Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding

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.

Prediction models for recurrence in patients with small bowel bleeding

Obscure gastrointestinal bleeding (OGIB) has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy. OGIB can present as overt bleeding or occult bleeding, and small bowel lesions are the most common causes. The small bowel can be evaluated using capsule endoscopy, device-assisted enteroscopy, computed tomography enterography, or magnetic resonance enterography. Once the cause of small-bowel bleeding is identified and targeted therapeutic intervention is completed, the patient can be managed with routine visits. However, diagnostic tests may produce negative results, and some patients with small bowel bleeding, regardless of diagnostic findings, may experience rebleeding. Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans. Several studies have identified different factors associated with rebleeding, and a limited number of studies have attempted to create prediction models for recurrence. This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding. These models may aid clinicians in forming tailored patient management and surveillance.

Convolutional neural network-based segmentation network applied to image recognition of angiodysplasias lesion under capsule endoscopy

BACKGROUND

Small intestinal vascular malformations (angiodysplasias) are common causes of small intestinal bleeding. While capsule endoscopy has become the primary diagnostic method for angiodysplasia, manual reading of the entire gastrointestinal tract is time-consuming and requires a heavy workload, which affects the accuracy of diagnosis.

AIM

To evaluate whether artificial intelligence can assist the diagnosis and increase the detection rate of angiodysplasias in the small intestine, achieve automatic disease detection, and shorten the capsule endoscopy (CE) reading time.

METHODS

A convolutional neural network semantic segmentation model with a feature fusion method, which automatically recognizes the category of vascular dysplasia under CE and draws the lesion contour, thus improving the efficiency and accuracy of identifying small intestinal vascular malformation lesions, was proposed. Resnet-50 was used as the skeleton network to design the fusion mechanism, fuse the shallow and depth features, and classify the images at the pixel level to achieve the segmentation and recognition of vascular dysplasia. The training set and test set were constructed and compared with PSPNet, Deeplab3+, and UperNet.

RESULTS

The test set constructed in the study achieved satisfactory results, where pixel accuracy was 99%, mean intersection over union was 0.69, negative predictive value was 98.74%, and positive predictive value was 94.27%. The model parameter was 46.38 M, the float calculation was 467.2 G, and the time length to segment and recognize a picture was 0.6 s.

CONCLUSION

Constructing a segmentation network based on deep learning to segment and recognize angiodysplasias lesions is an effective and feasible method for diagnosing angiodysplasias lesions.

Strategic Management of Bleeding Small Bowel Gastrointestinal Angiodysplasias (GIADs): A 12 Year Retrospective Review in a Veteran Population and Cost Comparison

BACKGROUND

Gastrointestinal angiodysplasias (GIADs), also known as gastrointestinal angioectasias, are dilated, abnormally thin-walled blood vessels that occur in the mucosa and submucosa throughout the gastrointestinal tract. As a common cause of small bowel bleeding, GIADs have a significant impact on patient's morbidity and healthcare costs. Presently, somatostatin has been used widely to treat GIADs, but it is unclear if other therapies are as beneficial and cost-effective as somatostatin in managing GIADs. (2) Methods: A retrospective chart review was performed, which included subjects treated with Lanreotide, a somatostatin analog, and other therapies at the VA Loma Linda Healthcare System (VALLHCC) from January 2006 to December 2018. Patients who had symptomatic GIADs were detected by video capsule endoscopy (VCE), a device-assisted enteroscopy (DAE) or, in our case, push enteroscopy (PE) with an Endocuff. (3) Results: Three hundred twelve patients were diagnosed with GIADs. In this group of patients, 72 underwent ablation (endoscopic BICAP) with the addition of Lanreotide (SST), 63 underwent ablation therapy, eight were treated with SST only, 128 received iron replacement only, 25 received iron plus SST therapy, and 61 were observed with no therapy. Each group was followed via their hemoglobin (Hgb) level immediately thereafter, and Hgb levels were then obtained every 3 months for a 12-month period. After ablation therapy, 63 patients maintained stable Hgb levels over the course of the study, suggesting a significant therapeutic effect by controlling active bleeding. The 27 patients receiving ablation +SST therapy did not show improvements when compared to ablation only and the 128 patients who received iron therapy alone. (4) Conclusions: Importantly, 12 years of managing these patients has given us a cost- and time-sensitive strategy to maintain the patients' Hgb levels and avoid hospital admissions for acute bleeding. Iron treatment alone is effective compared to SST treatment in recovering from GIADs. Eliminating SST treatment from therapeutic intervention would save $89,100-445,550 per patient, depending on the number of doses for private care patients and $14,286-28,772 for VA patients, respectively. A suggested therapy would be to perform DAE on actively bleeding patients, ablate the lesions using a coagulation method, and place the patient on iron. If that fails, gastroenterologists should repeat VCE and perform either PE with Endocuff or balloon enteroscopy (all DAEs).

Very High Yield of Urgent Small-Bowel Capsule Endoscopy for Ongoing Overt Suspected Small-Bowel Bleeding Irrespective of the Usual Predictive Factors

Evidence for an urgent approach to ongoing overt suspected small-bowel bleeding (SSBB) is scarce. We aimed to analyze our series of urgent small-bowel capsule endoscopies (SBCEs) for ongoing overt SSBB and to identify factors associated with positive findings and outcomes. A retrospective study of all SBCEs performed in the first 48 h after admission for overt SSBB between January 2006 and February 2022 was performed. Descriptive and inferential analyses (univariate and multivariable) were performed. Eighty-three urgent SBCEs were performed for overt SSBB. Patients were mostly men (69.2%, median age 68) and were followed for a median of 58.2 months (range 5-176). The diagnostic yield was 80.7%; in 60.2%, blood was detected in the small bowel (SB), while in 50.6%, a bleeding lesion was identified, mostly angioectasia. Patients with diabetes mellitus or taking NSAIDs were more prone to present SB findings, yet the explanatory power was low. Endoscopic or surgical treatments were performed in 28.9% and 19.3%, respectively, with the "non-conservative" therapeutic yield being 56.6%. Rebleeding occurred in 20.5% and was associated in the multivariable analysis with the female gender and anticoagulants use. This cohort of urgent SBCE, the largest from a European center, reinforces the usefulness of SBCE for ongoing overt SSBB management. This prompt performance of this procedure is highly effective, regardless of patients' features.

Efficacy of Early Video Capsule Endoscopy for Acute Overt Lower Gastrointestinal Bleeding with Colonic Diverticulosis: A Prospective Observational Study

BACKGROUND/AIMS

Although most patients with presumptive colonic diverticular bleeding (CDB) do not undergo a small bowel investigation in clinical practice, no prospective study supports this management. We evaluated the utility of early small bowel capsule endoscopy (CE) after negative colonoscopy results.

METHODS

This prospective study evaluated the diagnostic yield of early small bowel CE (≤3 days from visit) for consecutive patients with acute-onset hematochezia, when colonoscopy found colonic diverticulosis but did not identify the definite bleeding source (n = 51; presumptive CDB). As a matched control for comparing clinical outcomes, presumptive CDB patients without CE (n = 51) were retrospectively extracted.

RESULTS

On CE for the prospective cohort, the rates of total positive findings, P2 findings (high bleeding potential according to the P classification), and blood pooling in the colon were 57%, 12% (ulceration, 8%; angioectasia, 4%), and 24%, respectively. The rates of rebleeding within 30 and 365 days were 16% and 29% in the prospective cohort with CE, respectively, and were not significantly different from those in the retrospective cohort without CE (10% and 25%, respectively). In addition, thromboembolism and mortality within 30 and 365 days were not significantly different between those with and without CE.

CONCLUSION

Early CE detected a suspected small bowel bleeding source in 12% of acute-onset presumptive CDB patients but did not significantly improve major clinical outcomes. Therefore, routine CE is unnecessary for presumptive CDB patients after colonoscopy (UMIN000026676).

Pathophysiology and therapeutic management of anemia in gastrointestinal disorders

INTRODUCTION

Anemia is a common complication of gastrointestinal (GI) disorders, with a prevalence up to 60% in celiac disease (CeD) and inflammatory bowel disease (IBD). Iron deficiency anemia (IDA) is the most prevalent form of anemia in these conditions, but chronic inflammation and vitamin B12 deficiency represent other common contributing mechanisms, especially in IBD.

AREAS COVERED

We discuss the pathogenesis of anemia in various medical GI disorders, the sometime problematic distinction between IDA, anemia of inflammation (AI) and the association of the two, and therapeutic and preventive measures that can be useful for the management of anemia in GI disorders. Unfortunately, with the exception of IDA and AI in IBD, large RCT concerning the treatment of anemia in GI disorders are lacking.

EXPERT OPINION

Anemia management strategies in GI disorders are outlined, with a focus on the main prevention, diagnostic, and therapeutic measures. Specific problems and situations such as the role of gluten-free diet for IDA treatment in CeD, the choice between oral and parenteral supplementation of iron or vitamin B12 in carential anemias, the use of endoscopic procedures to stop bleeding in intestinal angiodysplasia and preventive/treatment strategies for NSAID-associated GI bleeding are discussed.

Diagnostic and therapeutic yields of early capsule endoscopy and device-assisted enteroscopy in the setting of overt GI bleeding: a systematic review with meta-analysis

BACKGROUND AND AIMS

Small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) are essential in obscure GI bleeding (OGIB) management. However, the best timing for such procedures remains unknown. This meta-analysis aimed to compare, for the first time, diagnostic and therapeutic yields, detection of active bleeding and vascular lesions, recurrent bleeding, and mortality of "early" versus "nonearly" SBCE and DAE.

METHODS

MEDLINE, ScienceDirect, and Cochrane Central Register of Controlled Trials were searched to identify studies comparing early versus nonearly SBCE and DAE. Random-effects meta-analysis was performed; reporting quality was assessed.

RESULTS

From 1974 records, 39 were included (4825 patients). Time intervals for the early approach varied, within 14 days in SBCE and 72 hours in DAE. The pooled diagnostic and therapeutic yields of early DAE were superior to those of SBCE (7.97% and 20.89%, respectively; P < .05). The odds for active bleeding (odds ratio [OR], 5.09; I² = 53%), positive diagnosis (OR, 3.99; I² = 45%), and therapeutic intervention (OR, 3.86; I² = 67%) were higher in the early group for SBCE and DAE (P < .01). Subgroup effects in diagnostic yield were only identified for the early group sample size. Our study failed to identify differences when studies were classified according to time intervals for early DAE (I² < 5%), but the analysis was limited because of a lack of data availability. Lower recurrent bleeding in early SBCE and DAE was observed (OR, .40; P < .01; I² = 0%).

CONCLUSIONS

The role of small-bowel studies in the early evaluation of OGIB is unquestionable, impacting diagnosis, therapeutic intervention, and prognosis. Comparative studies are still needed to identify optimal timing.

Video Capsule Endoscopy Optimal Timing in Overt Obscure Gastrointestinal Bleeding

Video capsule endoscopy (VCE) has become the noninvasive diagnostic standard in the investigation of overt obscure gastrointestinal bleeding (OGIB), with a high positive and negative predictive value. However, the diagnostic yield of the VCE is thought to depend on when it was performed. We evaluate the optimal timing performing VCE relative to overt OGIB to improve the diagnostic yield. A total 271 patients had admitted and underwent VCE for overt OGIB between 2007 and 2016 in Samsung Medical Center, Seoul, Korea. To evaluate the diagnostic yield of VCE for overt OGIB with respect to timing of the intervention, diagnostic yield was analyzed according to the times after latest bleeding. The finding of VCE was classified into P0 or P1 (no potential for bleeding or uncertain hemorrhagic potential) and P2 (high potential for bleeding, such as active bleeding, typical angiodysplasia, large ulcerations or tumors). The P2 lesion was found in 106 patients and diagnostic yield of was 39.1% for overt OGIB. Diagnostic yield of VCE to detect P2 lesion was higher when it is performed closer to the time of latest bleeding (timing of VCE between the VCE and latest bleeding: <24 h, 43/63 (68.3%); 1 days, 16/43 (34.9%); 2 days, 18/52 (34.6%); 3 days, 13/43 (30.2%); 4 days, 7/28 (25.0%); 5–7 days, 6/24 (25.0%), and ≥8 days, 4/18 (22.2%); ptrend < 0.001). The interval between the VCE and latest bleeding were categorized into <24 h (n = 63), 1–2 days (n = 95), 3–7 days (n = 95) and ≥8 days (n = 18). Multivariable analyses showed the odds ratio for P2 lesion detection was 4.99 (95% confidence interval, 1.47–16.89) in <24 h group, compared with ≥8 days group (p < 0.010). The overall re-bleeding rate for those with P2 lesion was higher than for those with P0 or P1 lesion at the end of mean follow up of 2.5 years. The proportion of patients who underwent therapeutic intervention including surgery, endoscopic intervention and embolization was higher when VCE is performed closer to the time of latest bleeding (p = 0.010). Early deployment of VCE within 24 h of the latest GI bleeding results in a higher diagnostic yield for patients with overt OGIB and consequently resulted in a higher therapeutic intervention rate

Evaluation and Validation of a New Score to Measure the Severity of Small Bowel Angiodysplasia on Video Capsule Endoscopy

INTRODUCTION

Angiodysplasias are responsible of 50% of small bowel bleeding. An endoscopic method that allows measuring its severity is not available.

AIMS

The aim of the study was to validate a new endoscopic score with VCE to measure the severity of small bowel angiodysplasias (SBAD).

METHODS

Four endoscopists independently reviewed VCE videos of 22 patients with SBAD. The score graded 3 variables: A - extent of lesions: E1, located in one half of the intestine and E2, in both halves; B - number of lesions: N1, <5; N2, 5-10; and N3, >10 lesions; C - probability of bleeding: P1, pale red spots; P2, bright red spots; P3, bleeding stigmata; and P4, active bleeding. Capsule Endoscopy Small Bowel Angiodysplasia Activity Index (CESBAI) was calculated as follows: E × 1 + N × 2 + P × 3. Interobserver variability was analyzed by Spearman's correlation and agreement Kappa statistic tests.

RESULTS

The mean CESBAI scores by observers were O1= 11.6 ± 4.1; O2 = 11.3 ± 4.8; O3 = 11.1 ± 4.9; and O4 = 11.8 ± 4.2 (p > 0.05). Spearman's correlation values of CESBAI between every 2 observers were from 0.61 to 0.94 (p < 0.001) with a global correlation of 0.73 among all observers. Kappa values of CESBAI between every 2 observers ranged from 0.42 to 0.87 (p < 0.001) with a global agreement of 0.57 among all observers. All evaluators stated that the method was easy to use.

CONCLUSIONS

CESBAI is a reliable and reproducible score. Nevertheless, these results must be validated in other studies with larger population before assessing its power for predicting bleeding recurrence.

Risk factors for rebleeding in patients with obscure gastrointestinal bleeding from southern China

Background

To identify the risk factors associated with rebleeding in obscure gastrointestinal bleeding (OGIB) patients from southern China.

Methods

This retrospective study involved 229 patients who underwent small bowel endoscopy in our hospital between 1 January 2018 and 1 December 2020. The clinical characteristics and risk factors related to rebleeding were retrospectively evaluated.

Results

Rebleeding patients were significantly older than non-rebleeding patients (53.0 ± 15.9 vs. 46.2 ± 17.8 years), had lower hemoglobin concentrations (89.2 ± 28.1 vs. 126.2 ± 25.1 g/L), and higher blood urea nitrogen concentrations (5.4 ± 2.6 vs. 4.5 ± 2.2 µmol/L), respectively. A higher percentage of rebleeding patients had diabetes mellitus (13.9% vs. 2.9%) and overt bleeding (70.4% vs. 38.6%), and required blood transfusions (43.1% vs. 8.0%), compared with non-rebleeding patients, respectively. Multivariate logistic analysis indicated that drinking alcohol (odds ratio (OR): 9.27; 95% confidence interval (CI) = 1.35–63.78), anemia (OR: 17.38; 95% CI = 5.48–55.10), and blood transfusion (OR: 3.76; 95% CI = 1.04–13.56) increased the risk of rebleeding in OGIB patients.

Conclusion

Our data suggested that OGIB patients who drink alcohol, have anemia, and require blood transfusion have an increased risk of rebleeding.

The role of early video capsule endoscopy in the diagnosis and prognosis of obscure gastrointestinal bleeding: A multi-center propensity score matching study

BACKGROUND AND AIM

Video capsule endoscopy (VCE) is a first-line procedure for the diagnosis of obscure gastrointestinal bleeding (OGIB). The opinions on the timing for such diagnostic evaluation remain unclear. We aimed to explore the role of early VCE in OGIB patients.

METHODS

A total of 997 patients that underwent VCE at Renji Hospital and Nagoya University from May 15, 2002, to December 28, 2016, were included in this study. We matched patients that underwent early VCE within 14 days of bleeding (early group, n = 678) to patients that did not (late group, n = 319) via 1:1 propensity score matching (PSM). We then compared VCE diagnostic rates and the prevalence of post-VCE rebleeding in patients with initial negative VCE findings within 1 year between these groups before and after PSM.

RESULTS

Following PSM, early VCE was associated with a significantly higher rate of OGIB diagnosis (56.4% vs 45.5%, P = 0.001) and with a significantly lower incidence of rebleeding within 1 year following treatment (24.7% vs 36.7%, P = 0.041). In univariate and multivariate analyses, VCE timing (odds ratio 0.648; 95% confidence interval 0.496-0.847, P = 0.001 and odds ratio 0.666; 95% confidence interval 0.496-0.894, P = 0.007, respectively) was found to be linked with a higher rate of positive findings.

CONCLUSION

Early VCE can improve the reliability of OGIB diagnosis while also reducing rates of post-VCE rebleeding. This suggests that timely and accurate diagnosis can help to improve OGIB patient treatment and prognosis.

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.

Systematic review and meta-analysis of the diagnostic and therapeutic yield of small bowel endoscopy in patients with overt small bowel bleeding

BACKGROUND

Small bowel endoscopy, including small bowel capsule endoscopy (SBCE) and balloon-assisted endoscopy (BAE), is useful for small bowel bleeding (SBB) assessment. However, the specific management strategy for overt SBB is not well established. This meta-analysis aimed to evaluate the pooled diagnostic yields (DYs) and therapeutic yields (TYs) of small bowel endoscopy in overt SBB and to determine the optimal endoscopy timing.

METHODS

A comprehensive literature search was performed of studies examining the DY and/or TY of small bowel endoscopy in overt SBB. Data on the DY, TY, and timing of small bowel endoscopy were extracted, pooled, and analyzed. The pooled DY and TY of small bowel endoscopy for patients with overt SBB were calculated. Meta-regression and subgroup analysis were performed.

RESULTS

Twenty-two studies were included. The pooled DY was 65.2% and 74.0% for SBCE and BAE, respectively. The pooled TY of SBCE and BAE was 55.9% and 35.8%, respectively. A meta-regression model showed that the timing of endoscopy was significantly associated with the DY of BAE and the TY of SBCE and BAE.

CONCLUSIONS

Small bowel capsule endoscopy and BAE would be useful diagnostic and therapeutic modalities in overt SBB. According to the subgroup analysis, in which the TY seemed to be higher within 2 days after bleeding for SBCE and BAE, the optimal timing of endoscopy would be within 2 days.

Artificial Intelligence in Small Bowel Endoscopy: Current Perspectives and Future Directions

Artificial intelligence (AI) is a computer system that is able to perform tasks which normally require human intelligence. The role of AI in the field of gastroenterology has been gradually evolving since its inception in the 1950s. Discovery of wireless capsule endoscopy (WCE) and balloon enteroscopy (BE) has revolutionized small gut imaging. While WCE is a relatively patient-friendly and noninvasive mode to examine the nonobstructed small gut, it is limited by a lengthy examination time and the need for expertise in reading images acquired by the capsule. Similarly, BE, despite having the advantage of therapeutic intervention, is costly, invasive, and requires general sedation. Incorporation of concepts like machine learning and deep learning has been used to handle large amounts of data and images in gastroenterology. Interestingly, in small gut imaging, the application of AI has been limited to WCE only. This review was planned to examine and summarize available published data on various AI-based approaches applied to small bowel disease.

We conducted an extensive literature search using Google search engine, Google Scholar, and PubMed database for published literature in English on the application of different AI techniques in small bowel endoscopy, and have summarized the outcome and benefits of these applications of AI in small bowel endoscopy. Incorporation of AI in WCE has resulted in significant advancements in the detection of various lesions starting from dysplastic mucosa, inflammatory and nonmalignant lesions to the detection of bleeding with increasing accuracy and has shortened the lengthy review time in image analysis. As most of the studies to evaluate AI are retrospective, the presence of inherent selection bias cannot be excluded. Besides, the interpretability (black-box nature) of AI models remains a cause for concern. Finally, issues related to medical ethics and AI need to be judiciously addressed to enable its seamless use in future.

What is the effective clinical use of small bowel capsule endoscopy in real life?

Capsule endoscopy is a noninvasive and easy method for evaluating the gastrointestinal tract. Since the wireless capsule endoscopy system was first developed, many new technical improvements have been made in order to gain maximum benefit from the procedure. However, at this stage, it remains a diagnostic modality, the main indication for its use being obscure gastrointestinal bleeding. Capsule endoscopy is only contraindicated in symptomatic intestinal obstruction. New indications for use and therapeutic options may become possible with the further development of nanotechnologies.

Indications and diagnostic yield of small-bowel capsule endoscopy in a real-world setting

Background

Indications and diagnostic yield of small-bowel video capsule endoscopy (SB-VCE) are communicated in recent clinical academic guidelines. However, guidelines are based mainly on relatively few, small, selection-biased studies at experienced centers, and thus we lack information on indications and diagnostic yield of SB-VCE in the real-world community setting. The aim of the study was to evaluate indications and diagnostic yield of SB-VCE in the real-world community setting.

Methods

Our local VCE clinical database was used to identify patients undergoing SB-VCE procedures over a 7-year period (2011–2018). Patients were broadly referred and underwent SB-VCE using PillCam™ SB 2 and SB 3 capsule systems. Procedures were reviewed by local endoscopists, who had undergone similar formal SB-VCE review training. Medical reports of the procedures were composed as such. We retrospectively reviewed all reports and gathered data regarding indications and findings. Diagnostic yield was considered positive if SB-VCE visualized any type of clinically significant pathological finding.

Results

536 SB-VCE procedures in 516 patients were included in final assessment. Patient mean (± SD) age was 50 ± 20 years with approximately even female/male ratio (275:241). The overall proportion of positive findings was 42% (225/536). The two main indications were obscure gastrointestinal bleeding (occult/anemia or overt/active, OGIB) of 46% (246/536) and definite/suspected Crohn’s disease (CD) of 39% (210/536). Positive SB-VCE findings were obtained in 44% (108/246) of procedures with indication of OGIB and in 50% (104/210) of procedures with indication of CD.

Conclusions

The indications for SB-VCE are largely consistent with guidelines but with an apparently relatively low diagnostic yield in our real-world community setting.

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.

Clinical Utility of Emergency Capsule Endoscopy for Diagnosing the Source and Nature of Ongoing Overt Obscure Gastrointestinal Bleeding

Background and Aims

In patients with ongoing overt obscure gastrointestinal bleeding (OGIB), prompt detection of the bleeding source is crucial to treatment success. However, there is no consensus on the optimal timing of diagnostic capsule endoscopy (CE). We investigated the clinical utility of emergency CE for detecting the source of ongoing overt OGIB.

Methods

We retrospectively evaluated 146 consecutive patients who, between February 2009 and July 2018, underwent emergency CE at Hiroshima University Hospital to detect the source of ongoing overt OGIB. Patients with a bleeding source located outside the small bowel were excluded. The remaining 127 patients were stratified according to the timing of CE relative to the onset of bleeding: patients in group A (n = 15, 12 men; mean age: 75 years; age range: 62–83 years) underwent CE within 48 hours of bleeding onset, whereas patients in group B (n = 112, 73 men; mean age: 65 years; age range: 17–88 years) underwent CE at >48 hours after bleeding onset. All patients underwent double-balloon endoscopy, and the final diagnosis was compared against the CE findings.

Results

The CE lesion detection rate was significantly higher in group A (12/15 patients, 80%) than in group B (53/112 patients, 47%) (p = 0.0174). There was no significant difference between the two groups regarding the patients' background characteristics. Vascular lesions were the most frequent finding in both groups. The diagnostic concordance rate between emergency CE and double-balloon endoscopy was 100% in group A and 92.9% in group B. Rebleeding after endoscopic treatment was confirmed in only one patient in group B.

Conclusions

Emergency CE represents a useful diagnostic modality in patients with ongoing overt OGIB, potentially improving detection rates and reducing rebleeding risk.

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.

Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

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.

High short-term rebleeding rate in patients undergoing a second endoscopic therapy for small-bowel angioectasias after recurrent bleeding

BACKGROUND

Angioectasias represents the most frequently found lesion in the small bowel by device-assisted enteroscopy for obscure gastrointestinal bleeding in Western countries. Recurrence of gastrointestinal bleeding after angioectasias therapy remains unclear and data regarding the efficacy of additional endoscopic therapeutic sessions to reduce the rebleeding rate is limited.

AIM

To evaluate the rebleeding rate in small bowel angioectasias after a second endoscopic treatment with balloon-assisted enteroscopy after an initial bleed during the first endoscopic treatment.

METHODS

A retrospective double-center study of patients with small-bowel angioectasias undergoing a second enteroscopy treatment due to a first rebleeding episode. The endpoint was rebleeding, defined as the need for a blood transfusion, the presence of overt bleeding or a decrease in hemoglobin ≥ 2 g/dL.

RESULTS

Fifteen of 37 (40.5%) patients with small-bowel angioectasias that underwent a second endoscopic therapy after a first rebleeding episode (n = 15) experienced a second rebleeding episode. Kaplan-Meier curve analysis showed that most rebleeding episodes occurred within the first 12 months of follow-up, resulting in a rebleeding rate of 33.1% at 6 months, 39.1% at 12 months and 52.6% at 24 months.

CONCLUSIONS

Despite the high absolute short-term rebleeding rate, further endoscopic treatments may be beneficial due to the effective reduction of rebleeding in a subset of patients.

Repeatability of small bowel transit time in capsule endoscopy in healthy subjects

BACKGROUND

There are no reports to prove the repeatability of gastric transit time (GTT) and small bowel transit time (SBTT) in capsule endoscopy (CE).

OBJECTIVE

To clarify the repeatability and factors that affect GTT/SBTT in CE.

METHODS

We analyzed the data of 150 healthy subjects from our previous randomized controlled trial that compared small intestinal injuries between two 14-day treatment groups: 1) celecoxib and 2) loxoprofen + lansoprazole. Correlation of GTT/SBTT with pre- and post-treatment CE was analyzed. In addition, the associations of pre-treatment CE SBTT with physical factors, post-treatment CE SBTT and the presence of small intestinal mucosal injuries were analyzed.

RESULTS

Analyses of 148 subjects pre-treatment CE and 146 subjects post-treatment CE were performed. There were no significant differences between mean GTT and SBTT before and after treatment. Both GTT (𝜌 = 0.22, p < 0.01) and SBTT (𝜌 = 0.47, p < 0.0001) showed positive correlations between pre- and post-treatment CE. In pre-treatment CE, physical factors and the presence of small intestinal mucosal injury had no associations with SBTT.

CONCLUSIONS

Moderate correlation in SBTT and slight correlation in GTT were shown on repeated CE. The factors affecting SBTT were not clarified in this analysis.

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.

An overview of angiodysplasia: management and patient prospects

Gastrointestinal angiodysplasias (GIADs) have a wide variety of presentations, which can be significant and debilitating in a subset of patients. Endoscopic ablation is currently the most effective treatment for GIADs, however re-bleeding rates are high. Several medical have been used for GIADs and reported in the literature, however these medications have significant side effect profiles and randomized controlled trials are lacking. A relatively poor understanding of the pathophysiology of GIAD formation has limited the development of more effective treatments and improved diagnostic and prognostic markers for GIAD. However, recent advances in research in the area of angiogenesis have identified a potential role for certain angiogenic factors including Angiopoeitin 1 and 2, in the pathophysiology of GIAD. Areas covered: We performed an extensive pubmed search of all articles mentioning GIAD and summarized our findings focussing on patient management and prospects. We summarize the available literature regarding the medical, endoscopic, and radiological management of GIAD and the value of clinical prognostic factors. Expert commentary: Although the area of angiogenesis is a novel area of research in GIAD, it represents an exciting avenue for development with the potential to improve diagnostic and prognostic tools to improve patient outcome.

Uncontrolled bleeding of the gastrointestinal tract

PURPOSE OF REVIEW

Acute gastrointestinal bleeding is a frequent emergency situation, whose incidence will likely rise as a result of the increasing use of direct anticoagulants and of the medical progresses resulting in longer life expectancy with underlying comorbidities. Updated guidelines and improvements in the diagnostic and therapeutic tools are now available and will likely improve the management of massive gastrointestinal bleeding in the near future.

RECENT FINDINGS

The assessment of severity has been improved by validated scores useable upon admission. Massive blood transfusion protocols and specific care in case of bleeding of patients treated with direct anticoagulants, including concentrates of coagulation factors and monoclonal antibodies are now available. The endoscopic management has been facilitated by the use of hemostatic powders and by the use of self-expanding metal stents in case of variceal hemorrhage. New diagnostic tools include emergency video-capsule endoscopy, multiphasic computed tomography angiography and enterography.

SUMMARY

The implementation of multidisciplinary diagnostic and therapeutic algorithms for the management of massive bleeding requires a close collaboration between emergency physicians, intensivists, endoscopists, radiologists and surgeons. A sequential strategy involving each of these specialists is desirable for a successful management of acute and massive gastrointestinal bleeding.

Diagnostic Benefit of Simultaneous Capsule Endoscopy Using Two Different Systems

Background/Aims

Capsule endoscopy (CE) is a noninvasive test for diagnosing small bowel disorders. However, several studies reported that the CE-based visualization is suboptimal. This study, the first to use two CEs simultaneously, aimed at evaluating the diagnostic ability of dual CE.

Methods

Dual CE procedures were prospectively conducted. All patients completed bowel cleansing 2 hours before examination. Subsequently, they simultaneously swallowed two capsules: MiroCam (IntroMedic, Seoul, Korea) and PillCam SB3 (Medtronic, Minneapolis, USA). We assessed the completeness and feasibility of small bowel examination and the detection rate of duodenal papilla and diagnostic yield.

Results

Twenty consecutive patients who underwent complete small bowel examination with dual CE were enrolled in the study. The mean time of small bowel passage was 245 ± 99 min. Dual CE examination increased the duodenal papilla detection rate to up to 75% (versus PillCam SB3 alone (P = 0.031) and MiroCam alone (P = 0.063)) and overall diagnostic yield to up to 70% (P = 0.063) in comparison to single CE. Adverse events or electrical interference during data transmission between the two capsule endoscopes were not detected.

Conclusions

In this study, we found that dual CE enhances diagnostic accuracy and could increase the diagnostic power of existing CE systems using simply applicable methods. This trial is registered with KCT0002541.

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.

Acute major gastrointestinal bleeding caused by hookworm infection in a patient on warfarin therapy: A case report

RATIONALE

The use of anticoagulants is a contributor to gastrointestinal (GI) bleeding. Most bleeding patients on anticoagulant therapy such as warfarin commonly have basic lesions existing in their GI mucosa.

PATIENT CONCERNS

We report a case of major GI bleeding following the use of anticoagulants in a patient with hookworm infection.

DIAGNOSES

The patient was diagnosed with nephrotic syndrome with pulmonary embolism.

INTERVENTIONS

He was treated with anticoagulants and suffered from acute major GI bleeding during the treatment. Capsule endoscopy revealed many hookworms in the lumen of jejunum where fresh blood was seen coming from the mucosa.

OUTCOMES

The patient was successfully rescued and cured with albendazole.

LESSONS

Latent hookworm infection can be a cause of massive small-bowel hemorrhage in patients on anticoagulant therapy and anthelmintic treatment is the key to stop bleeding.

Overview of small bowel angioectasias: clinical presentation and treatment options

Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.

Jejunal varices diagnosed by capsule endoscopy in patients with post-liver transplant portal hypertension

Portal hypertension secondary to portal vein obstruction following liver transplant occurs in 5%-10% of children. Jejunal varices are uncommon in this group. We present a case series of children with significant GI blood loss, negative upper endoscopy, and jejunal varices detected by CE. Case series of patients who had CE for chronic GI blood loss following liver transplantation. Three patients who had their initial transplants at a median age of 7 months were identified at our institution presenting at a median age of 8 years (range 7-16 years) with a median Hgb of 2.8 g/dL (range 1.8-6.8 g/dL). Upper endoscopy was negative for significant esophageal varices, gastric varices, and bleeding portal gastropathy in all three children. All three patients had significant jejunal varices noted on CE in mid-jejunum. Jejunal varices were described as large prominent bluish vessels underneath visualized mucosa, one with evidence of recent bleeding. The results led to venoplasty of the portal vein in two patients and a decompressive shunt in one patient with resolution of GI bleed and anemia. CE is useful to diagnose intestinal varices in children with portal hypertension and GI bleeding following liver transplant.

Clinical Practice Guidelines for the Use of Video Capsule Endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice.

METHODS

A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined.

CONCLUSIONS

CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.

Video capsule endoscopy in left ventricular assist device recipients with obscure gastrointestinal bleeding

AIM: To assess whether video capsule endoscopy (VCE) affects the outcomes of left ventricular assist devices (LVADs) recipients with gastrointestinal bleeding.

METHODS: This is a retrospective study of LVAD recipients with obscure gastrointestinal bleeding (OGIB) who underwent VCE at a tertiary medical center between 2005 and 2013. All patients were admitted and monitored with telemetry and all VCE and subsequent endoscopic procedures were performed as inpatients. A VCE study was considered positive only when P2 lesions were found and was regarded as negative if P1 or P0 were identified. All patients were followed until heart transplant, death, or the end of the study.

RESULTS: Between 2005 and 2013, 30 patients with LVAD underwent VCE. Completion rate of VCE was 93.3% and there was no capsule retention. No interference of VCE recording or the function of LVAD was found. VCE was positive in 40% of patients (n = 12). The most common finding was active small intestinal bleeding (50%) and small intestinal angiodysplasia (33.3%). There was no difference in the rate of recurrent bleeding between patients with positive and negative VCE study (50.0% vs 55.6%, P = 1.00) during an average of 11.6 ± 9.6 mo follow up. Among patients with positive VCE, the recurrent bleeding rate did not differ whether subsequent endoscopy was performed (50% vs 50%, P = 1.00).

CONCLUSION: VCE can be safely performed in LVAD recipients with a diagnostic yield of 40%. VCE does not affect recurrent bleeding in LVAD patients regardless of findings.

The Role of Emergency Endoscopy in Small Bowel Bleeding: A Review

There is no consensus on the timing and management of emergency overt obscure gastrointestinal bleeding. Emergency capsule endoscopy and balloon-assisted enteroscopy have a high diagnostic and therapeutic yield in these situations. Most lesions detected by small bowel endoscopy are amenable to endoscopic haemostasis, although some lesions still require surgery or interventional radiology. The management of these patients is varied, and doubt persists about which technique should be preferred as first-line treatment. This narrative review analyses the usefulness and impact of small bowel endoscopic techniques in the emergency setting for severe overt obscure gastrointestinal bleeding.

Multiple Polypoid Angiodysplasia with Obscure Overt Bleeding

Angiodysplasia (AD) is increasingly being recognized as a major cause of gastrointestinal bleeding. Morphologically flat lesions are common types of AD, whereas the polypoid types are rare. We report a case of multiple polypoid AD in the small bowel causing severe anemia and requiring surgical treatment. A 60-year-old male patient visited our hospital with dyspnea and hematochezia. He had a history of myocardial infarction and was taking both aspirin and clopidogrel. Capsule endoscopy, enteroscopy, computed tomography, and angiography revealed multifocal vascular lesions with a polypoid shape in the jejunum. Surgical resection was performed because endoscopic treatment was considered impossible with the number and the location of lesions. The risk of recurrent bleeding related to the use of antiplatelet agents also contributed to the decision to perform surgery. AD was histologically diagnosed from the surgical specimen. He resumed taking both aspirin and clopidogrel after surgery. He fully recovered and has been doing well during the several months of follow-up.

Video capsule endoscopy as the initial examination for overt obscure gastrointestinal bleeding can efficiently identify patients who require double-balloon enteroscopy

Background

Both double-balloon enteroscopy (DBE) and video capsule endoscopy (VCE) have similar diagnostic yields for patients with overt obscure gastrointestinal bleeding (OGIB). However, the choice of initial modality is still controversial. The aim of this study was to show the clinical outcome of the strategy of initial VCE, followed by DBE.

Methods

Eighty-nine consecutive overt OGIB patients who had undergone VCE as the initial examination were analyzed. The interpreters of VCE evaluated the necessity of performing DBE, and the antegrade or retrograde route was chosen, depending on the transit time of the capsule.

Results

Thirty-seven patients (42 %) underwent DBE depending on the findings of VCE. Of these, bleeding sites in the small bowel were identified in 29 patients with the initially selected route (21 antegrade and 8 retrograde). The remaining 8 later underwent DBE by the other route, but 7 had no bleeding lesion, which was confirmed by second-look VCE. One remaining patient had a jejunal varix found by VCE, but DBE from either side could not reach the lesion. The sensitivity and negative predictive value of VCE were 100 %, both for the presence of small bowel lesions and the requirement of hemostasis in the small bowel; this indicated that VCE never misses relevant findings in the small bowel, and that negative VCE findings correspond to the lack of necessity for further examination.

Conclusions

VCE as the initial examination can efficiently identify overt OGIB patients who require DBE. The strategy of initial VCE for overt OGIB appears to be reasonable.

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.

Efficacy and implications of a 48-h cutoff for video capsule endoscopy application in overt obscure gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

Early video capsule endoscopy (VCE) may provide a high diagnostic yield and improve clinical outcomes in patients with overt obscure gastrointestinal bleeding (OGIB); however, there is no practical recommendation for the ideal timing of VCE application in overt OGIB. Therefore, this study investigated the diagnostic yield and efficacy of VCE to assess overt OGIB with respect to the timing of application.

PATIENTS AND METHODS

We retrospectively enrolled patients who had undergone VCE for overt OGIB between April 2004 and February 2014 at a tertiary referral academic center. We included hemodynamically stable patients who underwent VCE for overt OGIB after negative bidirectional endoscopy. We analyzed the diagnostic yield of VCE, therapeutic intervention rate, and length of hospital stay.

RESULTS

A total of 94 patients underwent VCE to assess overt OGIB. The diagnostic yields in the groups that underwent VCE < 48 h and > 48 h from the last overt OGIB were 66.7 % and 40.6 %, respectively (P = 0.019). Therapeutic intervention was performed in 26.7 % and 9.4 % of patients in the < 48-h and > 48-h groups, respectively (P = 0.028). The mean lengths of hospital stay in the < 48-h and > 48-h groups were 5 days (95 % confidence interval [CI], 4.8 - 7.7) and 7 days (95 %CI, 6.9 - 10.1), respectively (P = 0.039).

CONCLUSIONS

Performing VCE within 2 days from the last overt OGIB results in a higher diagnostic yield, higher therapeutic intervention rate, and shorter hospital stay. Therefore, VCE application with a 48-h cutoff could improve the outcome of patients with overt OGIB.

Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results

BACKGROUND

In mid-GI bleeding, video capsule endoscopy (VCE) shows the best diagnostic yield for ongoing overt bleeding. To date, the utility of VCE in acute severe GI bleeding has been analyzed rarely.

OBJECTIVE

To evaluate the impact of VCE when performed on patients with acute severe GI bleeding immediately after an initial negative upper endoscopy result.

DESIGN

Prospective study.

SETTING

Tertiary-care center.

PATIENTS

Patients with melena, dark-red or maroon stool, hemodynamic instability, drop of hemoglobin level ≥2 g/dL/day, and/or need of transfusion ≥2 units of packed red blood cells per day were included.

INTERVENTIONS

After a negative upper endoscopy result, emergency VCE was performed by immediate endoscopic placement of the video capsule into the duodenum.

MAIN OUTCOME MEASUREMENTS

Rate of patients in whom emergency VCE correctly guided further diagnostic and therapeutic procedures.

RESULTS

Upper endoscopy showed the source of bleeding in 68 of 88 patients (77%). In the remaining 20 patients (23%), emergency VCE was performed, which was feasible in 19 of 20 patients (95%; 95% confidence interval [CI], 75%-99%). Emergency VCE correctly guided further diagnostic and therapeutic procedures in 17 of 20 patients (85%; 95% CI, 62%-97%) and showed a diagnostic yield of 75% (95% CI, 51%-91%).

LIMITATIONS

Single-center study, small sample size.

CONCLUSION

In patients with acute severe GI bleeding and negative upper endoscopy results, emergency VCE can be useful for the immediate detection of the bleeding site and is able to guide further therapy. (Clinical trial registration number: NCT01584869.)

[Capsule endoscopy and obscure gastrointestinal bleeding: does the form of presentation matter?]

INTRODUCTION

Obscure gastrointestinal bleeding (OGIB) is defined as bleeding from the gastrointestinal tract with no obvious cause after assessment with upper and lower gastrointestinal endoscopy. In these cases, the source is suspected to be in the small bowel. Obscure bleeding can be occult or overt. The aim of this study was to analyze the clinical and analytical characteristics and findings on capsule endoscopy in patients with OGIB and to determine the factors related to the detection of lesions in both forms of presentation.

METHODS

We performed a retrospective study of capsule endoscopies carried out between November 2009 and November 2012 for OGIB.

RESULTS

We analyzed 284 capsule endoscopies in 272 patients. Initially, 12 procedures could not be evaluated and were repeated. A total of 272 procedures were finally included in the analysis. The results of 114 (41.9%) capsule endoscopies were normal. Compared with patients with occult OGIB, those with overt OGIB were significantly older (70.2 vs. 67.5 years; p = 0.04), consumed more NSAID (24.2% vs. 11.9%; p = 0.01), had higher hemoglobin levels (9.3 vs. 10.4; p < 0,001) and more frequently required transfusion (64.5% vs 32.2%; p < 0.001). No differences were found between the two forms of presentation in the detection of canker sores-ulcers and polyps-masses. Vascular lesions were more frequently detected in overt than in occult OGIB (40.3% vs. 25.7%, respectively), (p < 0.05). When the total number of diagnoses carried out by capsule endoscopy was analyzed, no differences were found in diagnostic yield between overt OGIB (57%) and occult OGIB (54%), (p = 0.6). In overt OGIB, multivariate analysis showed that the variables that significantly predicted the detection of lesions on capsule endoscopy were consumption of medication NSAID (OR 2.75; p = 0.01), antiplatelets and anticoagulants (OR 2.64; p = 0.03) and analytical data hemoglobin (OR 3.23; p < 0.001) and INR (OR 1.8; p = 0.02). In occult OGIB, multivariate analysis showed that the factors significantly related to the detection of lesions on endoscopy were age (OR 1.9; p = 0.04) and NSAID consumption (OR 2.1; p = 0.01).

CONCLUSIONS

Capsule endoscopy is essential in the assessment of OGIB. Although the diagnostic yield was similar in both forms of presentation, vascular lesions were more frequently detected in overt OGIB. The diagnostic yield of capsule endoscopy could be optimized by taking into account the form of presentation (overt vs. occult) and certain clinical and analytic data (age, drug consumption, hemoglobin).