The role of wireless capsule endoscopy in investigating unexplained iron deficiency anemia after negative endoscopic evaluation of the upper and lower gastrointestinal tract

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.

Experiencia con el uso de videocápsula endoscópica en pacientes con anemia ferropénica inexplicada

Introducción: la prevalencia de la anemia ferropénica en países desarrollados se ha estimado entre 2 %-5 %, asociada con una alta morbimortalidad. La identificación etiológica a veces es difícil, y requiere de métodos diagnósticos, como la videocápsula endoscópica (VCE). Objetivo: el objeto del presente estudio fue caracterizar los hallazgos de esta técnica en pacientes con anemia ferropénica inexplicada. Materiales y métodos: estudio descriptivo, observacional y retrospectivo. Se describen los hallazgos de VCE (PillCamSB2-SB3) en todos los pacientes atendidos entre 2011 y 2019. Los hallazgos se interpretaron según la clasificación de Saurin: normal (P0), potencial incierto (P1) y alto potencial de sangrado (P2). Resultados: del total de 490 VCE realizadas durante el período del estudio, 155 se efectuaron con indicación de anemia ferropénica; 106 fueron mujeres (68,4 %) y la edad media fue de 57,1 ± 16,6 años. Las comorbilidades principales fueron cardiovasculares en 23 (18,3 %) e hipertensión arterial en 16 (12,6 %). La ingesta de antiplaquetarios se presentó en 18 (15,4 %) y anticoagulantes en 6 (5,1 %). Las lesiones en el intestino delgado fueron vasculares en 44 estudios (28,4 %), inflamatorias en 33 (21,2 %) y neoplásicas en 7 (4,5 %). Las angiectasias fueron las lesiones más frecuentes en 33 casos (21,3 %). En 53 VCE se presentaron lesiones P2 (34,2 %). Conclusiones: la VCE es útil en el estudio de la anemia ferropénica, y ayuda a detectar hallazgos positivos en el intestino medio en 3 de cada 4 pacientes en los cuales se indica su uso. Las lesiones P2 significativas más frecuentes fueron las vasculares. Estos hallazgos permiten enfocar un tratamiento adecuado.

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.

Endoscopic Delivery Method Using a Retrieval Net for Patients with Small-Bowel Capsule Endoscopy Stagnation in the Stomach

With the increasing use of capsule endoscopy (CE), screening tests for the small bowel can be performed with minimal invasiveness. However, occasionally, the entire small bowel cannot be observed because of decreased peristalsis of the stomach. For such cases, we perform delivery of CE by an endoscope. We retrospectively examined the usefulness of the endoscopic delivery method using a retrieval net for patients with CE stagnation in the stomach. From 2,270 patients who underwent small-bowel CE at Hiroshima University Hospital from January 2013 to January 2020, 29 consecutive patients (1.3% of the total number) in whom the small bowel could not be observed due to CE stagnation in the stomach at the time of the initial CE underwent the endoscopic delivery method using a retrieval net for secondary small-bowel CE. This study included 16 male (55%) and 13 female (45%) patients with a mean age of 69.2 ± 13.2 years. 11 patients (38%) had a history of gastrointestinal surgical resection. The entire small bowel could be observed in 19 patients (66%), and CE reached the terminal ileum in the remaining patients. A history of gastrointestinal surgical resection was significantly more frequent in the group where the entire small bowel could not be observed. The rate of small-bowel lesion detection was 55% (16/29). There were no adverse events associated with our endoscopic delivery method. Thus, the endoscopic delivery method using a retrieval net for patients with initial CE stagnation in the stomach may be safe and useful for the detection of small-bowel lesions.

Predictors of Positive Video Capsule Endoscopy Findings for Chronic Unexplained Abdominal Pain: Single-Center Retrospective Study and Meta-Analysis

Video capsule endoscopy (VCE) is an effective diagnostic modality for detecting small bowel lesions. However, the value of VCE for patients with chronic recurrent abdominal pain (CAP) of unknown etiology remains obscure. We retrospectively analyzed factors that could predict enteropathy based on the medical records of 65 patients with unexplained chronic recurrent abdominal pain (CAP) who were assessed using VCE between 2001 and 2021. We also conducted a systematic review and meta-analysis of the literature to validate our results. The positive findings of 27 (41.5%) of the 65 patients were mostly ulcerative lesions including stricture (n = 14, 60.9%) and erosion (n = 8, 29.7%). Multivariate analysis identified elevated ESR (OR, 1.06, 95% CI, 1.02–1.1, p = 0.004) as a significant risk factor for enteropathy predicted by VCE. Three eligible studies in the meta-analysis included 523 patients with CAP. Elevated C-reactive protein (CRP) (OR, 14.09; 95% CI, 2.81–70.60; p = 0.001) and erythrocyte sedimentation rate (ESR) (OR, 14.45; 95% CI, 0.92–227.33; p = 0.06) indicated VCE-positive findings in patients with unexplained abdominal pain. Elevated levels of the inflammatory markers ESR and CRP can thus predict positive VCE findings in patients with CAP.

Artificial intelligence using a convolutional neural network for automatic detection of small-bowel angioectasia in capsule endoscopy images

BACKGROUND AND AIM

Although small-bowel angioectasia is reported as the most common cause of bleeding in patients and frequently diagnosed by capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding, a computer-aided detection method has not been established. We developed an artificial intelligence system with deep learning that can automatically detect small-bowel angioectasia in CE images.

METHODS

We trained a deep convolutional neural network (CNN) system based on Single Shot Multibox Detector using 2237 CE images of angioectasia. We assessed its diagnostic accuracy by calculating the area under the receiver operating characteristic curve (ROC-AUC), sensitivity, specificity, positive predictive value, and negative predictive value using an independent test set of 10 488 small-bowel images, including 488 images of small-bowel angioectasia.

RESULTS

The AUC to detect angioectasia was 0.998. Sensitivity, specificity, positive predictive value, and negative predictive value of CNN were 98.8%, 98.4%, 75.4%, and 99.9%, respectively, at a cut-off value of 0.36 for the probability score.

CONCLUSIONS

We developed and validated a new system based on CNN to automatically detect angioectasia in CE images. This may be well applicable to daily clinical practice to reduce the burden of physicians as well as to reduce oversight.

The Clinical Usefulness of the PillCam Progress Indicator for Route Selection in Double Balloon Endoscopy

Objective The utility of capsule endoscopy (CE) findings in the route selection for double balloon endoscopy (DBE) has not been adequately discussed. The PillCam Progress Indicator in the RAPID 6.5 software program graphically demonstrates the progress of the capsule endoscope through the small-bowel. This study aimed to clarify the usefulness of the PillCam Progress Indicator in choosing the initial DBE route. Methods We retrospectively examined 50 consecutive patients with 50 target lesions detected on both CE and DBE at Hiroshima University Hospital from January 2011 to February 2018. In this study, we selected antegrade DBE on the basis of % Capsule Progress <50% as a clinical trial. The association between the PillCam Progress Indicator data and the DBE route to the target lesion was analyzed. Results The target lesion was reached via the initial DBE route in 96% (48/50) of cases. The cutoff values for selecting an antegrade route for DBE were 50% for % Capsule Progress and 42% for % SB Time. At the cutoff value, the sensitivity, specificity, and positive and negative predictive values for route selection were 100%, 91%, 93%, and 100% for % Capsule Progress and 96%, 91%, 93%, and 95% for % SB Time. Conclusion The PillCam Progress Indicator was useful for determining the appropriate initial DBE route.

Repeat capsule endoscopy in suspected gastrointestinal bleeding

Objectives: This study aims to review the utility of repeat capsule endoscopy (CE) with on-going concern of small bowel (SB) bleeding following initial SB investigation with CE. Materials and methods: A specifically designed database of CE examinations performed over 13 years, with hospital records, was retrospectively interrogated for patients undergoing multiple CEs to investigate iron deficiency anaemia (IDA) or suspected SB bleeding. Results: 1335/2276 (58.7%) of CEs were performed to investigate IDA or SB bleeding; 92 were repeat CEs carried out for ongoing clinical concern. The median time interval between initial and repeat CE procedures was 466.5 (range 1-3066) days. Twenty-four patients had initially normal CE; on repeat examination, abnormalities were detected in 11/24 (45.8%). 3/21 (14.2%) of patients with angioectasia on first CE had alternative causes for IDA or GI bleeding detected on repeat CE. Six patients with active bleeding, without an identifiable source on initial CE, undergoing repeat CE had a cause isolated in 5/6 (83.3%). Changing CE device did not affect diagnostic yield (DY) compared to repeat CE using the same device (27.5% to 26.8%). Conclusions: It is known that CE can miss clinically relevant and serious lesions. Our results suggest that patients with an initially negative or inconclusive CE frequently have a cause of SB bleeding detected on repeat CE. The DY of repeat CE is highest in those with bleeding on their initial CE (83.3%) and lower in those with initially normal examinations (45.8%) or when an alternative cause, such as angioectasia is seen (14.2%).

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.

Small bowel capsule endoscopy: Indications, results, and clinical benefit in a University environment

Capsule endoscopy (CE) opened a new method for visualization of the small intestine. We here further explore its clinical implications.We retrospectively analyzed the clinical benefit of CE in view of medical history, diagnostics, and therapy. Our patient collective consisted of 203 patients. CE was investigated in the context of bleeding, anemia, abdominal pain, diarrhea, Crohn's disease, and suspected tumors.The study collective consisted of 118 male and 85 female patients with a mean age of 58 years (range 8-90 years). Complete bowel transit took place in 82% of the patients. The diagnostic yield in the detection of obscure gastrointestinal bleeding was 80% and for anemia 78%. Mucosal lesions were the most common finding (43%). Unclear abdominal pain had the lowest diagnostic yield (41%). Ensuing therapeutic interventions were mostly medical (66%), and to a minor extent surgical (4.4%) as well as endoscopic (4%).In conclusion, small intestinal CE is a secure method to clarify small intestinal diseases, especially obscure gastrointestinal bleeding, even in pre-operated patients without stenosis symptoms. Our study emphasizes in a collective of patients with extensive prior diagnostics that due to CE therapeutic measures resulted in 73%.

Practical gastrointestinal investigation of iron deficiency anaemia

About 10% of oesophagogastroduodenoscopies (OGDs) and colonoscopies are done for investigation of iron deficiency anemia (IDA) . Much of the existing guidance on investigation of IDA predates CRC screening, which has driven significant improvements in colonoscopy quality and completion rates, as well as a reduction in Helicobacter pylori prevalence and increase in PPI usage, and therefore probably needs re-consideration. New investigations, e.g. CT colonography, enteroscopy and capsule endoscopy have also been introduced. Areas covered: This review updates the approach to practical investigation of IDA. Medline was searched using the terms iron deficiency AND anemia AND/OR gastroscopy, colonoscopy, capsule and enteroscopy, together with review of recent relevant published abstracts on the topic. Expert commentary: Gastrointestinal pathology is now a more common cause of IDA than upper GI causes, reflecting better colonoscopy accuracy and completion rates as well as changing disease patterns, and carcinomas are more likely cause IDA than benign adenomas. Increasing use of antiplatelet and anticoagulants is driving greater presentation of IDA. Capsule endoscopy, enteroscopy and CT colonography are increasingly used. Fecal occult blood testing may be a useful simple screening method in the frail, as a negative test can avoid the need for invasive tests.

Evaluation of the Usefulness of Virtual Chromoendoscopy with Different Color Modes in the MiroCam® System for Characterization of Small Bowel Lesions

Background

Virtual chromoendoscopy (VC) in small bowel capsule endoscopy can improve the visualization and characterization of different small bowel lesions (SBLs). There are few studies of its usefulness in the Given® system, and there is no evidence yet of its utility in the MiroCam® system.

Aim

The aim of this study was to evaluate whether VC can improve the characterization of SBLs with the MiroCam® system.

Methods

Twenty-two patients were selected, in which 100 elementary lesions were identified, including erosions (n = 45), ulcers (n = 17), and angioectasias (n = 38). For each lesion identified, images were captured without chromoendoscopy (normal image [NI]) and with chromoendoscopy modes 1 (color mode [CM] 1), 2 (CM2), and 3 (CM3). A score from 1 to 4 was assigned to each image, in which a better evaluation of the characteristics and limits of the lesion was classified in ascending order, where 1 is the worst and 4 the best evaluation. The scores of the various modes were compared with Kendall's tau-c coefficient.

Results

The average scores attributed to the photographs in NI, CM1, CM2, and CM3 were 3.83, 2.89, 1.85, and 1.43, respectively (tau-c = -0.75, p < 0.001). Evaluating the elementary lesions independently, the average scores for modes NI, CM1, CM2, and CM3 were 3.83, 2.92, 1.86, and 1.38 (tau-c = -0.77, p < 0.001) for erosions, respectively; 3.87, 2.96, 1.76, and 1.40 (tau-c = -0.80, p < 0.001) for ulcers, respectively; and 3.81, 2.82, 1.87, and 1.50 (tau-c = -0.71, p < 0.001) for angioectasias, respectively.

Conclusions

VC using the CMs available in the MiroCam® system has not proven useful for a better assessment of any of the SBLs.

Clinical outcome of patients with obscure gastrointestinal bleeding during antithrombotic drug therapy

BACKGROUND

The clinical outcome of patients with obscure gastrointestinal bleeding (OGIB) during antithrombotic drug therapy has not been fully investigated.

METHODS

Patients who underwent video capsule endoscopy (VCE) for the investigation of OGIB at Okayama University Hospital from January 2009 to March 2016 were enrolled. We evaluated the VCE findings, the patterns of OGIB, and the rate of rebleeding within 1 year in antithrombotic drug users and antithrombotic drug nonusers.

RESULTS

A total of 181 patients were enrolled. Among the antithrombotic drug users, the rate of VCE positivity in the patients with overt OGIB was significantly higher in comparison with patients with occult OGIB (45% versus 16%, p = 0.014), whereas there was no significant difference among the antithrombotic drug nonusers (27% versus 26%, p = 1.0). Among the antithrombotic drug users, the rate of rebleeding among the VCE-positive patients was significantly higher in comparison with the VCE-negative patients (50% versus 5.9%, p = 0.011). Moreover, among antithrombotic drug users who did not receive therapeutic intervention, the rate of rebleeding among the VCE-positive patients was significantly higher in comparison with the VCE-negative patients (75% versus 6.3%, p = 0.001). However, among the antithrombotic drug nonusers who did not receive therapeutic intervention, the rebleeding rate of the VCE-positive patients was not significantly different from that of the VCE-negative patients (20% versus 9.4%, p = 0.43).

CONCLUSION

Therapeutic intervention should be considered for patients with overt OGIB who are VCE positive and who use antithrombotic drugs due to the high risk of rebleeding.

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.

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.

Indications for Small-bowel Capsule Endoscopy in Patients with Chronic Abdominal Pain

Objective The aim of the present study is to assess the difference in the detection rates of small-bowel lesions in chronic abdominal pain (CAP) patients with irritable bowel syndrome (IBS) and non-IBS. Patients Ninety-nine CAP patients who were scheduled to undergo capsule endoscopy (CE) to investigate their abdominal symptoms were included in this study. Among the subjects, 34 patients fulfilled the Rome III criteria for IBS (IBS group); the remaining 65 patients were categorized as the non-IBS group. CE was performed in both groups and the total enteroscopy achievement rate, small-bowel lesion detection rate, and the presence of small-bowel lesions were evaluated. We also evaluated the patients' blood test results and the rate at which abdominal symptoms improved following internal medication. Results Total enteroscopy was achieved in 62% (21/34) and 86% (56/65) of the IBS and non-IBS patients, respectively. The total enteroscopy achievement rate was significantly higher in non-IBS patients. The small-bowel lesion detection rates were 3% (1/34) and 19% (12/65), respectively, and the detection rate was significantly higher in the non-IBS patients. In the non-IBS patients, mean C-reactive protein (CRP) was significantly higher in the patients with small-bowel lesions. The abdominal symptoms of 12 (92%) of the CAP patients with small-bowel lesions were improved by internal medication. Conclusion CE may be considered for non-IBS CAP patients with high levels of CRP.

Efficacy of repeat review with flexible spectral imaging color enhancement in patients with no findings by capsule endoscopy

BACKGROUND/AIM

The efficacy of flexible spectral imaging color enhancement (FICE) ch. 1 (F1) for the detection of ulcerative lesions and angioectasias in the small intestine with capsule endoscopy (CE) has been reported. In the present study, we evaluated whether F1 could detect incremental findings in patients with no findings in a standard review mode.

PATIENTS AND METHODS

In total, 52 patients (age: 60.1 ± 15.3 years; 30 males) with obscure gastrointestinal bleeding (OGIB) who underwent CE and in whom no lesion was detected in the small intestine in the standard mode (first review) were enrolled. Two experienced endoscopists independently reviewed CE videos again by F1 (second review). The following findings were defined to be significant: Ulcers, erosions, aphthas, angioectasias, tumors, and bleeding. Incremental findings at the second review were checked at F1 and in standard mode by the two reviewers (third review). Finally, the findings were confirmed by the agreement of the two reviewers at the third review.

RESULTS

F1 detected five significant lesions in three patients with overt OGIB; three erosions, one aphtha, and one angioectasia. For nonsignificant lesions, F1 detected 12 red mucosas and 16 red spots. Moreover, 29 patients with 71 findings were considered false positives.

CONCLUSION

F1 detected incremental significant findings in a small percentage of patients with no findings in the standard review mode. In addition, F1 showed many false-positive findings. The incremental effect of a repeated review by F1 in patients with no findings in the first review is limited.

The Utility of Capsule Endoscopy in Patients under 50 Years of Age with Recurrent Iron Deficiency Anaemia: Is the Juice Worth the Squeeze?

Background and Aims. The role of capsule endoscopy (CE) in the <50 years of age patients with iron deficiency anaemia (IDA) remains unclear. We aim to assess its utility in this cohort. Methods. All patients referred for CE for recurrent IDA were included retrospectively. Patients were divided into Group 1 (<50 years) and Group 2 (≥50 years). Results. There were 971 patients with recurrent IDA and 28% belonged to Group 1. The mean age was 40 years in this group with a DY of 28% (n = 76). Significant diagnoses included erosions and ulcers (26%; n = 71), small bowel (SB) angioectasia (AE) (10%; n = 27), SB tumours (3%; n = 7), Crohn's disease (3%; n = 7), SB bowel strictures (1%; n = 3), and SB varices (1%; n = 2). On logistic regression, the presence of diabetes (P = 0.02) and the use of warfarin (P = 0.049) was associated with increased DY. The DY in Group 2 was 38% which was significantly higher than in Group 1 (P = 0.02). While SB tumours were equally common in both groups, AE was commoner in Group 2 (P < 0.001). Conclusion. A significant proportion of patients <50 years are referred for CE. Although the DY is lower compared to those ≥50 years, significant pathology is found in this age group. CE is advisable in patients <50 years old with recurrent IDA and negative bidirectional endoscopies.

Current status of capsule endoscopy through a whole digestive tract

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

Wireless capsule endoscopy: perspectives beyond gastrointestinal bleeding

Wireless capsule endoscopy (CE) is a technology developed for the endoscopic exploration of the small bowel. The first capsule model was approved by the Food and Drug Administration in 2001, and its first and essential indication was occult gastrointestinal (GI) bleeding. Over subsequent years, this technology has been refined to provide superior resolution, increased battery life, and capabilities to view different parts of the GI tract. Indeed, cases for which CE proved useful have increased significantly over the last few years, with new indications for the small bowel and technical improvements that have expanded its use to other parts of the GI tract, including the esophagus and colon. The main challenges in the development of CE are new devices with the ability to provide therapy, air inflation for a better vision of the small bowel, biopsy sampling systems attached to the capsule and the possibility to guide and move the capsule with an external motion control. In this article we review the current and new indications of CE, and the evolving technological changes shaping this technology, which has a promising potential in the coming future of gastroenterology.

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.

Is Occult Obscure Gastrointestinal Bleeding a Definite Indication for Capsule Endoscopy? A Retrospective Analysis of Diagnostic Yield in Patients with Occult versus Overt Bleeding

Background/Aim. Usefulness of capsule endoscopy (CE) for diagnosing small-bowel lesions in patients with obscure gastrointestinal bleeding (OGIB) has been reported. Most reports have addressed the clinical features of overt OGIB, with few addressing occult OGIB. We aimed to clarify whether occult OGIB is a definite indication for CE. Methods. We retrospectively compared the cases of 102 patients with occult OGIB and 325 patients with overt OGIB, all having undergone CE. The diagnostic yield of CE and identification of various lesion types were determined in cases of occult OGIB versus overt OGIB. Results. There was no significant difference in diagnostic yield between occult and overt OGIB. The small-bowel lesions in cases of occult OGIB were diagnosed as ulcer/erosive lesions (n = 18, 18%), vascular lesions (n = 11, 11%), and tumors (n = 4, 3%), and those in cases of overt OGIB were diagnosed as ulcer/erosive lesions (n = 51, 16%), vascular lesions (n = 31, 10%), and tumors (n = 20, 6%). Conclusion. CE detection rates and CE identification of various small-bowel diseases do not differ between patients with occult versus overt OGIB. CE should be actively performed for patients with either occult or overt OGIB.

PBPK models for the prediction of in vivo performance of oral dosage forms

Drug absorption from the gastrointestinal (GI) tract is a highly complex process dependent upon numerous factors including the physicochemical properties of the drug, characteristics of the formulation and interplay with the underlying physiological properties of the GI tract. The ability to accurately predict oral drug absorption during drug product development is becoming more relevant given the current challenges facing the pharmaceutical industry. Physiologically-based pharmacokinetic (PBPK) modeling provides an approach that enables the plasma concentration-time profiles to be predicted from preclinical in vitro and in vivo data and can thus provide a valuable resource to support decisions at various stages of the drug development process. Whilst there have been quite a few successes with PBPK models identifying key issues in the development of new drugs in vivo, there are still many aspects that need to be addressed in order to maximize the utility of the PBPK models to predict drug absorption, including improving our understanding of conditions in the lower small intestine and colon, taking the influence of disease on GI physiology into account and further exploring the reasons behind population variability. Importantly, there is also a need to create more appropriate in vitro models for testing dosage form performance and to streamline data input from these into the PBPK models. As part of the Oral Biopharmaceutical Tools (OrBiTo) project, this review provides a summary of the current status of PBPK models available. The current challenges in PBPK set-ups for oral drug absorption including the composition of GI luminal contents, transit and hydrodynamics, permeability and intestinal wall metabolism are discussed in detail. Further, the challenges regarding the appropriate integration of results from in vitro models, such as consideration of appropriate integration/estimation of solubility and the complexity of the in vitro release and precipitation data, are also highlighted as important steps to advancing the application of PBPK models in drug development. It is expected that the "innovative" integration of in vitro data from more appropriate in vitro models and the enhancement of the GI physiology component of PBPK models, arising from the OrBiTo project, will lead to a significant enhancement in the ability of PBPK models to successfully predict oral drug absorption and advance their role in preclinical and clinical development, as well as for regulatory applications.

Characteristics of the small bowel lesions detected by capsule endoscopy in patients with chronic kidney disease

Obscure gastrointestinal bleeding (OGIB) is one of the common complications in patients with chronic kidney disease (CKD), especially those who are on maintenance hemodialysis (HD). However, little is known about the characteristics of the small-bowel lesions in these patients, or of the factors that could predict the presence of such lesions. Therefore we enrolled a total of 42 CKD patients (including 19 HD patients and 23 non-HD patients), and compared the incidence of the small-bowel lesions among two groups. Furthermore, to identify predictive factors for the presence of small-bowel lesions, we performed multivariate logistic-regression-analyses. The incidence of small-bowel vascular lesions was significantly higher in CKD patients than in age-and-sex matched non-CKD patients (P < 0.001). On the other hand, there was any significant difference of the incidence of small-bowel lesions between HD and non-HD patients. In CKD patients, past history of blood transfusion (OR 5.66; 95% CI 1.10–29.1, P = 0.04) was identified as an independent predictor of the presence of vascular lesions, and history of low-dose aspirin use (OR 6.00; 95% CI 1.13–31.9, P = 0.04) was identified as that of erosive/ulcerated lesions. This indicated that proactive CE examination would be clinically meaningful for these patients.

Negative capsule endoscopy in patients with obscure gastrointestinal bleeding reliable: recurrence of bleeding on long-term follow-up

AIM

To assess the rate of recurrent bleeding of the small bowel in patients with obscure bleeding already undergone capsule endoscopy (CE) with negative results.

METHODS

We reviewed the medical records related to 696 consecutive CE performed from December 2002 to January 2011, focusing our attention on patients with recurrence of obscure bleeding and negative CE. Evaluating the patient follow-up, we analyzed the recurrence rate of obscure bleeding in patient with a negative CE. Actuarial rates of rebleeding during follow-up were calculated, and factors associated with rebleeding were assessed through an univariate and multivariate analysis. A P value of less than 0.05 was regarded as statistically significant. The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of negative CE were calculated.

RESULTS

Two hundred and seven out of 696 (29.7%) CE studies resulted negative in patient with obscure/overt gastrointestinal bleeding. Overall, 489 CE (70.2%) were positive studies. The median follow-up was 24 mo (range 12-36 mo). During follow-up, recurrence of obscure bleeding was observed only in 34 out of 207 negative CE patients (16.4%); 26 out of 34 with obscure overt bleeding and 8 out of 34 with obscure occult bleeding. The younger age (< 65 years) and the onset of bleeding such as melena are independent risk factors of rebleeding after a negative CE (OR = 2.6703, 95%CI: 1.1651-6.1202, P = 0.0203; OR 4.7718, 95%CI: 1.9739-11.5350, P = 0.0005). The rebleeding rate (CE+ vs CE-) was 16.4% vs 45.1% (χ(2) test, P = 0.00001). The sensitivity, specificity, and PPV and NPV were 93.8%, 100%, 100%, 80.1%, respectively.

CONCLUSION

Patients with obscure gastrointestinal bleeding and negative CE had a significantly lower rebleeding rate, and further invasive investigations can be deferred.

Factors predicting the presence of small bowel lesions in patients with obscure gastrointestinal bleeding

AIM

To identify the predictive factors for the presence of small bowel lesions in patients with obscure gastrointestinal bleeding (OGIB).

METHODS

A total of 242 patients with OGIB (overt 149: occult 93) were retrospectively included in the present study. Capsule endoscopy (CE) was carried out to investigate the small bowel, and detected lesions were classified according to the P0-P2 system. Only P2 lesions were defined as significant lesions. Univariate and multivariate logistic regression analyses were carried out to define the predictive factors for the presence of small bowel lesions.

RESULTS

In patients with overt OGIB, chronic kidney disease (CKD) ≥stage 4 (odds ratio [OR] 4.03; 95% confidence interval [CI] 1.45-11.1, P = 0.007) was identified as an independent predictor of the presence of vascular lesions, and a history of non-steroidalanti-inflammatory drug (NSAID) use as that of erosive/ulcerated lesions (OR 4.73; 95% CI 1.47-15.2, P = 0.009). However, in patients with occult OGIB, no significant predictors of the presence of vascular lesions were identified, whereas a history of low-dose aspirin (LDA) (OR 3.57; 95% CI 1.21-10.5, P = 0.02) and proton pump inhibitor (PPI) use (OR 3.18; 95% CI 1.02-9.92, P = 0.05) were identified as independent predictors of the presence of erosive/ulcerated lesions.

CONCLUSIONS

Our results indicated that bleeding pattern and clinical characteristics could contribute to predicting the origin of OGIB.

The use of small bowel capsule endoscopy in iron deficiency anaemia: low impact on outcome in the medium term despite high diagnostic yield

INTRODUCTION

Small bowel capsule endoscopy (SBCE) is a useful diagnostic modality in small bowel disorders. Iron deficiency anaemia (IDA) is one of the most common indications for SBCE. However, there are limited data on the diagnostic yield for IDA alone, and little is known about the clinical impact and long-term outcome of patients following SBCE.

AIM

To determine the diagnostic yield of SBCE in IDA and to examine outcome.

MATERIALS AND METHODS

A retrospective review of a tertiary referral centre's database over a 21-month time period was carried out. Information on follow-up and management was obtained through chart review.

RESULTS

In all, 309 SBCEs were identified, 30% (n=93) for anaemia and in 70% (n=65), follow-up data were available. The small bowel diagnostic yield for IDA was 53% (n=35), including angiodysplasia 49% (n=17), nonspecific inflammation 34% (n=12), active bleeding 11% (n=4) and Crohn's disease 6% (n=2). In addition, 16% (n=10) had abnormalities (gastritis, gastric antral vascular ectasia, duodenitis) outside the small bowel. In all, 42% (n=27) were persistently anaemic after a mean follow-up of 9.3 months. Of these, 52% (n=14) and 48% (n=13) had positive and negative SBCEs, respectively. In total, SBCE led to a change in treatment in 28 patients (44%), of whom 17 (61%) remained anaemic.

CONCLUSION

This study shows a high overall diagnostic yield for SBCE in IDA 71% (n=45). Despite the majority, 53% (n=24), of patients with positive tests receiving specific treatment, 61% (n=17) remained anaemic in the long term. SBCE results were not predictive of long-term outcome even when stratified for a change in management.

Long-term outcomes and prognostic factors for patients with endoscopy-negative iron deficiency

BACKGROUND AND AIM

Iron deficiency anemia (IDA) is a common problem among the elderly, and often no cause is identified after routine upper endoscopy and colonoscopy exams. The purpose of this study was to determine the long-term outcomes and predictors of gastrointestinal pathology and death in patients with endoscopy-negative IDA.

METHODS

This was a retrospective review of consecutive endoscopy negative-IDA patients during 2002-2004 at the VA San Diego Healthcare System.

RESULTS

Mean age was 69.3 years (range 42-93), and included 105 men and nine women. Mean length of follow-up was 65.1 months. IDA resolved in 56 patients. None of these patients developed evidence of any clinically significant gastrointestinal pathology. The remaining 58 patients had persistent anemia (n = 47) or recurrent anemia (n = 11). Only 2/47 patients with persistent anemia were found to have clinically significant but benign gastrointestinal pathology during follow-up. In contrast, 6/11 patients with recurrent anemia were subsequently found to have gastrointestinal pathology. Deaths during follow-up occurred in 7 (12.5 %) patients with resolved anemia, compared with 20 (34.5 %) patients with recurrent or persistent anemia (p = 0.006). Significant independent predictors of death included persistent or recurrent anemia, anti-platelet or anticoagulant use, and congestive heart failure.

CONCLUSIONS

Patients with iron deficiency anemia and negative upper endoscopy and colonoscopy often have a favorable outcome, especially if the anemia resolves with treatment. In patients with recurrent anemia a malignancy within reach of standard endoscopy and colonoscopy are possible, and repeating these procedures is warranted before consideration of further investigations.

Guideline for capsule endoscopy: obscure gastrointestinal bleeding

Capsule endoscopy (CE) is considered as a noninvasive and reliable diagnostic tool of examining the entire small bowel. CE has been performed frequently at many medical centers in South Korea; however, there is no evidence-based CE guideline for adequate diagnostic approaches. To provide accurate information and suggest correct testing approaches for small bowel disease, the guideline on CE was developed by the Korean Gut Image Study Group, a part of the Korean Society of Gastrointestinal Endoscopy. Operation teams for developing the guideline were organized into four areas: obscure gastrointestinal bleeding, small bowel preparation, Crohn's disease, and small bowel tumor. A total of 20 key questions were selected. In preparing this guideline, MEDLINE, Cochrane library, KMbase, KISS, and KoreaMed literature searches were performed. After writing a draft of the guideline, opinions from various experts were reflected before approving the final document. The guideline should be regarded as recommendations only to gastroenterologists in providing care to their patients. These are not absolute rules and should not be construed as establishing a legal standard of care. Although further revision may be necessary as new data appear, this guideline is expected to play a role for adequate diagnostic approaches of various small bowel diseases.

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

BACKGROUND

Iron-deficiency anemia (IDA) is the most common cause of anemia worldwide. Current guidelines recommend the use of small-bowel capsule endoscopy (SBCE) in IDA. Evidence of the validity of SBCE in patients with IDA alone is still limited.

OBJECTIVE

To assess the diagnostic yield (DY) of SBCE in IDA by pooling data from relevant studies.

DESIGN

Systematic review and meta-analysis. Fixed-effects or random-effects models were used as appropriate.

SETTING

Studies that estimated the DY of SCBE in IDA were identified. Two investigators independently conducted the search and data extraction.

PATIENTS

A total of 24 studies enrolling 1960 patients with IDA who underwent SBCE were included.

MAIN OUTCOME MEASUREMENTS

Per-patient DY, with 95% confidence intervals. Subgroup analysis was also performed.

RESULTS

The pooled DY of SBCE in IDA, evaluated by a random-effects model, was 47% (95% CI, 42%-52%), but there was statistically significant heterogeneity among the included studies (inconsistency index [I(2)] = 78.8%, P < .0001). The pooled DY of SBCE in studies focused solely on patients with IDA (subset 1, 4 studies) was 66.6% (95% CI, 61.0%-72.3%; I(2) = 44.3%); conversely, that of studies not focusing only on IDA patients (subset 2, 20 studies) was 44% (95% CI, 39%-48%; I(2) = 64.9%). In particular, more vascular (31% vs 22.6%, P = .007), inflammatory (17.8% vs 11.3%, P = .009), and mass/tumor (7.95% vs 2.25%, P < .0001) lesions were detected with SBCE in patients participating in the studies in subset 1.

LIMITATIONS

Heterogeneity of studies, retrospective design, and selection bias.

CONCLUSIONS

This analysis demonstrates the validity of SBCE in the investigation of patients with IDA and negative findings on a previous diagnostic workup, although certain factors such as heterogeneity and quality of the included studies should be taken into account.

The use of small-bowel capsule endoscopy in iron-deficiency anemia alone; be aware of the young anemic patient

BACKGROUND & AIM

The role of Small-Bowel Capsule Endoscopy (SBCE) in Iron Deficiency Anemia (IDA) alone is still under validation. We aim to assess the usefulness of SBCE in patients with IDA alone.

METHODS

Retrospective study; patients with IDA (no GI symptoms or known previous diagnosis), who underwent SBCE were included. SBCE findings were classified as clinically significant/sinister (small-bowel malignancy, significant/sinister inflammation and/or strictures and coeliac disease) or vascular, i.e., signifcant/angioectasias (P1/P2 lesions).

RESULTS

A total of 221 (151F/70M) patients had SBCE for IDA as the sole indication. The diagnostic yield (DY) was 30.7% (68/221). The DY for significant/sinister pathology and significant/angioectasias was 9% and 21.7%, respectively. In those ≤ 40 years (20; 13F/7M), significant pathology was found in 25% (5/20); in the >40-year group (201; 138F/63M), significant/sinister pathology was found in 7.5% (15/201), p = 0.0231. None of the patients ≤40 years had angioectasias, such lesions were found in 48/201 (21.7%) of those >40 years, p = 0.009. Fifty percent of those >80 years (16; 12F/4M) had angioectasias, but none had significant/sinister pathology (p = 0.0126). On multiple regression analysis, only prior blood transfusion was predictive of higher DY in SBCE.

CONCLUSIONS

IDA alone is one of the main indications (27%) for referral to SBCE; the majority of patients are >40 years. In our cohort, the DY of SBCE for IDA was 30.7% and the commonest finding was angioectasias. The detection rate of sinister small-bowel pathology for those >40 years is low decreasing to zero in the >80 age group. In contrast, 25% of those ≤40 years had a sinister diagnosis.

Capsule endoscopy with flexible spectral imaging color enhancement reduces the bile pigment effect and improves the detectability of small bowel lesions

BACKGROUND

Capsule endoscopy with flexible spectral imaging color enhancement (CE-FICE) has been reported to improve the visualization and detection of small-bowel lesions, however, its clinical usefulness is still not established. Therefore, we conducted a study to evaluate whether CE-FICE contributes to improve the detectability of small-bowel lesions by CE trainees.

METHODS

Four gastroenterology trainees without prior CE experience were asked to read and interpret 12 CE videos. Each of the videos was read by conventional visualization method and under three different FICE settings. To evaluate whether the lesion recognition ability of the CE trainees could be improved by the FICE technology, the lesion detection rate under each of the three FICE settings was compared with that by conventional CE. CE trainees tend to miss small-bowel lesions in bile-pigment-positive condition, therefore we evaluated whether CE-FICE contributes to reducing the bile-pigment effect. The bile-pigment condition was determined by the color values around the small-bowel lesions according to the results of the receiver-operating-characteristic analysis. Moreover, we also evaluated whether poor bowel preparion might affect the accuracy of lesion recognition by CE-FICE.

RESULTS

Of a total of 60 angioectasias, CE trainees identified 26 by conventional CE, 40 under FICE setting 1, 38 under FICE setting 2, and 31 under FICE setting 3. Of a total of 82 erosions/ulcerations, CE trainees identified 38 by conventional CE, 62 under FICE setting 1, 60 under FICE setting 2, and 20 under FICE setting 3. Compared with conventional CE, FICE settings 1 and 2 significantly improved the detectability of angioectasia (P = 0.0017 and P = 0.014, respectively) and erosions/ulcerations (P = 0.0012 and P = 0.0094, respectively). Although the detectability of small-bowel lesions by conventional CE (P = 0.020) and under FICE setting 2 (P = 0.0023) was reduced by the presence of bile-pigments, that under FICE setting 1 was not affected (P = 0.59). Our results also revealed that in poor bowel visibility conditions, CE-FICE yielded a high rate of false-positive findings.

CONCLUSIONS

CE-FICE may reduce the bile-pigment effect and improve the detectability of small-bowel lesions by CE trainees; the reliability of CE-FICE may be improved by good bowel preparation.

Increased diagnostic yield of small bowel tumors with PillCam: the role of capsule endoscopy in the diagnosis and treatment of gastrointestinal stromal tumors (GISTs). Italian single-center experience

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for 1-3% of all gastrointestinal malignancies; they are, however, the most common gastric and small bowel mesenchymal tumors. The length and relative inaccessibility of the small bowel have long constrained the diagnosis of GISTs mainly presenting with chronic or intermittent bleeding as the sole clinical manifestation.

AIM

To report on the prevalence of small bowel GISTs in a prospectively recorded series of patients undergoing capsule endoscopy (CE).

PATIENTS AND METHODS

Between 2001 and 2007 five hundred patients were referred to our endoscopy unit for small bowel evaluation with capsule endoscopy. We retrospectively evaluated all charts. The main indications for CE were obscure-occult or obscure-overt bleeding. Two hundred eighty-nine patients underwent CE for either obscure-occult or obscure-overt bleeding and 211 for other indications. Patient outcome and care processes were measured by follow-up telephone interviews and chart review. Statistical computations were performed using Fisher's exact test and Student's t-test.

RESULTS

CE identified a small bowel tumor in 20 patients (4.0%) and 9 tumors turned out to be GISTs (45.0%). Traditional endoscopic and radiological imaging failed to detect the GIST in all these cases. In one case a small bowel GIST was diagnosed by angiography and CE proved false negative. Overall, CE was able to diagnose a small bowel GIST in 9 out of 10 cases. All patients underwent surgical treatment and showed normalized hemoglobin levels at follow-up. The main limitation of this study is the small number of cases.

CONCLUSIONS

CE is an effective and sensitive diagnostic device compared with conventional radiology and plays an important role in the algorithm for the diagnostic work-up of suspected small bowel tumors.

Advances in small bowel imaging

The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Within the past 10 years, advances have led to an explosion of technologies that facilitate examination of the entire small intestine. Wireless video capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computer tomography (CT) and magnetic resonance (MR) enterography have facilitated the diagnosis, monitoring, and management of patients with small intestinal diseases. These technologies are complementary, each with its advantages and limitations. Capsule endoscopy provides a detailed view of the mucosal surface and has excellent patient acceptance, but does not allow therapeutics. Deep enteroscopy allows careful inspection of the mucosa and therapeutics, but is time consuming and invasive. Enterography (CT or MR) allows examination of the small bowel wall and surrounding structures. The initial best test for detecting small intestinal disease depends on clinical presentation and an astute differential diagnosis.

Is faecal-immunochemical test useful in patients with iron deficiency anaemia and without overt bleeding?

BACKGROUND

Both upper and lower endoscopies are indicated in patients with iron deficiency anaemia. However, these examinations are negative in a high proportion of cases.

AIMS

To assess whether faecal-immunochemical test (FIT) may be useful in selecting patients at higher risk of bleeding lesions in iron deficiency anaemia patients.

METHODS

Iron deficiency anaemia patients without overt bleeding were prospectively enrolled. All patients performed FIT, and underwent both upper and lower endoscopy. Predictive factors of potential bleeding lesions were evaluated at multivariate analysis.

RESULTS

FIT was positive in 48 (34.3%) out of 140 enrolled patients, and a potential bleeding lesion was present in 63 (45%) patients. An endoscopic lesion was detected more frequently in FIT-positive than -negative patients (79.2% vs 27.2%; p<0.0001), at both upper endoscopy (52.1% vs 18.5%; p=0.0002) and colonoscopy (33.3% vs 8.7%; p=0.001). At multivariate analysis, FIT was found to be an independent predictor of both bleeding lesions (OR=9.5; 95% CI: 4.1-22; p<0.001) and cancer (OR=4.0, CI: 1.1-15; p=0.029).

CONCLUSIONS

FIT positive-iron deficiency anaemia patients without overt bleeding are at increased risk to present with a bleeding lesion at endoscopy, including cancer. FIT positivity in this setting could be useful to prioritize urgent endoscopy.

Outcomes after symptomatic capsule retention in suspected small bowel obstruction

BACKGROUND AND AIM

Capsule endoscopy (CE) has been proven to be a sensitive and a safe tool for the examination of the small bowel. However, careful patient selection is required to avoid complications, primarily capsule retention. The aims of this study were to evaluate the rate of capsule retention in patients with suspected chronic small bowel obstruction and to analyze the role and the impact of subsequent surgical intervention.

METHODOLOGY

Fifteen patients referred for CE with a clinical picture suggestive of chronic small bowel obstruction and with negative imaging studies were retrospectively analyzed.

RESULTS

Capsule retention occurred in three (20%) patients who developed symptoms of subacute obstruction and subsequently underwent surgery. Radiation enteritis, Crohn's disease, and an ileal tumor were demonstrated as the causes of the capsule retention in these patients. Surgical removal of the retained capsule was performed and the underlying small bowel disease was treated.

CONCLUSION

Capsule retention is a frequent complication of CE in patients with symptoms of chronic small bowel obstruction. Surgery, with the removal of the retained capsule, is proven to be beneficial in identifying the location of, and treating, the underlying disease in these patients.

Improved diagnostic yield with severity of bleeding

OBJECTIVE

Video capsule endoscopy (VCE) is an important tool for non-invasive imaging of the small bowel. Whether there is a dose-related effect of anemia severity on the diagnostic yield of VCE is unknown. The aim of this study was to determine the influence of anemia severity on VCE outcome measures.

METHODS

VCE studies from the Sacramento Veterans Affairs Medical Center for 300 consecutive patients were retrospectively screened. Those with anemia were selected. Patients were grouped as mildly, moderately or severely bleeding. Outcomes data including completion of study, diagnostic yield and further intervention were compared.

RESULTS

Of the 300 patients, 210 (70%) were found to have anemia. Overall 32 (15.24%) patients were mildly, 145 (69.05%) were moderately and 33 (15.71%) were severely bleeding. The diagnostic yield was significantly higher in severe (72.73%) relative to moderate (32.41%) and mild bleeding (12.50%); P = 0.0001. Significantly more angioectasias were detected in severely bleeding patients (42.42%) than in those bleeding moderately (14.48%) and mildly (0.00%), P = 0.0001. The ability of VCE to guide further intervention was significantly higher in patients bleeding severely (69.70%, P = 0.006).

CONCLUSIONS

Our data showed a significant increase in diagnostic yield with the increasing degree of anemia. Relative difference in hemoglobin rather than absolute values may be a better predictor. The ability of VCE to guide further intervention reached significance in severely bleeding patients. The hypothesis that use of VCE prior to esophagogastroduodenoscopy or colonoscopy in the severely bleeding group deserves to be evaluated.

Do clinical characteristics predict the presence of small bowel angioectasias on capsule endoscopy?

BACKGROUND AND AIMS

Angioectasias (AVMs) are the most common vascular anomaly of the gastrointestinal (GI) tract, and these lesions are often associated with obscure gastrointestinal bleeding (OGIB). It is unknown if the presence of upper and/or lower gastrointestinal AVMs are predictive of small bowel AVMs. The aims of this study are to define the small bowel segmental distribution of AVMs and to identify the factors predicting the presence of small bowel AVMs among a cohort of patients with a known history of AVMs in the upper and/or lower GI tracts who are undergoing capsule endoscopy (CE) for OGIB.

METHODS

We performed a retrospective cohort analysis of 1,125 patients undergoing CE at our institution between 11/1/2001 and 8/31/2007. Inclusion criteria were: (1) complete esophagoduodenoscopy (EGD), CE, and colonoscopy, (2) OGIB indication for CE, and (3) history of ≥ 1 AVM on EGD and/or colonoscopy that was previously treated in the past or deemed not to be a clinically significant source of bleeding. Exclusion criteria were: (1) history of radiation therapy to the GI tract, and (2) presence of a congenital or systemic disease associated with GI AVMs. Data were extracted on: (1) age; (2) gender; (3) presence of diabetes, (4) presence of hypertension, (5) presence of aortic stenosis, (6) history of non-steroidal anti-inflammatory therapy, (7) history of anticoagulant therapy, (8) hemoglobin, platelet, and INR values prior to CE; (9) baseline serum creatinine; and (10) presence and GI tract segmental location of AVMs. Multivariate logistic regression was used to identify independent predictors of small bowel AVMs.

RESULTS

1,125 patients underwent EGD, CE, and colonoscopy. One hundred and fourteen patients had a history of ≥ 1 AVM on EGD and/or colonoscopy and met inclusion and exclusion criteria. The mean age was 69 years, and 63% of patients were women. 37% of patients were found to have ≥ 1 jejunal AVM and 15% were found to have ≥ 1 ileal AVM. In multivariate analysis, age ≥ 65 (OR 2.62, P = 0.05) and the presence of AVMs on EGD (OR 4.61, P = 0.02) were predictive of jejunal AVMs. AVMs on colonoscopy alone were not predictive of jejunal or ileal AVMs. No factors were found to predict the presence of ileal AVMs.

CONCLUSIONS

Patients with AVMs on EGD have an increased risk of jejunal AVMs on CE, particularly if they are elderly. Future studies should validate these findings in a prospective cohort.

A prospective evaluation of iron deficiency anemia in the GI endoscopy setting: role of standard endoscopy, videocapsule endoscopy, and CT-enteroclysis

BACKGROUND

Iron deficiency anemia (IDA) is a frequently encountered condition in clinical practice. After conventional endoscopy, the cause of anemia remains unknown in up to 40% of patients.

OBJECTIVE

To evaluate prospectively the diagnostic efficacy of a systematic endoscopic approach to IDA and to compare the diagnostic yield of videocapsule endoscopy (VCE) and CT-enteroclysis in endoscopy-negative patients.

DESIGN

Consecutive patients with IDA were enrolled prospectively.

SETTING

Open-access endoscopy within an academic hospital.

PATIENTS

This study involved 189 patients with IDA, including 98 women and 91 men; mean (±standard deviation) age 68 years±16.6 years.

INTERVENTION

Patients with IDA underwent gastroscopy and colonoscopy plus ileoscopy. Endoscopy-negative patients were further blindly evaluated by both CT-enteroclysis and VCE.

MAIN OUTCOME MEASUREMENTS

Diagnostic yield of conventional endoscopy; diagnostic yield of VCE versus CT-enteroclysis.

RESULTS

Endoscopy results were positive in 144 of 189 patients (76.2%). CT-enteroclysis and VCE allowed a diagnosis in 37 of 45 endoscopy-negative patients (82.2%). Overall, VCE was superior to CT-enteroclysis (77.8% vs 22.2%; P<.001), in particular when flat lesions were found.

LIMITATIONS

Single-center study.

CONCLUSION

A systematic approach to IDA, which includes standard endoscopy, VCE, and CT-enteroclysis allows an overall diagnostic rate of 95.7%; however, CT-enteroclysis should be limited to cases of nondiagnostic VCE.

Improved visibility of lesions of the small intestine via capsule endoscopy with computed virtual chromoendoscopy

BACKGROUND

We can now enhance video capsule endoscopy (CE) images in real time by means of a flexible spectral imaging color enhancement (FICE) digital processing system. Reports on the clinical usefulness of this system are few.

OBJECTIVE

To clarify whether visualization of lesions of the small intestine is improved by FICE image analysis.

DESIGN

A retrospective study.

SETTING

Academic medical center.

METHODS

Five physicians compared FICE images with corresponding conventional images of 145 lesions obtained from 122 patients who underwent video CE at our hospital. The lesions were classified as angioectasia (n=23), erosion/ulceration (n=45), or tumor (n=75), and 3 different sets of FICE images were viewed (ie, at 3 different wavelength settings). Physicians rated the visibility of the lesions on FICE images as follows: +2 (improved visibility), +1 (somewhat improved visibility), 0 (visibility equivalent to that of conventional video CE visibility), -1 (somewhat decreased visibility), and -2 (decreased visibility). Scores for each lesion were totaled (per FICE setting) and evaluated. Intraobserver agreement was also examined.

RESULTS

With FICE setting 1 (red 595 nm, green 540 nm, blue 535 nm), improvement was achieved for 87% (20/23) of angioectasia images, 53.3% (26/47) of erosion/ulceration images, and 25.3% (19/75) of tumor images. With setting 2 (red 420 nm, green, 520 nm, blue 530 nm), improvement was achieved for 87% (20/23), 25.5% (12/47), and 20.0% (15/75), respectively. With setting 3, only equivalence was achieved. Intraobserver agreement was good to satisfactory at 5.4 or higher.

LIMITATIONS

Single-center study.

CONCLUSIONS

CE-FICE improves visibility of small-bowel angioectasia, erosion/ulceration, and tumor.

Video capsule endoscopy: what is the future?

Video capsule endoscopy (VCE) that was launched 10 years ago has become a first-line procedure for examining the small bowel, especially in the case of obscure gastrointestinal bleeding. Other major indications include Crohn disease (CD), celiac disease, and intestinal polyposis syndrome. In the case of small bowel diseases, the use of VCE must be integrated in a global diagnostic and therapeutic approach. More recently, wireless endoscopy has been adapted for examining the colon, opening up larger perspectives for colorectal cancer screening or colon examination. Technologic modifications of the second-generation colon capsule increase the sensitivity of this method for detecting polyps. Other new developments, including remote magnetic manipulation, power management, drug delivery capsule, microbiopsy capsule, and adaptation of technologies such as chromoendoscopy, are sure to enhance the capabilities of wireless endoscopy in gastrointestinal disorders.

Minimally invasive surgery for obscure idiopathic ileal varices diagnosed by capsule endoscopy and double balloon endoscopy: report of a case

Small intestinal bleeding is difficult to detect and can be life-threatening. Capsule endoscopy (CE) is a new, minimally invasive diagnostic procedure designed to detect gastrointestinal (GI) bleeding. We report the successful management of idiopathic ileal varices by capsule endoscopy and laparoscopic surgery. Massive bleeding occurred suddenly with intermittent melena, and the patient was finally admitted to a local hospital in hypovolemic shock. Her condition was stabilized with conservative therapy but the site of bleeding was not defined by endoscopy, computed tomography, scintigraphy, or angiography. Thus, she was transferred to our hospital. On admission, CE revealed idiopathic ileal varices, so we performed laparoscopic partial ileal resection immediately. Follow-up CE has shown no evidence of recurrence in the 2 years since surgery. Idiopathic ileal varices are rare, difficult to diagnose, and often fatal. Capsule endoscopy is a minimally invasive diagnostic procedure that detects this disorder in time for laparoscopic surgery to be performed effectively and safely.

Small bowel capsule endoscopy in clinical practice: a multicenter 7-year survey

BACKGROUND AND AIM

Data about small bowel capsule endoscopy (SBCE) come from studies involving small and highly selected populations. The study aim was to describe extent of use, indications, results, complications, and practical issues of SBCE in clinical practice in a Northern Italian Region (Lombardia).

MATERIALS AND METHODS

Twenty-three out of 29 invited centers fulfilled a specific questionnaire.

RESULTS

Between 2001 and 2008, 2921 procedures were performed and both the number of centers performing SBCE (from 5 to 29) and the number of SBCE (from 7.2 to 69.2 per month) increased steadily. The main indications for SBCE were: obscure gastrointestinal bleeding (OGIB) (43.4%), unexplained anemia (23.9%), suspected Crohn's disease (7.8%) and abdominal pain (5.3%). Overall, SBCE was positive in 50% of cases, negative in 36% and undefined in 14%. The highest diagnostic yields were observed in patients with OGIB (62.5%), polypoid syndromes (74.1%), known (54.8%) or suspected (47.3%) inflammatory bowel disease, while the yields were low in patients examined for chronic diarrhea (27.4%) and abdominal pain (14.9%), 61 patients (2.1%) experienced capsule retention. Thirty-two of them eventually excreted the capsule naturally while endoscopic or surgical retrieval was necessary in 29 (1%) (in two because of obstruction).

CONCLUSION

Over a period of 7 years the use of SBCE in Lombardia increased steadily confirming, in clinical practice, a high diagnostic yield and an acceptable safety profile.

Outcome of patients with obscure gastrointestinal bleeding after negative capsule endoscopy: results of a one-year follow-up study

BACKGROUND

Capsule endoscopy (CE) is an effective method for investigating the small bowel, especially in cases of obscure gastrointestinal bleeding (OGIB), although the long-term outcome of patients with a negative CE is generally not known.

PATIENTS AND METHODS

For 49 patients with OGIB and a negative CE, their referring physicians filled out a follow-up questionnaire to assess bleeding recurrence and any repeat investigations after negative video capsule endoscopy (VCE).

RESULTS

A minimum follow-up duration of one year (median: 15.9 months) was available for 35 patients with an overall rebleeding rate of 23% (n=8). Of these eight patients, four women presented with recurrence prior to new investigations. In the four remaining patients, repeat endoscopy work-ups after negative CE were performed and revealed previously missed lesions with bleeding potential, mainly in the stomach. Overall, 13 patients, with or without rebleeding, had repeat endoscopy work-ups after a negative CE, leading to a definitive diagnosis in nine patients, with lesions located in the stomach and colon in eight of them.

CONCLUSION

Patients with OGIB and a negative CE had a low rate of rebleeding. This study highlights the importance of the initial endoscopy work-up, and suggests that CE be proposed after a minimum of two gastroscopies and one complete colonoscopy.

Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?

BACKGROUND

In around 30% of iron deficiency anaemia (IDA) cases a definite diagnosis cannot be made.

AIM

To investigate the role of capsule endoscopy (CE) in detecting lesions in patients with unexplained IDA after a negative endoscopic, serologic and haematologic diagnostic work up and its possible role in influencing clinical outcome.

METHODS

138 patients suffering from IDA were identified among 650 consecutive patients undergoing CE at our unit.

RESULTS

CE revealed the following positive findings in 91/138 patients: angiodysplasias in 51 patients; jejunal and/or ileal micro-ulcerations in 12; tumours/polyps in 9; erosive gastritis in 4; Crohn's disease in 5; jejunal villous atrophy in 5; a solitary ileal ulcer in 1 and active bleeding in the last 4 patients. Follow up data were available for 80/91 patients (87.9%). In 15 out of 46 patients with angiodysplasias IDA spontaneously resolved without any treatment; 9 patients required iron supplementation; 10 patients healed after lanreotide administration; APC was performed in 9 out of 46 patients and 3 patients underwent regular blood transfusion without any success on IDA. 10 out of the 12 patients with small bowel micro-ulcers spontaneously recovered from IDA whilst 2 patients after iron supplementation. All 9 patients affected by tumours/polyps were surgically addressed. In all erosive gastritis cases, patients recovered from IDA after PPI and Helicobacter pylori eradication. Four patients with Crohn's disease diagnosis restored to health with medical therapy. One out of the 4 patients with jejunal villous atrophy and the sole patient with a solitary ileal ulcer spontaneously healed. In 1 out of 3 patients with active bleeding IDA resolved without further treatment after blood transfusion whilst 2 patients were referred for surgical treatment. At follow up, complete resolution of IDA was achieved in 96.25%.

CONCLUSIONS

Small bowel investigation is a matter of great importance in IDA patients after negative upper and lower gastrointestinal endoscopy.