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Hung HJ, Chung CS, Tai CM, Chang CW, Tseng CM, Huang GS, Lin MC, Huang TY. Clinical characteristics and risk factors for rebleeding in uremic patients with obscure gastrointestinal bleeding undergoing deep enteroscopy: A multi-center retrospective study in Taiwan. PLoS One 2022; 17:e0277434. [PMID: 36449459 PMCID: PMC9710796 DOI: 10.1371/journal.pone.0277434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND/PURPOSE Recurrent obscure gastrointestinal bleeding (OGIB) in patients with chronic kidney disease is a challenge often faced by physicians, given the need for repeated hospitalizations, multiple extensive examinations, limited treatment options, and high medical costs. The purpose of this study was to identify the clinical characteristics of uremic patients undergoing deep enteroscopy for OGIB and analyze the risk factors for rebleeding in these patients after undergoing single-balloon enteroscopy (SBE). METHODS Out of 765 patients with OGIB who underwent 1004 procedures of SBE in four teaching hospitals, 78 uremic patients with OGIB were enrolled. Clinical characteristics and endoscopic findings were collected, and multiple variables were analyzed to determine the risk of rebleeding after SBE. RESULTS The diagnostic yield was 75.6%, and the rebleeding rate was 29.5% in the enrolled uremic patients. The most common etiology was angiodysplasia (74.6%) and the most common site was the jejunum (50.8%). The endoscopic intervention rate was 62.8% and most patients were treated with argon plasma coagulation (75.6%). Among the eight patients with valvular heart disease (VHD), four (50%) had severe aortic stenosis, and the remaining had non-aortic stenosis-VHD. VHD (p < 0.05) and angiodysplasia (p < 0.05) were both associated with a higher rebleeding rate. CONCLUSION VHD may be an independent risk factor associated with rebleeding after SBE in uremic patients with OGIB. Moreover, uremic patients with angiodysplasia-related bleeding appear to have a higher rebleeding rate than those with alternative causes of bleeding.
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Affiliation(s)
- Hsuan-Jen Hung
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
| | - Chi-Ming Tai
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Chen-Wang Chang
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chao-Ming Tseng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Go-Shine Huang
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Meng-Chiung Lin
- Division of Gastroenterology, Department of Internal Medicine, Taichiung Armed Forces General Hospital, Taichiung, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
- * E-mail:
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Atypical Blue Rubber Bleb Nevus in an African-American Male. Case Rep Gastrointest Med 2021; 2021:9992111. [PMID: 34567811 PMCID: PMC8463248 DOI: 10.1155/2021/9992111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/09/2021] [Indexed: 11/17/2022] Open
Abstract
Blue Rubber Bleb Nevus Syndrome (BRBNS), also known as Bean Syndrome, is a rare condition characterized by vascular ectasias that typically present systemically. Most diagnoses are made in early childhood due to cutaneous lesions in Caucasians with familial inheritance. Treatment is usually patient centered due to the wide variance in clinical presentation of the disease. Here, we present a case of BRBNS in a 65-year-old African-American patient with episodic gastrointestinal (GI) bleeding with no previous history. This case emphasizes the need for a higher clinical suspicion of the disease in patients with recurrent GI bleeding.
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3
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Rosa B, Margalit-Yehuda R, Gatt K, Sciberras M, Girelli C, Saurin JC, Cortegoso Valdivia P, Cotter J, Eliakim R, Caprioli F, Baatrup G, Keuchel M, Ellul P, Toth E, Koulaouzidis A. Scoring systems in clinical small-bowel capsule endoscopy: all you need to know! Endosc Int Open 2021; 9:E802-E823. [PMID: 34079861 PMCID: PMC8159625 DOI: 10.1055/a-1372-4051] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/26/2020] [Indexed: 02/08/2023] Open
Abstract
AbstractCapsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2
3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4
5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8
9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.
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Affiliation(s)
- Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal,ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Reuma Margalit-Yehuda
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Kelly Gatt
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Carlo Girelli
- Department of Internal Medicine, Gastroenterology & Digestive Endoscopy, Hospital of Busto Arsizio, Italy
| | - Jean-Christophe Saurin
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastro-Entérologie et d'Endoscopie Digestive, Lyon, France
| | - Pablo Cortegoso Valdivia
- Gastroenterology & Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Jose Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal,ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Flavio Caprioli
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Cà Granda, Ospedale Policlinico di Milano, Milan, Italy
| | - Gunnar Baatrup
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Pierre Ellul
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Ervin Toth
- Skåne University Hospital, Lund University, Malmö, Sweden
| | - Anastasios Koulaouzidis
- Endoscopy Unit, The Royal Infirmary of Edinburgh, Scotland, UK,Department of Social Medicine & Public Health, Pomeranian Medical University, Szczecin, Poland
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4
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Mahady SE, Margolis KL, Chan A, Polekhina G, Woods RL, Wolfe R, Nelson MR, Lockery JE, Wood EM, Reid C, Ernst ME, Murray A, Thao LTP, McNeil JJ. Major GI bleeding in older persons using aspirin: incidence and risk factors in the ASPREE randomised controlled trial. Gut 2021; 70:717-724. [PMID: 32747412 PMCID: PMC7957959 DOI: 10.1136/gutjnl-2020-321585] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/08/2020] [Accepted: 07/12/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There is a lack of robust data on significant gastrointestinal bleeding in older people using aspirin. We calculated the incidence, risk factors and absolute risk using data from a large randomised, controlled trial. DESIGN Data were extracted from an aspirin versus placebo primary prevention trial conducted throughout 2010-2017 ('ASPirin in Reducing Events in the Elderly (ASPREE)', n=19 114) in community-dwelling persons aged ≥70 years. Clinical characteristics were collected at baseline and annually. The endpoint was major GI bleeding that resulted in transfusion, hospitalisation, surgery or death, adjudicated independently by two physicians blinded to trial arm. RESULTS Over a median follow-up of 4.7 years (88 389 person years), there were 137 upper GI bleeds (89 in aspirin arm and 48 in placebo arm, HR 1.87, 95% CI 1.32 to 2.66, p<0.01) and 127 lower GI bleeds (73 in aspirin and 54 in placebo arm, HR 1.36, 95% CI 0.96 to 1.94, p=0.08) reflecting a 60% increase in bleeding overall. There were two fatal bleeds in the placebo arm. Multivariable analyses indicated age, smoking, hypertension, chronic kidney disease and obesity increased bleeding risk. The absolute 5-year risk of bleeding was 0.25% (95% CI 0.16% to 0.37%) for a 70 year old not on aspirin and up to 5.03% (2.56% to 8.73%) for an 80 year old taking aspirin with additional risk factors. CONCLUSION Aspirin increases overall GI bleeding risk by 60%; however, the 5-year absolute risk of serious bleeding is modest in younger, well individuals. These data may assist patients and their clinicians to make informed decisions about prophylactic use of aspirin. TRIAL REGISTRATION NUMBER ASPREE. NCT01038583.
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Affiliation(s)
- Suzanne E Mahady
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia .,Gastroenterology, Melbourne Health, Parkville, Victoria, Australia
| | | | - Andrew Chan
- Clinical and Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Galina Polekhina
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Robyn L Woods
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Rory Wolfe
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Jessica E Lockery
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Erica M Wood
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Christopher Reid
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
| | - Anne Murray
- Division of Geriatrics, Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA,Berman Center for Outcomes and Clinical Research, Hennepin Healthcare Research Institute, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - LTP Thao
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - John J McNeil
- School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
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5
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Verma S, Attallah MA, Jarrin Jara MD, Gautam AS, Khan S. Angiodysplasia in Renal Disease Patients: Analysis of Risk Factors and Approach to Manage Such Patients. Cureus 2020; 12:e9784. [PMID: 32953300 PMCID: PMC7491692 DOI: 10.7759/cureus.9784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Gastrointestinal bleeding due to angiodysplasia is a common problem in patients with renal insufficiency. There are several theories to explain the increased occurrence of these lesions in this specific group of patients, including various metabolic factors and existence of comorbidities. Advancements made in diagnostic measures have helped route the approach in patients with different risk factors and have also helped solve the dual purpose involving therapeutic intervention with endoscopy. We conducted a thorough literature search on PubMed to extract relevant data. A total of 29 articles were chosen after applying the inclusion and exclusion criteria. Although the clinical presentations may vary in this cohort of patients, and bleeding is known to stop spontaneously, a conservative approach may not be enough. Endoscopic treatment, use of hormones like estrogen, octreotide, and vasopressin, arterial embolization, and lastly surgery are valuable therapeutic tools.
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Affiliation(s)
- Sadhika Verma
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Marline A Attallah
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfiled, USA
| | | | - Avneesh S Gautam
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
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Dumic I, Nordin T, Jecmenica M, Stojkovic Lalosevic M, Milosavljevic T, Milovanovic T. Gastrointestinal Tract Disorders in Older Age. Can J Gastroenterol Hepatol 2019; 2019:6757524. [PMID: 30792972 PMCID: PMC6354172 DOI: 10.1155/2019/6757524] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.
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Affiliation(s)
- Igor Dumic
- 1Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- 2Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
| | - Terri Nordin
- 2Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
- 3Department of Family Medicine, Mayo Clinic Health System, Eau Claire WI, USA
| | - Mladen Jecmenica
- 4Gastroenterology Fellowship Program, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | | | - Tomica Milosavljevic
- 5Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- 6School of Medicine, Belgrade University, Belgrade, Serbia
| | - Tamara Milovanovic
- 5Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- 6School of Medicine, Belgrade University, Belgrade, Serbia
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7
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Hágendorn R, Farkas N, Vincze Á, Gyöngyi Z, Csupor D, Bajor J, Erőss B, Csécsei P, Vasas A, Szakács Z, Szapáry L, Hegyi P, Mikó A. Chronic kidney disease severely deteriorates the outcome of gastrointestinal bleeding: A meta-analysis. World J Gastroenterol 2017; 23:8415-8425. [PMID: 29308001 PMCID: PMC5743512 DOI: 10.3748/wjg.v23.i47.8415] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/23/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To understand the influence of chronic kidney disease (CKD) on mortality, need for transfusion and rebleeding in gastrointestinal (GI) bleeding patients. METHODS A systematic search was conducted in three databases for studies on GI bleeding patients with CKD or end-stage renal disease (ESRD) with data on outcomes of mortality, transfusion requirement, rebleeding rate and length of hospitalization (LOH). Calculations were performed with Comprehensive Meta-Analysis software using the random effects model. Heterogeneity was tested by using Cochrane's Q and I2 statistics. Mean difference (MD) and OR (odds ratio) were calculated. RESULTS 1063 articles (EMBASE: 589; PubMed: 459; Cochrane: 15) were found in total. 5 retrospective articles and 1 prospective study were available for analysis. These 6 articles contained data on 406035 patients, of whom 51315 had impaired renal function. The analysis showed a higher mortality in the CKD group (OR = 1.786, 95%CI: 1.689-1.888, P < 0.001) and the ESRD group (OR = 2.530, 95%CI: 1.386-4.616, P = 0.002), and a rebleeding rate (OR = 2.510, 95%CI: 1.521-4.144, P < 0.001) in patients with impaired renal function. CKD patients required more unit red blood cell transfusion (MD = 1.863, 95%CI: 0.812-2.915, P < 0.001) and spent more time in hospital (MD = 13.245, 95%CI: 6.886-19.623, P < 0.001) than the controls. CONCLUSION ESRD increases mortality, need for transfusion, rebleeding rate and LOH among GI bleeding patients. Prospective patient registries and observational clinical trials are crucially needed.
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Affiliation(s)
- Roland Hágendorn
- Department of Gastroenterology, First Department of Medicine, University of Pécs, Pécs 7624, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, University of Pécs, Pécs 7624, Hungary
| | - Áron Vincze
- Department of Gastroenterology, First Department of Medicine, University of Pécs, Pécs 7624, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, University of Pécs, Pécs 7624, Hungary
| | - Dezső Csupor
- Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged 6720, Hungary
| | - Judit Bajor
- Department of Gastroenterology, First Department of Medicine, University of Pécs, Pécs 7624, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - Péter Csécsei
- Department of Neurology, University of Pécs, Pécs 7623, Hungary
| | - Andrea Vasas
- Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged 6720, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - László Szapáry
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
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8
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Nennstiel S, Machanek A, von Delius S, Neu B, Haller B, Abdelhafez M, Schmid RM, Schlag C. Predictors and characteristics of angioectasias in patients with obscure gastrointestinal bleeding identified by video capsule endoscopy. United European Gastroenterol J 2017; 5:1129-1135. [PMID: 29238592 DOI: 10.1177/2050640617704366] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/12/2017] [Indexed: 12/13/2022] Open
Abstract
Background In obscure gastrointestinal bleeding, angioectasias are common findings in video capsule endoscopy (VCE). Objective The objective of this study was to identify predictors and characteristics of small bowel angioectasias. Methods Video capsule examinations between 1 July 2001 and 31 July 2011 were retrospectively reviewed. Patients with obscure gastrointestinal bleeding were identified, and those with small bowel angioectasia were compared with patients without a definite bleeding source. Univariate and multivariable statistical analyses for possible predictors of small bowel angioectasia were performed. Results From a total of 717 video capsule examinations, 512 patients with obscure gastrointestinal bleeding were identified. Positive findings were reported in 350 patients (68.4%) and angioectasias were documented in 153 of these patients (43.7%). These angioectasias were mostly located in the proximal small intestine (n = 86, 56.6%). Patients' age >65 years (odds ratio (OR) 2.15, 95% confidence interval (CI) 1.36-3.38, p = .001) and overt bleeding type (OR 1.89, 95% CI 1.22-2.94, p = .004) were identified as significant independent predictors of small bowel angioectasia. Conclusion Angioectasias are the most common finding in VCE in patients with obscure gastrointestinal bleeding. They are mostly located in the proximal small bowel and are associated with higher age and an overt bleeding type.
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Affiliation(s)
- Simon Nennstiel
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Annkathrin Machanek
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Stefan von Delius
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Bruno Neu
- Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Academic Teaching Hospital, Technische Universität München, Landshut, Germany
| | - Bernhard Haller
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Mohamed Abdelhafez
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Christoph Schlag
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
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9
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Hosoe N, Matsukawa S, Kanno Y, Naganuma M, Imaeda H, Ida Y, Tsuchiya Y, Hibi T, Ogata H, Kanai T. Cross-sectional small intestinal surveillance of maintenance hemodialysis patients using video capsule endoscopy: SCHEMA study. Endosc Int Open 2016; 4:E589-96. [PMID: 27227120 PMCID: PMC4874804 DOI: 10.1055/s-0042-105203] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/21/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Small intestinal pathology in hemodialysis (HD) patients has been studied in only a small number of retrospective case series. One method for noninvasively surveying small intestinal disorders is video capsule endoscopy (VCE). The primary aim of this study was to investigate the prevalence of small intestinal abnormalities among asymptomatic maintenance HD outpatients using VCE. The secondary aim was to assess the clinical impact of these abnormalities. PATIENTS AND METHODS This study consisted of two phases. In phase I, a cross-sectional study, a cohort of patients who received maintenance HD three times weekly at an outpatient hemodialysis clinic were studied using VCE. Phase II was a prospective cohort study with follow up for 1 year after VCE. RESULTS Fifty-six patients were enrolled in this study, and two were excluded from analysis due to capsule retention in the stomach. The prevalence of small bowel abnormalities in HD patients was 64.8 % (35/54) (95 % confidential interval 52.1 % - 77.6 %). Of 54 patients, 21 (38.9 %) had mucosal lesions, 10 (18.5 %) had vascular lesions, and 4 (7.4 %) had both lesion types. During the 1-year follow-up period, events occurred in four patients. A small bowel-associated event was observed in one patient, who underwent laparoscopy-assisted small intestinal partial resection 3 months after diagnosis by VCE. All patients in whom events were seen had small bowel abnormalities; no events were observed in the VCE-negative group. CONCLUSIONS Although asymptomatic maintenance HD patients had a high prevalence of small bowel abnormalities (64.8 %), they did not have a high incidence of small bowel-associated events during the 1-year follow-up.
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Affiliation(s)
- Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.,Corresponding author Naoki Hosoe, MD, PhD Center for Diagnostic and Therapeutic EndoscopySchool of MedicineKeio University35 ShinanomachiShinjuku, Tokyo 160-8582Japan+81-3-3357-2778
| | - Shigeaki Matsukawa
- Keishinkai Tama Nagayama Jin-Naika Clinic, 1-4 Nagayama, Tama city, Tokyo 206-0025, Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku, Tokyo 160-0023, Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Hiroyuki Imaeda
- Department of General Internal Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Yosuke Ida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yoshitsugu Tsuchiya
- Keishinkai Tama Nagayama Jin-Naika Clinic, 1-4 Nagayama, Tama city, Tokyo 206-0025, Japan
| | - Toshifumi Hibi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan ,Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, 5-9-1 Shirokane, Minato-ku, Tokyo 108-8642, Japan.
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110:1265-87; quiz 1288. [PMID: 26303132 DOI: 10.1038/ajg.2015.246] [Citation(s) in RCA: 381] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/01/2015] [Indexed: 02/06/2023]
Abstract
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.
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Magalhães-Costa P, Bispo M, Santos S, Couto G, Matos L, Chagas C. Re-bleeding events in patients with obscure gastrointestinal bleeding after negative capsule endoscopy. World J Gastrointest Endosc 2015; 7:403-410. [PMID: 25901220 PMCID: PMC4400630 DOI: 10.4253/wjge.v7.i4.403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/27/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate long-term re-bleeding events after a negative capsule endoscopy in patients with obscure gastrointestinal bleeding (OGIB) and the risk factors associated with the procedure.
METHODS: Patients referred to Hospital Egas Moniz (Lisboa, Portugal) between January 2006 and October 2012 with OGIB and a negative capsule endoscopy were retrospectively analyzed. The following study variables were included: demographic data, comorbidities, bleeding-related drug use, hemoglobin level, indication for capsule endoscopy, post procedure details, work-up and follow-up. Re-bleeding rates and associated factors were assessed using a Cox proportional hazard analysis. The Kaplan-Meier method was used to estimate the cumulative incidence of re-bleeding at 1, 3 and 5 years, and the differences between factors were evaluated.
RESULTS: The study population consisted of 640 patients referred for OGIB investigation. Wireless capsule endoscopy was deemed negative in 113 patients (17.7%). A total of 64.6% of the population was female, and the median age was 69 years. The median follow-up was forty-eight months (interquartile range 24-60). Re-bleeding occurred in 27.4% of the cases. The median time to re-bleeding was fifteen months (interquartile range 2-33). In 22.6% (n = 7) of the population, small-bowel angiodysplasia was identified as the culprit lesion. A univariate analysis showed that age > 65 years old, chronic kidney disease, aortic stenosis, anticoagulant use and overt OGIB were risk factors for re-bleeding; however, on a multivariate analysis, there were no risk factors for re-bleeding. The cumulative risk of re-bleeding at 1, 3 and 5 years of follow-up was 12.9%, 25.6% and 31.5%, respectively. Patients who presented with overt OGIB tended to re-bleed sooner (median time for re-bleeding: 8.5 mo vs 22 mo).
CONCLUSION: Patients with OGIB despite a negative capsule endoscopy have a significant re-bleeding risk; therefore, these patients require an extended follow-up strategy.
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Docherty E, Koulaouzidis A, Douglas S, Plevris JN. Use of small bowel capsule endoscopy in patients with chronic kidney disease: experience from a University Referral Center. Ann Gastroenterol 2015; 28:99-104. [PMID: 25608445 PMCID: PMC4290011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/19/2014] [Indexed: 12/03/2022] Open
Abstract
Background There are only few reports on the diagnostic yield (DY) of small bowel capsule endoscopy (SBCE) in patients with chronic kidney disease (CKD). We aim to report our SBCE experience in patients with CKD. Methods Retrospective study; case notes of patients with low estimated glomerular filtration rate (eGFR) who underwent SBCE (March 2005-August 2012) for anemia and/or obscure gastrointestinal bleeding (OGIB) were retrieved and abstracted. Severity of CKD was defined according to Renal Association recommendations as: stage 3 (eGFR: 30-59); stage 4 (eGFR: 15-29); and stage 5 (eGFR <15 or on dialysis). Results In the aforementioned period, 69 patients with CKD [stage 3: 65/69 (92.8%), stage 4 or 5:4/69 (7.2%)] had SBCE. 51/65 (78.5%) patients with stage 3 CKD had SBCE due to unexplained anemia and/or OGIB [43 (66.1%) and 8 (12.3%), respectively]. In 25/51 (49%), the SBCE was normal and in 17/51 (33.3%) showed small-bowel angiectasias. Other findings were active bleeding (n=2), fold edema (n=2), ileal erosions (n=1), adenocarcinoma (n=1), and inconclusive/videos not available (n=3). All patients (n=4) with CKD grade 4 or 5 were referred due to unexplained anemia; 3/4 (75%) had angiectasias and 1 normal SBCE. Fecal calprotectin (FC) was measured in 12 patients with CKD stage 3 and unexplained anemia prior to their SBCE; no significant small-bowel inflammation was found in this subgroup. Conclusion SBCE has limited DY in CKD patients referred for unexplained anemia. Sinister SB pathology is rare, while the most common finding is angiectasias. Furthermore, FC measurement prior to SBCE -in this cohort of patients- is not associated with increased DY.
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Affiliation(s)
- Emily Docherty
- Medical School, The University of Edinburgh (Emily Docherty, John N. Plevris), Scotland, UK
| | - Anastasios Koulaouzidis
- Endoscopy Unit, Center for Liver and Digestive Disorders, The Royal Infirmary Edinburgh (Anastasios Koulaouzidis, Sarah Douglas, John N. Plevris), Scotland, UK
| | - Sarah Douglas
- Endoscopy Unit, Center for Liver and Digestive Disorders, The Royal Infirmary Edinburgh (Anastasios Koulaouzidis, Sarah Douglas, John N. Plevris), Scotland, UK
| | - John N Plevris
- Medical School, The University of Edinburgh (Emily Docherty, John N. Plevris), Scotland, UK ; Medical School, The University of Edinburgh (Emily Docherty, John N. Plevris), Scotland, UK
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Abstract
The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.
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Affiliation(s)
- Deepak Gunjan
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder S Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepak K Bhasin
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Characteristics of the small bowel lesions detected by capsule endoscopy in patients with chronic kidney disease. Gastroenterol Res Pract 2013; 2013:814214. [PMID: 24065987 PMCID: PMC3770067 DOI: 10.1155/2013/814214] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 07/05/2013] [Indexed: 12/22/2022] Open
Abstract
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.
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Yang JY, Lee TC, Montez-Rath ME, Paik J, Chertow GM, Desai M, Winkelmayer WC. Trends in acute nonvariceal upper gastrointestinal bleeding in dialysis patients. J Am Soc Nephrol 2012; 23:495-506. [PMID: 22266666 DOI: 10.1681/asn.2011070658] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Impaired kidney function is a risk factor for upper gastrointestinal (GI) bleeding, an event associated with poor outcomes. The burden of upper GI bleeding and its effect on patients with ESRD are not well described. Using data from the US Renal Data System, we quantified the rates of occurrence of and associated 30-day mortality from acute, nonvariceal upper GI bleeding in patients undergoing dialysis; we used medical claims and previously validated algorithms where available. Overall, 948,345 patients contributed 2,296,323 patient-years for study. The occurrence rates for upper GI bleeding were 57 and 328 episodes per 1000 person-years according to stringent and lenient definitions of acute, nonvariceal upper GI bleeding, respectively. Unadjusted occurrence rates remained flat (stringent) or increased (lenient) from 1997 to 2008; after adjustment for sociodemographic characteristics and comorbid conditions, however, we found a significant decline for both definitions (linear approximation, 2.7% and 1.5% per year, respectively; P<0.001). In more recent years, patients had higher hematocrit levels before upper GI bleeding episodes and were more likely to receive blood transfusions during an episode. Overall 30-day mortality was 11.8%, which declined significantly over time (relative declines of 2.3% or 2.8% per year for the stringent and lenient definitions, respectively). In summary, despite declining trends worldwide, crude rates of acute, nonvariceal upper GI bleeding among patients undergoing dialysis have not decreased in the past 10 years. Although 30-day mortality related to upper GI bleeding declined, perhaps reflecting improvements in medical care, the burden on the ESRD population remains substantial.
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Affiliation(s)
- Ju-Yeh Yang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Shirazian S, Radhakrishnan J. Gastrointestinal disorders and renal failure: exploring the connection. Nat Rev Nephrol 2010; 6:480-92. [PMID: 20606629 DOI: 10.1038/nrneph.2010.84] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Gastrointestinal complications are known to commonly occur in patients with renal failure. Uremia and dialysis have long been speculated to increase the risk of lesions in the gastrointestinal tract and accessory organs. In addition, gastrointestinal procedures such as gastrointestinal bypass surgery and the administration of colonoscopy preparations can lead to the development of renal complications. Results from studies that have attempted to define the association between renal dysfunction and gastrointestinal complications are, however, conflicting and limited by small and varied sample populations. No clear management guidelines currently exist for many of the gastrointestinal problems that accompany renal failure. This Review examines the existing data on gastrointestinal complications in patients with chronic kidney disease and end-stage renal disease and aims to outline the etiology and management of common gastrointestinal disorders in such patients.
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Affiliation(s)
- Shayan Shirazian
- Division of Nephrology, Columbia University Medical Center, 622 W 168th Street, PH4-124, New York, NY 10032, USA
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Somsouk M, Gralnek IM, Inadomi JM. Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis. Clin Gastroenterol Hepatol 2008; 6:661-70. [PMID: 18550005 PMCID: PMC2652579 DOI: 10.1016/j.cgh.2008.02.033] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) allow complete small-bowel examination but consume additional health care resources. A cost-minimization analysis determined the optimal initial management strategy for obscure occult gastrointestinal bleeding (OGIB). METHODS We compared 5 strategies: initial small-bowel follow-through, enteroclysis, push enteroscopy (PE), CE, or DBE. Incorporation of multiple tests was allowed with costs taken from a third-party payer perspective. We modeled medically refractory disease with 2 separate model end points in which treatment or definitive diagnosis was necessary and in which visual diagnosis was sufficient to suspend testing. Sensitivity analyses included variations in parameter estimates, Monte Carlo simulation, and structural variations in the model in which DBE was not available as an initial strategy. RESULTS When treatment or definitive diagnosis was necessary, the optimal strategy was initial DBE at a cost of $3824. An initial CE strategy costs an incremental $440. CE was preferred when DBE exceeded $1849 or when the sensitivity of DBE decreased to less than 68%. If DBE was unavailable as an initial test then CE was preferred to PE unless CE exceeded $1190, capsule retention was greater than 3%, or 64% of lesions were within reach of PE. When visual diagnosis was sufficient, initial CE was preferred. CONCLUSIONS For OGIB, initial DBE may be the least expensive strategy when treatment or definitive diagnosis is necessary and initial CE may be preferred when visual identification is sufficient. In settings where DBE is not available as an initial test, initial CE may be the preferred strategy.
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Affiliation(s)
- Ma Somsouk
- Department of Gastrointestinal Health Outcomes, Policy and Economics Research Program, University of California, San Francisco, 513 Parnassus Avenue, Box 0538, San Francisco, California 94143, USA.
| | - Ian M. Gralnek
- Department: Rappaport Faculty of Medicine Institution: Technion Israel Institute of Technology. Haifa, Israel,Department: Gastroenterology, Institution: Rambam Health Care Campus. Haifa, Israel
| | - John M. Inadomi
- Department: GI Health Outcomes, Policy and Economics (HOPE) Research Program Institution: University of California, San Francisco. San Francisco, CA and the Division of Gastroenterology, San Francisco General Hospital, San Francisco, CA
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