gastroesophageal reflux disease/Barrett's esophagus, and esophageal varices. However, the clinical benefit of ECE is unconfirmed. Magnetically guided CE (MGCE) was developed to visualize the gastric mucosa. MGCE is a new concept with room for improvement of capsule navigation and the preparation protocol. Recently, two new small-bowel CE tools were released. First-generation colon CE (CCE-1) has moderate sensitivity and specificity compared with colonoscopy for colorectal neoplasia surveillance. To obtain higher accuracy, a second-generation CCE (CCE-2) was developed with a high sensitivity for detecting clinically relevant polypoid lesions. A possible application of CCE is for inflammatory bowel disease. In the near future, CE may include diagnostic and therapeutic functions such as magnifying endoscopy systems, targeted biopsy forceps, and drug delivery systems.