Diagnostic yield of small-bowel capsule endoscopy in patients with iron-deficiency anemia: a systematic review

The Diagnostic Yield of Video Capsule Endoscopy for Uncomplicated Asymptomatic Iron Deficiency Anemia With Negative Bidirectional Endoscopy in a Large Military Gastroenterology Program

BACKGROUND

 Iron-deficiency anemia (IDA) often results from gastrointestinal (GI) bleeding. Video capsule endoscopy (VCE) is increasingly used to investigate suspected small bowel bleeding, particularly when bidirectional endoscopy is nondiagnostic. However, the diagnostic yield of VCE in asymptomatic patients with IDA and negative bidirectional endoscopy is not well-established, leading to variability in clinical guidelines.

METHODS

We conducted a retrospective review of patients at Brooke Army Medical Center who underwent VCE from January 2019 to April 2023 following negative bidirectional endoscopy for IDA, defined as ferritin <45 ng/mL. We analyzed demographic data, VCE findings, and outcomes, including need for further intervention, persistence of IDA, and hospitalizations. We also assessed the impact of referral delays on outcomes.

RESULTS

Out of 238 patients, 75 met the inclusion criteria. VCE revealed abnormal findings in 36% of cases, with 8% having actionable findings necessitating repeat endoscopy. The most common abnormality was small bowel angiodysplasias. No small bowel malignancies were detected. Patients aged over 65 had a higher rate of abnormal findings and actionable lesions. Delays in subspecialty evaluation (>180 days) did not significantly affect patient outcomes.

CONCLUSION

In asymptomatic IDA patients with negative bidirectional endoscopy, VCE demonstrates a 36% diagnostic yield, primarily identifying small bowel angiodysplasias, with limited impact on detecting malignancies. This study highlights the importance of individualizing VCE use to each patient, and suggests that delays in referral do not adversely affect outcomes. Further prospective studies are needed to refine diagnostic guidelines and enhance cost-effectiveness.

Diagnostic Yield of Small Bowel Videocapsule Endoscopy in Patients with Iron Deficiency Anemia. A Systematic Review and meta-analysis

BACKGROUND AND AIM

Gastrointestinal (GI) bleeding or malabsorption represents the most frequent aetiologies of iron deficiency anemia (IDA). The cause of IDA remains undetermined in ~10% to 20% of patients undergoing upper and lower GI endoscopies. In this scenario, a small bowel examination with videocapsule endoscopy (VCE) is recommended. We performed a systematic review with meta-analysis to evaluate the diagnostic yield of VCE in patients with IDA without overt bleeding, assessing the prevalence of either any lesion or lesions at high potential of bleeding.

MATERIALS AND METHODS

A computerized literature search was performed using relevant keywords to identify all the pertinent articles published until March 2023.

RESULTS

Twelve studies with a total of 1703 IDA patients (Males: 47%; age range: 19-92 y) were included in this systematic review. The diagnostic yield of VCE for overall lesions in the small bowel was 61% (95% CI=44-77; 95 CI=97.2-98.1; I2 =97.7%). When analyzing only small bowel lesions likely responsible of IDA, the diagnostic yield was 40% (95% CI=27-53; 95% CI=95.3-97; I2 =96.3%).

CONCLUSION

VCE plays a relevant role in the diagnostic work-up of patients with IDA without overt bleeding with a satisfactory diagnostic yield.

Clinical and demographic features of patients undergoing video-capsule endoscopy management: A descriptive study

BACKGROUND

Video-capsule endoscopy (VCE) is an efficient tool that has proven to be highly useful in approaching several gastrointestinal diseases. VCE was implemented in Colombia in 2003, however current characterization of patients undergoing VCE in Colombia is limited, and mainly comes from two investigations conducted before the SARS-CoV-2 pandemic period.

AIM

To describe the characteristics of patients undergoing VCEs and establish the main indications, findings, technical limitations, and other outstanding features.

METHODS

A descriptive study was carried out using data from reports of VCE (PillCam SB3 system) use in a Gastroenterology Unit in Bogotá, Colombia between September 2019 and January 2023. Demographic and clinical variables such as indication for the VCE, gastric and small bowel transit times (GTT, SBTT), endoscopic preparation quality, and limitations were described [n (%), median (IQR)].

RESULTS

A total of 133 VCE reports were analyzed. Most were in men with a median age of 70 years. The majority had good preparation (96.2%), and there were technical limitations in 15.8% of cases. The main indications were unexplained anemia (91%) or occult bleeding (23.3%). The median GTT and SBTT were 14 and 30 minutes, respectively. The frequencies of bleeding stigma (3.79%) and active bleeding (9.09%) were low, and the most frequent abnormal findings were red spots (28.3%), erosions (17.6%), and vascular ectasias (12.5%).

CONCLUSION

VCE showed high-level safety. The main indication was unexplained anemia. Active bleeding was the most frequent finding. Combined with artificial intelligence, VCE can improve diagnostic precision and targeted therapeutic interventions.

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.

Small bowel lesions in patients with iron deficiency anaemia without overt bleeding: a multicentre study

The diagnostic work-up in iron deficiency anaemia (IDA) patients can be challenging when bleedings or malabsorption are not clinically manifest. Lesions on the small bowel mucosa may cause IDA. We evaluated the prevalence of lesions on the small bowel mucosa detected at Videocapsule Endoscopy (VCE) in IDA patients following negative upper and lower endoscopies. Clinical and endoscopic data collected in 5 centres were retrieved. Lesions with a high bleeding potential (P2) were computed, and predictive factors investigated at multivariate analysis. By considering data of 230 patients, the endoscopic examination detected a total of 96 (41.7%; 95% CI: 35.4-48.1) P2 lesions on the small bowel mucosa, including 4 (1.7%) cancers. The use of non-steroidal anti-inflammatory drugs was found to be the only associated factor at both univariate (OR: 5.7, 95% CI: 2.4-13.4; P <0.001) and multivariate (OR: 2.8; 95% CI: 1.7-3.9, P <0.01) analyses. Present study showed that evaluation of small bowel mucosa with VCE allows to disclose a potential cause of IDA in near half patients. The cooperation between haematologists and gastroenterologists in the diagnostic work-up may be useful.

Small Bowel Capsule Endoscopy and Enteroscopy: A Shoulder-to-Shoulder Race

Traditional methods have their limitations when it comes to unraveling the mysteries of the small bowel, an area historically seen as the "black box" of the gastrointestinal tract. This is where capsule endoscopy and enteroscopy have stepped in, offering a remarkable synergy that transcends the sum of their individual capabilities. From their introduction, small bowel capsule endoscopy and device-assisted enteroscopy have consistently evolved and improved, both on their own and interdependently. Each technique's history may be told as a success story, and their interaction has revolutionized the approach to the small bowel. Both have advantages that could be ideally combined into a perfect technique: safe, non-invasive, and capable of examining the entire small bowel, taking biopsies, and applying therapeutical interventions. Until the realization of this perfect tool becomes a reality, the key for an optimal approach lies in the right selection of exploration method. In this article, we embark on a journey through the intertwined development of capsule endoscopy and enteroscopy, exploring the origins, technological advancements, clinical applications, and evolving inquiries that have continually reshaped the landscape of small bowel imaging.

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.

Application of validated bleeding risk scores for atrial fibrillation in obscure gastrointestinal bleeding patients increases videocapsule endoscopy's diagnostic yield: a retrospective monocentric study

BACKGROUND

Videocapsule endoscopy (VCE) is considered the gold standard for overt and obscure gastrointestinal bleeding (OGIB), after negative upper and lower endoscopy. Nonetheless, VCE's diagnostic yield is suboptimal, and it represents a costly, time-consuming, and often not easily available technique. In order to evaluate bleeding risk in patients with atrial fibrillation, several scoring systems have been proposed, but their utilization outside the original clinical setting has rarely been explored. The aim of the study is to evaluate potential role of bleeding risk scoring systems in predicting the occurrence of positive findings at VCE examination, and therefore in increasing VCE diagnostic yield.

METHODS

Data from consecutive patients undergoing VCE between April 2015 and June 2020 were retrospectively retrieved, and clinical and demographic characteristics were collected. HAS-BLED, ATRIA, and ORBIT scores were calculated, and patients were considered at low or high risk of bleeding accordingly. Discriminative ability of the scores for positive VCE findings has been evaluated by area under receiver operator characteristic curve (AUC) calculation. Diagnostic yield of scores in high- and low-risk patients was calculated.

RESULTS

A total of 413 patients underwent VCE examination, among which 368 (89%) for OGIB. Positive findings were observed in 246 patients (67%), with angiodysplasias being the most frequent lesion (92%). The three scores displayed similar consistent discriminative ability for positive VCE findings (mean AUC = 0.69), and identified high-risk group of patients in which VCE has a higher diagnostic yield.

CONCLUSIONS

In the present retrospective study, bleeding scores accurately discriminated patients with higher probability of positive findings at VCE examination. Bleeding scores utilization may help in the management of patients with OGIB, with a potential consistent resource optimization and cost-saving.

AdvanCE, a capsule endoscope delivery device, is effective in investigating a waterfall stomach

AdvanCE is a useful device in patients who cannot swallow capsule endoscopes, or when these remain in the patient's stomach without passing into the duodenum. A net or snare may be used to guide the capsule endoscope into the duodenum when the capsule endoscope becomes stuck in the stomach, but it may be difficult to guide the capsule into the duodenum in some cases, particularly in those of waterfall stomach. In such cases, AdvanCE is found to be an effective guidance tool.

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.

Capsule endoscopy - a non-invasive modality to investigate the GI tract: out with the old and in with the new?

INTRODUCTION

Capsule endoscopy has had significant development since it was introduced into the field of medicine in 2000. It is non-invasive, well tolerated, does not require sedation and is a first-line small bowel investigative modality. As it transits through the entire gastrointestinal (GI) tract, it has the potential to provide a pan-enteric examination.

AREAS COVERED

In this review we will discuss the new diagnostic modalities along with traditional methods which have been used for examination of the gastro intestinal (GI) tract. The main focus of this review will be on the use of capsule endoscopy for pan-enteric examination.

EXPERT OPINION

Capsule endoscopy is an accepted first-line investigation for the small bowel. Diagnostic sensitivity of the colon capsule is comparable to colonoscopy in controlled trials and is being evaluated in high-risk patients in routine clinical practice in national programs. Preliminary data suggest that a magnetic-controlled examination of the upper GI tract could be developed to enable a complete upper GI examination.

Video capsule endoscopy in patients with iron deficiency anaemia: experience at a regional Australian service

OBJECTIVE

The objective of this study was to identify the diagnostic performance of video capsule endoscopy (VCE) among patients presenting with iron deficiency anaemia (IDA) and negative bidirectional endoscopy to a gasteroendoscopy practice in regional Australia. The secondary objectives were to identify the distribution of findings and factors predictive of positive findings in a regional setting.

RESULTS

In total 123 procedures were included in the study. Mean age of the patients was 67.9 years. Females made up 60.2% (n = 74) of the study population. Mean haemoglobin and ferritin levels were 93.3 g/L and 11.9 ug/L, respectively. Positive findings were present in 67 procedures (54.5%) with the most frequent finding being small bowel angiodysplasia (53.7%, n = 36/67), followed by ulceration/significant erosion (26.8%, n = 18/67), fresh blood (20.8%, n = 14/67) and tumour/polyp (16.4%, n = 11/67). Haemoglobin level was the only variable associated with positive findings (p = 0.005) in the study population. Of the procedures reporting positive findings outside the small bowel, the majority (80%) were within reach of conventional upper endoscopy and may have implications for future practice, particularly when allocating health resources in a rural setting.

Small bowel lymphoma: clinical update and challenges for the gastroenterologist

PURPOSE OF REVIEW

The diagnosis of small bowel lymphoma (SBL) can be challenging, as they are very rare and also have a varied presentation. In this review, we aim to provide a broad overview of the types of SBL and also about the various modalities used for their diagnosis. We also discuss the overview of treatment strategies for a gastroenterologist.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) and devise-assisted enteroscopy (DAE) has revolutionized the way we investigate the small bowel. DAE also makes it possible to obtain histological samples for further characterization of SBL. This has led to a significant improvement in diagnosis and management of the disease in conjunction with cross-sectional imagining.

SUMMARY

The diagnosis and management of small bowel lymphoma remains challenging despite the development of newer techniques such as SBCE and DAE. The current available diagnostic modalities have limitations; in the absence of a gold standard, the current investigative modalities compliment each other in reaching the final diagnosis.

Deep Learning for Automatic Identification and Characterization of the Bleeding Potential of Enteric Protruding Lesions in Capsule Endoscopy

Background and Aims

Capsule endoscopy (CE) revolutionized the study of the small intestine, overcoming the limitations of conventional endoscopy. Nevertheless, reviewing CE images is time-consuming. Convolutional Neural Networks (CNNs) are an artificial intelligence architecture with high performance levels for image analysis. Protruding lesions of the small intestine exhibit enormous morphologic diversity in CE images. We aimed to develop a CNN-based algorithm for automatic detection of varied small-bowel protruding lesions.

Methods

A CNN was developed using a pool of CE images containing protruding lesions or normal mucosa/other findings. A total of 2565 patients were included. These images were inserted into a CNN model with transfer learning. We evaluated the performance of the network by calculating its sensitivity, specificity, accuracy, positive predictive value, and negative predictive value.

Results

A CNN was developed based on a total of 21,320 CE images. Training and validation data sets comprising 80% and 20% of the total pool of images, respectively, were constructed for development and testing of the network. The algorithm automatically detected small-bowel protruding lesions with an accuracy of 97.1%. Our CNN had a sensitivity, specificity, positive, and negative predictive values of 95.9%, 97.1%, 83.0%, and 95.7%, respectively. The CNN operated at a rate of approximately 355 frames per second.

Conclusion

We developed an accurate CNN for automatic detection of enteric protruding lesions with a wide range of morphologies. The development of these tools may enhance the diagnostic efficiency of CE.

Effectiveness of Capsule Endoscopy and Double-Balloon Enteroscopy in Suspected Complicated Celiac Disease

BACKGROUND & AIMS

Complicated celiac disease (CCD) is a rare but severe condition with a poor prognosis. Guidelines recommend use of capsule endoscopy (CE) to explore the small bowel (SB), followed by a double-balloon enteroscopy (DBE) in selected cases with suspected CCD. Our study aimed to evaluate the diagnostic yield (DY) of CE and DBE in identifying and monitoring CCD.

METHODS

Consecutive suspected CCD patients were enrolled prospectively to undergo CE and/or DBE in the presence of: persistent symptoms despite a correct gluten-free diet (GFD), increased anti-transglutaminase antibodies titer, lack of adherence to the GFD, and CCD monitoring. The DY of CE and DBE were calculated. The incidence of neoplastic complications and mortality were assessed.

RESULTS

In total, 130 patients (97 women; age, 49 ± 16 y) underwent 151 CEs and 23 DBEs. The DY of CE was 46%. Patients older than age 50 years (at CE examination or at CD diagnosis) with a CD duration shorter than 5 years were at higher risk of positive CE (relative risk, 1.6 and 1.7 in case of enrollement or CD diagnosis after 50 years of age, and 1.5 in case of short CD duration; P < .05) than their counterparts. Up to 40% of SB lesions were unreachable by upper endoscopy. At the end of the diagnostic work-up, 25 patients with premalignant/malignant lesions were identified: 12 type 1 refractory CD (RCD-1), 7 type 2 RCD (RCD-2), and 6 enteropathy-associated T-cell lymphoma (EATL). Six patients died: 2 patients with RCD-2 and 4 patients with EATL.

CONCLUSIONS

In case of suspected CCD, CE should be the first-line approach to detect complications and to identify patients deserving DBE. Older and symptomatic patients with suspected CCD deserve a careful evaluation of the SB, especially during the first years after diagnosis.

Faecal calprotectin increases the diagnostic yield in patients with suspected small bowel disease - a multicenter retrospective cohort study

AIM OF THE STUDY

Diagnosing small bowel pathology is challenging, and the diagnostic yield of small bowel capsule endoscopy is highly variable. Faecal calprotectin is a non-invasive intestinal inflammation marker that could be used as a selection tool to identify patients who might benefit from small bowel capsule endoscopy and increase its diagnostic yield. This study aimed to investigate the value of faecal calprotectin in detecting small bowel lesions in an unselected patient population.

METHODS

We performed a retrospective analysis of consecutive patients who underwent small bowel capsule endoscopy at the University Hospital Basel and the University Medical Clinic Cantonal Hospital Baselland, Switzerland, between 2010 and 2018. Patients without faecal calprotectin testing were excluded from the analysis. The primary endpoint was the presence of a clinically significant small bowel finding.

RESULTS

Patients with positive faecal calprotectin results were more likely to have small bowel findings (66.7% vs 39.4%; P = 0.007). The optimal faecal calprotectin cut-off to identify clinically significant small bowel lesions was 63 μg/g with 78.3% (95% confidence interval: 66.7-87.9) sensitivity, 47.9% (33.3-62.8) specificity, 1.50 (1.1-2.0) positive and 0.45 (0.3-0.8) negative likelihood ratios, 68.4% (61.6-74.4) positive and 60.5% (47.3-72.4) negative predictive values, and 65.0% overall accuracy. Faecal calprotectin performed best in patients with suspected inflammatory bowel disease, with 66.7% (48.2-82.0) sensitivity, 70.6% (44.0-89.7) specificity, 2.27 (1.0-4.9) positive and 0.47 (0.3-0.8) negative likelihood ratios, 81.5% (67.0-90.5) positive and 54.5% (39.7-68.6) negative predictive values, and 71.4% overall accuracy.

CONCLUSION

Faecal calprotectin testing increases the diagnostic yield of small bowel capsule endoscopy and may help identify patients at risk of small bowel disease.

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.

Assessment of the Role of a Second Evaluation of Capsule Endoscopy Recordings to Improve Diagnostic Yield and Patient Management

INTRODUCTION

The diagnostic yield (DY) of small-bowel capsule endoscopy (SBCE) varies considerably according to its indication. Some strategies have been used to increase DY with varying results. The intention of this study was to identify whether evaluation of the SBCE recordings by a second reviewer can increase DY and change patient management.

METHODS

One hundred SBCEs with different indications, already read by an endoscopist were read by a second blinded endoscopist. When the results of the 2 readings were different, the images were discussed by the endoscopists; if no consensus was reached, they took the opinion of a third endoscopist into account. All the participating endoscopists had experience in reading SBCEs (i.e., >50 per year). The SBCE findings were divided into positive (vascular lesions, ulcers, and tumors), equivocal (erosions or red spots), and negative. The interobserver agreement and the increase in DY were assessed as well as the percentage of false-negatives (FNs) in the first evaluation.

RESULTS

The indications for SBCE were small-bowel bleeding (SBB) in 48 cases, Crohn's disease (CD) in 30, and other causes (iron-deficiency anemia, small-bowel tumors, and diarrhea) in 22. There was substantial interobserver agreement between evaluations (κ = 0.79). The findings in the first evaluation were positive in 60%, equivocal in 20% and, negative in 20%. In the second evaluation, 66% were positive, 18% were equivocal, and 16% were negative. The increase in DY with the second reading was 6% (p = 0.380), i.e., 6.3% for SBB, 4.4% for CD and 9.2% for other indications, resulting in a change in management of 4% of the patients. FNs in the first SBCE reading were found in 4% of the SBCEs.

DISCUSSION

A second evaluation of the SBCE recordings identified significant pathology that the first evaluation had missed, resulting in a nonsignificant 6% increase in DY and a change in the management of 4% of the patients.

Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia

Small bowel malignancies are rare and usually asymptomatic or symptoms are nonspecific. Therefore, small bowel tumors are difficult to diagnose. In patients with iron deficiency anemia (IDA) who have negative bidirectional endoscopy results, the small bowel may be considered the source of bleeding. However, in asymptomatic IDA patients with negative bidirectional endoscopy results, evidence supporting the routine use of capsule endoscopy (CE) is insufficient. CE can be considered in selected patients with recurrent or persistent IDA. The frequency of small bowel malignancies is low in patients undergoing CE for IDA, but the usefulness of CE for the diagnosis of small bowel malignancies in younger age groups with IDA has been reported. For patients with risk factors for small bowel malignancy, investigation of the small bowel should be considered. Efforts should be made to prevent adverse events, such as capsule retention or capsule aspiration, through meticulous history taking and endoscopic capsule delivery as necessary.

Colon Capsule Endoscopy in the Assessment of Mucosal Healing in Crohn's Disease

BACKGROUND

Patients with Crohn's disease (CD) undergo frequent endoscopic procedures, with visualization of the gastrointestinal mucosa central to treatment decision-making. Subsequently, a noninvasive alternative to optical colonoscopy (OC) would be welcomed. One such technology is capsule endoscopy, including the PillCam COLON 2 (PCC2), though research validating its use in ileocolonic CD is limited. This study aims to compare PCC2 with ileocolonoscopy (OC) in assessing mucosal CD through use of a standardized scoring system.

METHODS

At an Australian tertiary hospital, same-day PCC2 and ileocolonoscopy results of 47 CD patients, with known nonstricturing disease, were prospectively collected and analyzed for correlation and agreement. Deidentified recordings were reported by a single expert gastroenterologist. Mucosal disease was quantified using the Simple Endoscopic Score for Crohn's Disease (SES-CD). The SES-CD results of paired endoscopic modalities were compared in total per bowel segment and per SES-CD variable.

RESULTS

Of 47 PCC2 recordings, 68% were complete, fully assessing terminal ileum to rectum, and OC was complete in 89%. Correlation (r) between total SES-CD scores was strongest in the terminal ileum (r = 0.77, P < .001), with the SES-CD variable of "ulcer detection" showing the strongest agreement. The PCC2 (vs OC) identified additional ulcers in the terminal ileum; ascending, transverse, and descending colon; and rectum; scores were 5 (1), 5 (3), 1 (1), 2 (1), and 2 (2), respectively.

CONCLUSIONS

The PCC2 shows promise in assessing ileocolonic mucosa, especially in proximal bowel segments, with greater reach of visualization in the small bowel. Given the resource and safety considerations raised by the Coronavirus disease 2019 pandemic, capsule endoscopy has particular significance.This article aims to contribute to the limited body of research surrounding the validity of capsule endoscopy technology in assessing ileocolonic mucosa in Crohn's Disease patients. In doing so, an alternative option for patients enduring frequent endoscopies is given potential.

British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA-for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease- with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.

Small bowel adenocarcinoma: Case reports and review of the literature

Small bowel adenocarcinomas (SBAs) are rare tumors of the gastrointestinal tract. Patients often present with advanced disease due to nonspecific symptoms and delayed diagnoses. In combination with non-uniform treatment paradigms, patients who present with SBA often have poor prognoses. In this case series, we present four cases of SBA and review the most recent literature with regard to diagnosis and management. One patient presented with iron-deficient anemia (IDA), and three patients presented with clinical obstruction. The patient with IDA was subjected to protracted investigations, whereas the three patients with obstruction were diagnosed quickly after presentation. All four patients underwent surgical resection, and one patient was eligible for post-operative adjuvant chemotherapy. SBA should be highly suspected in patients who present with occult gastrointestinal bleeds, and appropriate investigations must be initiated. Following diagnosis, surgical resection is the mainstay of treatment for this disease. Our review supports the use of both neoadjuvant and adjuvant chemotherapy in localized disease.

Magnetically Controlled Capsule Endoscopy Versus Conventional Gastroscopy: A Systematic Review and Meta-Analysis

BACKGROUND

The introduction of magnetically controlled capsule endoscopy overcame the restriction of passive capsule endoscopy movement, thus allowing an improved visualization of the gastrointestinal lumen, where other imaging studies seem to be unhelpful. The aim of this study is to systematically review the performance of magnetically controlled capsule endoscopy and evaluate its potential as a less invasive diagnostic method in the detection of gastric lesions.

METHODS

A systematic search was performed in PubMed (Medline), EMBASE, Google Scholar, Scopus, Who Global Health Library (GHL), Virtual Health Library (VHL), Clinicaltrials.gov, Cochrane Library, and ISI Web of Science databases. Proportion meta-analyses were performed to estimate the pooled sensitivity of magnetically controlled capsuled endoscopy in the detection of gastrointestinal lesions.

RESULTS

Among the 3026 studies that were initially assessed, 7 studies were finally included, with a total of 916 patients and 745 gastric lesions. The mean capsule endoscopy examination time was 21.92±8.87 minutes. The pooled overall sensitivity of magnetically controlled capsule endoscopy was 87% [95% confidence interval (CI), 84%-89%]. Subgroup analysis showed that the sensitivity of identifying gastric ulcers was 82% (95% CI: 71%-89%), gastric polyps was 82% (95% CI: 76%-87%), and gastric erosions was 95% (95% CI: 86%-98%). In general, magnetically controlled capsule endoscopy was well tolerated by the participants with minimal adverse events.

CONCLUSION

The magnetically controlled capsule endoscopy demonstrated an acceptable sensitivity of identifying gastric lesions. Further prospective comparative studies are needed to identify the risks and benefits of this new technique, as well as to determine its role as a replacement for conventional gastroscopy.

Indications, Contraindications, and Considerations for Video Capsule Endoscopy

Video capsule endoscopy is indicated in a broad range of clinical settings, most commonly in evaluating suspected small bowel bleeding. It is also useful in diagnosing Crohn's disease and monitoring patients with known Crohn's. Video capsule endoscopy has a role in evaluating patients with refractory celiac disease symptoms and in surveying patients with polyposis syndromes. The only absolute contraindication to video capsule endoscopy is luminal gastrointestinal tract obstruction. Despite manufacturer statement, video capsule endoscopy can be used safely in patients with implantable cardiac devices including pacemakers, defibrillators, and ventricular assist devices.

Role of Video Capsule in Small Bowel Bleeding

Video capsule endoscopy has an essential role in the diagnosis and management of small bowel bleeding and is the first-line study recommended for this purpose. This article reviews the risk factors for small bowel bleeding, optimal timing for video capsule endoscopy testing, and algorithms recommended for evaluation. Used primarily for the assessment of nonacute gastrointestinal blood loss, video capsule endoscopy has an emerging role for more urgent use in emergency settings and in special populations. Future software incorporation of neural networks to enhance lesion detection will likely result in an augmented role of video capsule endoscopy in small bowel bleeding.

Training, Reading, and Reporting for Small Bowel Video Capsule Endoscopy

Video capsule endoscopy (VCE) is an established modality for examining the small bowel. Formal training in interpretation and reporting of VCE examinations, along with assessment of performance metrics, is advocated for all gastroenterology fellowship programs. This review provides an overview of VCE minimum training requirements and competency assessment, cognitive and technical aspects of interpretation, and standardized reporting of findings. In order to optimize and advance the clinical utility of VCE, efforts must continue to promote and encourage consensus and standardization of training, definition and assessment of competence, enhancements of VCE reading tools, and use of appropriate nomenclature in VCE reports.

Effectiveness of Improved Use of Chewing Gum During Capsule Endoscopy in Decreasing Gastric Transit Time: A Prospective Randomized Controlled Study

Background/Aim: Chewing gum throughout small bowel capsule endoscopy (SBCE) increases completion rates (CRs) but decreases small bowel transit time (SBTT) and diagnostic yield (DY). We determined the effects of chewing gum early during SBCE on gastric transit time (GTT), SBTT, CR, DY, and gastroscopy intervention. Methods: We prospectively enrolled patients (ages 16-80 years) undergoing SBCE between January and June 2019. Patients were randomized to a chewing gum group (103 patients) and a control group (102 patients). Patients in the former group chewed one piece of gum for ~15 min every 30 min during the first hour of SBCE. Two gastroenterologists blinded to the study group examined the data. Results: GTT was shorter in the chewing gum group (19.0 min, interquartile range: 17.0-52.0 min) than in the control group [42.5 min (23.25-60 min); P = 0.01]. SBTT was similar in the two groups [318.5 min (239.5-421.3 min) vs. 287.0 min (216.0-386.0 min); P = 0.08]. Gastroscopy rate was lower in the chewing gum group (15.53 vs. 32.35%, P = 0.005). CR (95.15 vs. 89.22%, P = 0.114) and DY (66.02 vs. 59.80%, P = 0.359) did not differ between the groups. The number of abnormal-lesion types detected per patient was higher in the chewing gum group [1.0 (0.0-2.0) vs. 2.0 (0.0-2.0); P = 0.049]. Conclusions: Chewing gum early during SBCE significantly reduced GTT and gastroscopy intervention, with no influence on SBTT (Trial number: NCT03815136).

Positive Fecal Occult Blood Test is a Predictive Factor for Gastrointestinal Bleeding after Capsule Endoscopy in Patients with Unexplained Iron Deficiency Anemia: A Korean Multicenter CAPENTRY Study

BACKGROUND/AIMS

Capsule endoscopy (CE) is recommended as the primary method for the evaluation of unexplained anemia. This study aimed to assess the diagnostic yield of CE in patients with unexplained iron deficiency anemia (IDA) without overt bleeding, and to evaluate their long-term outcomes and related clinical factors.

METHODS

Data of patients who underwent CE for the evaluation of IDA were reviewed from a CE registry in Korea. Additional clinical data were collected by the involved investigators of each hospital through a review of medical records.

RESULTS

Among a total of 144 patients, the diagnostic yield of CE was 34%. Gastrointestinal (GI) bleeding was found in 6.3% (n=9) of the patients (occult bleeding in four patients and overt bleeding in five patients) during a mean follow-up of 17.8 months. Patients with a positive fecal occult blood test (FOBT) result at the initial diagnosis had a higher rate of GI bleeding after CE (p=0.004). In addition, a positive FOBT result was the only independent predictive factor for GI bleeding (hazard ratio, 5.30; 95% confidence interval, 1.41-19.85; p=0.013).

CONCLUSION

Positive FOBT is a predictive factor for GI bleeding during follow-up after CE in patients with unexplained IDA without overt bleeding. Thus, patients with positive FOBT need to be more closely followed up.

Clinical utility of the small bowel capsule endoscopy in the study of small bowel diseases in Colombia: Results of a national registry

INTRODUCTION

The small bowel capsule endoscopy (SBCE) has revolutionised the study of small bowel diseases. The objective of this study is to determine the indications, findings and diagnostic yield of SBCE in a national registry.

PATIENTS AND METHODS

An observational, analytical cross-sectional study was carried out, analysing the SBCE records at seven centres in the country, where different variables were collected.

RESULTS

1,883 SBCEs were evaluated. The average age was 55.4 years (5.6-94.2). The most frequent indications were suspicion of small bowel bleeding (SBB) (64.4%), study of Crohn's disease (15.2%) and chronic diarrhoea (11.2%). 54.3% were prepared with laxatives. The most frequent lesions found were erosions/ulcers (31.6%), angioectasias (25.7%) and parasitosis (2.7%). The diagnostic yield (P1+P2, Saurin classification) of SBCE in SBB was 60.6%, being higher in overt SBB (66.0%) compared to occult SBB (56.0%) (P=.003). The studies with better preparation showed higher detection of lesions (93.8% vs. 89.4%) (OR=1.8, CI: 95%: 1.2-2.6; P=.004). The SBCE complication rate was 3.1%, with complete SB visualisation at 96.6% and SB retention rate of 0.7%. 81.5% of SBCEs were performed on an outpatient basis, and presented a greater complete SB visualisation than hospital ones (97.1% vs. 94.3%) (OR=2.1, CI: 95%, 1.2-3.5; P=.008).

CONCLUSIONS

The indications, findings and diagnostic performance of SBCEs in Colombia are similar to those reported in the literature, with a high percentage of complete studies and a low rate of complications.

Clinical Impact of Small Bowel Capsule Endoscopy in Obscure Gastrointestinal Bleeding

Background and objectives: The most frequent indications for small bowel capsule endoscopy (SBCE) are obscure gastrointestinal bleeding (OGIB) and iron deficiency anemia (IDA). The aim of this study was to evaluate the diagnostic yield (DY) of SBCE in overt and occult OGIB, as well as its impact on the clinical outcome. Materials and Methods: This study retrospectively included all cases of OGIB investigated by SBCE in a tertiary care referral center, between 1st January 2016 and 31st December 2018. OGIB was defined by overt or occult gastrointestinal bleeding, with negative upper and lower endoscopy. Occult gastrointestinal bleeding was either proved by a fecal test or presumptively incriminated as a cause for IDA. DY was defined as the detection rate for what were thought to be clinically significant findings. DYs for overt and occult bleeding were assessed and compared. Gender, age, hemoglobin levels, NSAID consumption and the use of anticoagulants were recorded. Following SBCE results, individual therapeutic decisions were made, and follow-up data were recorded. Results: 224 SBCE examinations were performed for OGIB, of which 148 were for overt OGIB, and 76 for unexplained IDA. Positive findings were found in 139 patients, resulting in an overall DY for OGIB of 62%, higher in overt OGIB (75%) compared to IDA (37%). The most frequent findings were small bowel angioectasias (62.2% in overt OGIB and 78.5% in IDA). On multivariate logistic regression analysis, only hemoglobin level <10 g/dL and anticoagulants were the variables independently associated with positive findings. All patients received medical, endoscopic or surgical treatment and had good clinical outcome during follow-up. Conclusion: SBCE has a high diagnostic yield and a positive impact on management of patients with OGIB.

Changes in performance of small bowel capsule endoscopy based on nationwide data from a Korean Capsule Endoscopy Registry

BACKGROUND/AIMS

Capsule endoscopy (CE) is widely used for the diagnosis of small bowel diseases. The clinical performance and complications of small bowel CE, including completion rate, capsule retention rate, and indications, have been previously described in Korea. This study aimed at estimating the recent changes in clinical performance and complications of small bowel CE based on 17-year data from a Korean Capsule Endoscopy Registry.

METHODS

CE registry data from 35 hospitals were retrospectively analyzed. Clinical information, including completion rate, capsule retention rate, and indications, was collected and analyzed. In addition, the most recent 5-year data for CE examinations were compared with the previous 12-year data.

RESULTS

A total of 4,650 CE examinations were analyzed. The most common indication for CE was obscure gastrointestinal bleeding (OGIB). The overall incomplete examination rate was 16% and the capsule retention rate was 3%. Crohn's disease was a risk factor for capsule retention. Inadequate bowel preparation was significantly associated with capsule retention and incomplete examination. An indication other than OGIB was a risk factor for incomplete examination. A recent increasing trend of CE diagnosis of Crohn's disease was observed. The most recent 5-year incomplete examination rate for CE examinations decreased compared with that of the previous 12 years.

CONCLUSION

The 17-year data suggested that CE is a useful and safe tool for diagnosing small bowel diseases. The incomplete examination rate of CE decreased with time, and OGIB was consistently the main indication for CE. Inadequate bowel preparation was significantly associated with capsule retention and incomplete examination.

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.

Use of video capsule endoscopy to identify gastrointestinal lesions in dogs with microcytosis or gastrointestinal hemorrhage

Background

Video capsule endoscopy (VCE) is a noninvasive imaging modality that can identify mucosal lesions not detected with traditional endoscopy or abdominal sonography. In people, VCE is used in diagnostic and management protocols of various gastrointestinal (GI) disorders, particularly in GI bleeding of obscure origin or unexplained iron deficiency anemia (IDA).

Objective

To evaluate the utility of VCE in the identification of mucosal lesions in dogs with evidence of GI hemorrhage.

Animals

Sixteen client‐owned dogs that underwent VCE.

Methods

Retrospective case‐control study. Medical records were reviewed to include dogs with microcytosis, low normal mean corpuscular volume, or clinical GI bleeding that received VCE.

Results

Median age of dogs was 8.7 years (range, 8 months to 15 years) with a median weight of 21.7 kg (range, 6.9‐62.5 kg). Abdominal ultrasound (16), abdominal radiography (4), and abdominal CT (1) did not identify a cause for GI blood loss. Gastric mucosal lesions were identified by VCE in 15 of 16 dogs and small intestinal lesions in 12 of 14 dogs, with 2 capsules remaining in the stomach. Endoscopy was performed in 2 dogs before VCE; 1 dog had additional small intestinal lesions identified through the use of VCE.

Conclusions and Clinical Importance

Video capsule endoscopy is a minimally invasive diagnostic tool that can identify GI lesions in dogs presenting with microcytosis with or without GI hemorrhage when ultrasonography is inconclusive; however, the majority of lesions identified would have been apparent with conventional endoscopy.

Influence of demographic and clinical features of the patient on transit times and impact the on the diagnostic yield of capsule endoscopy

BACKGROUND

transit times in the gastric cavity and the small bowel can be easily calculated using capsule endoscopy software. The factors that can influence these times and impact on diagnostic yield have not been completely assessed.

AIMS

to analyze the influence of demographic and clinical features on transit times and the impact on diagnostic yield.

METHODS

a retrospective, single-center study of examinations between January 2013 and November 2017 was performed. The analyzed features included gender, age, body mass index, diabetes, thyroid disease and indications. The association and correlation between the variables were assessed, as well as the presence of positive and significant findings.

RESULTS

six hundred and thirty-one patients were included in the study. Gastric and small bowel transit times were 36.10 ± 48.50 and 251.82 ± 116.42 minutes, respectively. Gastric time was not affected by any of the variables. Small bowel time was longer in males, patients over 60 years of age and diabetics. Prolonged small bowel time, male gender and older age were associated with a higher diagnostic yield. Age over 60 years was the only factor independently associated with positive findings (OR: 1.550 [1.369-1.754]; p: 0.007).

CONCLUSIONS

patients over 60 years have a longer small bowel transit time and higher probability of having small bowel lesions. Males and diabetic patients also seem more likely to have longer transit times and higher rates of positive findings.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

Diagnosis of chronic anaemia in gastrointestinal disorders: A guideline by the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP)

Anaemia is a common pathologic condition, present in almost 5% of the adult population. Iron deficiency is the most common cause; other mechanisms can be involved, making anaemia a multi-factorial disorder in most cases. Anaemia being a frequent manifestation in the diseases of the gastrointestinal tract, patients are often referred to gastroenterologists. Furthermore, upper and lower endoscopy and enteroscopy are pivotal to the diagnostic roadmap of anaemia. In spite of its relevance in the daily clinical practice, there is a limited number of gastroenterological guidelines dedicated to the diagnosis of anaemia. For this reason, the Italian Association of Hospital Gastroenterologists and Endoscopists and the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition commissioned a panel of experts to prepare a specific guideline on anaemia and its diagnostic roadmap in the gastroenterological scenario. The panel also discussed about the potential involvement of gastroenterologists and endoscopists in the management of patients with anaemia, with particular attention to the correct use of investigations. The panel paid particular attention to practical issues with the aim to support gastroenterologists in their clinical practice when dealing with patients with anaemia.

The Spectrum of Small Intestinal Lesions in Patients with Unexplained Iron Deficiency Anemia Detected by Video Capsule Endoscopy

Background and objectives: Video-capsule endoscopy (VCE) has shown a large range (38⁻83%) of diagnostic yield in unexplained iron deficiency anemia (IDA) and obscure-occult bleeding. Therefore, we retrospectively investigated the VCE-detected spectrum and the prevalence of small bowel injuries and associated risk factors in inpatients with both of the above reported conditions. Methods: We selected inpatients with IDA (hemoglobin <12 g/dL in women, <13 g/dL in men) and obscure-occult bleeding. We excluded VCE indications other than IDA. Complete medical histories and laboratory tests were collected. All subjects underwent PillCam SB2/SB3. The VCE feature Lewis score was calculated when appropriate. We used the t-test and Fisher's exact test for continuous and categorical variables, respectively, in univariate analysis. For multivariate analysis, we used binomial logistic regression. Results: We retrieved 109 patients (female:male ratio of 53:56; age 63.4 ± 18.9 years). Eighty patients (73.4%) showed ≥1 small bowel lesions. The Lewis score was calculated in 41 patients: 13 (31.7%) showed a mild (<135) and 28 (68.3%) a moderate-severe (135⁻790 and >790, respectively) score. In univariate analysis, the small bowel transit time (6.2 ± 2.9 versus 5.2 ± 2.1 h; p = 0.049) and non-steroidal anti-inflammatory drug use for at least two weeks (17.5% versus 0%; p = 0.01) were significantly higher in subjects with injuries. These associations were not confirmed at multivariate analysis. The severity of a lesion directly correlated with proton pump inhibitor (PPI) use and duration (not confirmed in multivariate analysis). VCE can reveal the source of obscure-occult bleeding in a high percentage of unexplained IDAs. A wide spectrum of endoscopic pictures may be found. Known as well as supposed risk factors for small bowel lesions may be detected.

No significant difference in clinically relevant findings between Pillcam® SB3 and Pillcam® SB2 capsules in a United States veteran population

BACKGROUND

Capsule endoscopy (CE) allows for a non-invasive small bowel evaluation for a wide range of gastrointestinal (GI) symptoms and diseases. Capsule technology has been rapidly advancing over recent years, often improving image frequency and quality. The Pillcam^® SB3 (SB3) capsule is one such technology that offers an adaptive frame rate advantage over the previous versions of the capsule the Pillcam^® SB2 (SB2). Some have proposed that this improvement in capsule technology may lead to increased diagnostic yields; however, real world clinical data is currently lacking.

AIM

To evaluate the clinically relevant findings of SB3 and SB2 capsules in a population of United States veterans.

METHODS

A retrospective analysis of 260 consecutive CE studies was performed including 130 SB3 and 130 SB2 capsule studies. Recorded variables included: age, gender, type of capsule, body mass index, exam completion, inpatient status, opioid use, diabetes, quality of preparation, gastric transit time, small bowel transit time, indication, finding, and if the exam resulted in a change in clinical management. The primary outcome measured was the detection of clinically relevant findings between SB3 and SB2 capsules.

RESULTS

Mean age of the study population was 67.1 ± 10.4 years and 94.2% of patients were male. Of these 28.1% were on opioid users. The most common indications for capsule procedure were occult GI bleeding (74.6%) and overt GI bleeding (14.6%). Rates of incomplete exam were similar between SB3 and SB2 groups (16.9% vs 9.2%, P = 0.066). The overall rate of clinically relevant finding was 48.9% in our study. No significant difference was observed in SB3 vs SB2 capsules for clinically relevant findings (46.2% vs 51.5%, P = 0.385) or change in clinical management (40.8% vs 50.0%, P = 0.135).

CONCLUSION

Our study found no significant difference in clinically relevant findings between SB3 and SB2 capsules.

Follow-up on: optimizing lesion detection in small bowel capsule endoscopy and beyond: from present problems to future solutions

This review presents noteworthy advances in clinical and experimental Capsule Endoscopy (CE), focusing on the progress that has been reported over the last 5 years since our previous review on the subject. Areas covered: This study presents the commercially available CE platforms, as well as the advances made in optimizing the diagnostic capabilities of CE. The latter includes recent concept and prototype capsule endoscopes, medical approaches to improve diagnostic yield, and progress in software for enhancing visualization, abnormality detection, and lesion localization. Expert commentary: Currently, moving through the second decade of CE evolution, there are still several open issues and remarkable challenges to overcome.

Yield of capsule endoscopy in obscure gastrointestinal bleeding: A comparative study between premenopausal and menopausal women

AIM

To evaluate differences in capsule endoscopy (CE) performed in the setting of obscure gastrointestinal bleeding (OGIB) among premenopausal women (PMW) and menopausal women (MW).

METHODS

Retrospective, single-center study, including female patients submitted to CE in the setting of OGIB between May 2011 and December 2016. Patients were divided into 2 groups according to age, considering fertile age as ≤ 55 years and postmenopausal age as > 55 years. The diagnostic yield (DY), the rebleeding rate and the time to rebleed were evaluated and compared between groups. Rebleeding was defined as a drop of Hb > 2 g/dL or need for transfusional support or presence of melena/hematochezia.

RESULTS

A hundred and eighty three female patients underwent CE for OGIB, of whom 30.6% (n = 56) were PMW and 69.4% (n = 127) were MW. The DY was 30.4% in PMW and 63.8% in MW. The most common findings were angiodysplasias in both groups (PMW: 21.4%, MW: 44.9%) (P = 0.003). In PMW, only 1.8% required therapeutic endoscopy. In 17.3% of MW, CE findings led to additional endoscopic treatment. Rebleeding at 1, 3 and 5 years in PMW was 3.6%, 10.2%, 10.2% and 22.0%, 32.3% and 34.2% in MW. Postmenopausal status was significantly associated with higher DY (P < 0.001), TY (P = 0.003), rebleeding (P = 0.031) and lower time to rebleed (P = 0.001).

CONCLUSION

PMW with suspected OGIB are less likely to have significant findings in CE. In MW DY, need for endoscopic treatment and rebleeding were significantly higher while time to rebleed was lower.

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.

IMPACT OF SMALL BOWEL CAPSULE ENDOSCOPY IN IRON DEFICIENCY ANEMIA: INFLUENCE OF PATIENT'SAGE ON DIAGNOSTIC YIELD

BACKGROUND

Iron deficiency anemia remains one of the main indications to perform small bowel capsule endoscopy. Literature suggests that diagnostic yield is influenced by patient's age but with conflicting results regarding age cutoff.

OBJECTIVE

We aimed to clarify the differences in diagnostic yield and incidence of specific findings according to age.

METHODS

Retrospective single-center study including 118 patients performing small bowel capsule endoscopy in the study of iron deficiency anemia. Videos were reviewed and small bowel findings that may account for anemia were reported. Incomplete examinations were excluded. Findings were compared between patients ≤60 and >60 years.

RESULTS

Patients had a mean age of 58 years old (SD ±17.9) with 69.5% females (n=82). The overall diagnostic yield was 49% (58/118), being higher among patients >60 years (36/60, diagnostic yield 60%) than those ≤60 years (20/58, diagnostic yield 34%), (P<0.01). Angioectasias were more frequent in patients >60 years (45% vs 9%, P<0.01). Patients ≤60 years presented more frequently significant inflammation (Lewis score >135 in 10.3% vs 1.7%, P<0.05) and other non-vascular lesions (24% vs 10%, P=0.04).

CONCLUSION

In our cohort small bowel capsule endoscopy diagnosed clinically relevant findings in the setting of iron deficiency anemia in almost half the patients. Diagnostic yield was higher in patients older than 60 years (60%), with vascular lesions being more frequent in this age group. Despite the lower diagnostic yield in patients ≤60 years, significant pathology was also found in this age group, mainly of inflammatory type.

Diagnostic yield and predictive factors of findings in small-bowel capsule endoscopy in the setting of iron-deficiency anemia

INTRODUCTION

 Despite the widespread use of small-bowel capsule endoscopy (CE), there is still limited data on its utility and effectiveness for the diagnosis and management of patients with iron-deficiency anemia (IDA).

AIM

 To assess the diagnostic yield of CE and the factors predicting positive findings in patients with IDA.

METHODS

 Patients with unexplained IDA and negative upper and lower endoscopy were included. A positive diagnostic yield was considered when CE diagnosed one or more lesions that could explain the IDA. Sex, age, NSAID consumption, blood transfusion requirement, and ferritin and hemoglobin levels were recorded.

RESULTS

 In total, 120 CE were included (mean age 58.5 years; F/M 82:38). Mean hemoglobin levels were 9 g/dL and mean ferritin levels were 15.7 ng/mL. Positive findings were present in 50 % of patients. The most frequent was angiodysplasia (45 %). Despite several baseline variables being significantly associated with positive findings, using a logistic regression model, it was verified that male sex (OR 3.93; 95 %CI 1.57 - 9.86), age (OR 1.03; 95 %CI 1.00 - 1.06), and hemoglobin levels (OR 0.73; 95 %CI 0.57 - 0.94) were the variables having an independent effect on the probability of obtaining positive findings. Age older than 50 years (OR 14.05; 95 %CI 1.69 - 116.23) and male sex (OR 3.63; 95 %CI 1.29 - 10.17) were the variables which increased the risk of diagnosing angiodysplasia.

CONCLUSIONS

 CE is a useful technique in patients with IDA. To improve its yield, it is necessary to select patients carefully. Male sex, older age, and low hemoglobin levels were associated with a risk of positive finding in this group of patients. The risk of diagnosing angiodysplasia increased with male sex and older age.

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.

Iron deficiency anemia in older adults: A review

Anemia in older adults is a risk factor for numerous negative outcomes. There is no standard definition, but in most studies, anemia is defined as a hemoglobin value <12 g/dL for women and <13 g/dL for men. Absolute iron deficiency anemia is defined as the combination of anemia and the absence of total body iron. Serum ferritin is the most frequently used diagnostic parameter, but its concentration increases with age and in the presence of inflammatory diseases. Other laboratory tests, such as transferrin saturation, soluble transferrin receptor and the soluble transferrin receptor/ferritin index might provide useful information, but there is a wide variety in the cut-off values and interpretation of the results. Recent research regarding hepcidin as a central regulator of iron homeostasis is promising, but it has not been used yet for the routine diagnosis of iron deficiency anemia. In older iron deficiency anemia patients, an esophagogastroduodenoscopy and colonoscopy should be initiated in order to identify the underlying bleeding cause. CT colonography can replace a colonoscopy, and in specific cases, a video capsule is recommended. It remains crucial to keep in mind which potential benefits might be expected from these investigations in this vulnerable population, taking into account the comorbidity and life expectancy, and one should discuss in advance the possible therapeutic options and complications with the patient, a family member or a proxy. Oral iron administration is the standard treatment, but parenteral iron is a convenient and safe way to provide the total iron dose in one or a few sessions. Geriatr Gerontol Int 2018; 18: 373-379.

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.

Appropriateness of the study of iron deficiency anemia prior to referral for small bowel evaluation at a tertiary center

AIM

To evaluate the adequacy of the study of iron deficiency anemia (IDA) in real life practice prior to referral to a gastroenterology department for small bowel evaluation.

METHODS

All consecutive patients referred to a gastroenterology department for small bowel investigation due to iron deficiency anemia, between January 2013 and December 2015 were included. Both patients referred from general practitioners or directly from different hospital departments were selected. Relevant clinical information regarding prior anemia workup was retrospectively collected from medical records. An appropriate pre-referral study was considered the execution of esophagogastroduodenoscopy (EGD) with Helicobacter pylori (H. pylori) investigation, colonoscopy with quality standards (recent, total and with adequate preparation) and celiac disease (CD) screening (through serologic testing and/or histopathological investigation).

RESULTS

A total of 77 patients (58.4% female, mean age 67.1 ± 16.7 years) were included. Most (53.2%) patients were referred from general practitioners, 41.6% from other hospital specialties and 5.2% directly from the emergency department. The mean pre-referral hemoglobin concentration was 8.8 ± 2.0 g/dL and the majority of anemias had microcytic (71.4%) and hypochromic (72.7%) characteristics. 77.9% of patients presented with an incomplete pre-referral study: EGD in 97.4%, with H. pylori investigation in 58.3%, colonoscopy with quality criteria in 63.6%, and CD screening in 24.7%. Patients with an appropriate study at the time of referral were younger (48.7 ± 17.7 vs 72.3 ± 12.3 years, P < 0.001). Small bowel evaluation was ultimately undertaken in 72.7% of patients, with a more frequent evaluation in patients with a quality colonoscopy at referral (78.6% vs 23.8%); P < 0.001 (OR = 11.7, 95%CI: 3.6-38.6). The most common diagnosis regarded as the likely cause of IDA was small bowel angioectasia (18.2%) but additional causes were also found in the upper and lower gastrointestinal tracts of near 20% of patients. Small bowel studies detected previously unknown non-small bowel findings in 7.7% of patients.

CONCLUSION

The study of anemia prior to referral to gastroenterology department is unsatisfactory. Only approximately a quarter of patients presented with an appropriate study.

Colonic obstruction caused by video capsule entrapment in a metal stent

Video capsule endoscopy (VCE) has become the method of choice for visualizing the small bowel mucosa and is generally considered to be a safe method. Although uncommon, the most feared complication of VCE is capsule retention that can potentially lead to life-threatening bowel obstruction. Herein, we present for the first time a case of capsule retention in a colonic stent. The patient had known Crohn's disease with colonic involvement and underwent an uneventful but incomplete small bowel VCE for assessment of disease activity and extension for optimizing medical treatment. Five months later, the patient presented with intestinal obstruction due to a Crohn's-stricture in the sigmoid colon, which was successfully decompressed with a self-expandable metal stent. Nonetheless, two days later the patient showed signs of bowel obstruction again and abdominal X-ray showed that the capsule was trapped in the metal stent in the sigmoid colon. Subsequently, emergency surgery was performed and the patient fully recovered. Intestinal capsule retention necessitating interventional removal is rare. This report describes a unique case of capsule retention in a colonic metal stent and highlights the potential risk of performing capsule endoscopy examinations in patients with gastrointestinal stents.