Risk factors for small bowel angioectasia: The impact of visceral fat accumulation

Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes

BACKGROUND

Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes.

METHODS

This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups.

RESULTS

Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037).

CONCLUSIONS

Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.

Small Bowel Angioectasias Rebleeding and the Identification of Higher Risk Patients

BACKGROUND

Small bowel capsule endoscopy (SBCE) is the gold standard for suspected small bowel bleeding (SBB). Angioectasias are the most common vascular anomalies in the gastrointestinal tract and have been reported as the source of SBB in up to 80% of patients. Considering their frequency, their usual intermittent bleeding nature, and their risk of rebleeding, the aim of this study was to identify some features and possible predictors of rebleeding in the presence of these lesions.

METHODS

This is a retrospective study, which included consecutive SBCE with angioectasias between April 2008 and December 2017 with a minimum follow-up of 12 months. Rebleeding was defined as a drop of hemoglobin ≥ 2 g/dl and/or in the presence of hematochezia or melenas with negative esophagogastroduodenoscopy and ileocolonoscopy. Data were collected from medical records, and angioectasias were classified by number, location, size, and type. Univariate and multivariable statistical analysis was performed to identify possible predictors of rebleeding.

RESULTS

From a total of 630 patients submitted to SBCE for suspected SBB, 129 with angioectasias were included; 59.7% were female, with a median age of 72 (19-91) years old and a mean follow-up of 44.0 ± 31.9 months. In 32.6% (n = 42) of the patients, at least one episode of rebleeding was documented. The presence of heart failure (OR 3.41; IC95% 1.18-9.89; p = 0.024), the size of the angioectasias (OR 5.41; IC95% 2.15-13.6; p < 0.001), and smoking status (OR 3.15; IC95% 1.07-9.27; p = 0.038) were independent predictor factors of rebleeding.

CONCLUSION

Heart failure, smoking status, and angioectasias with a size superior to 5 mm are independent predictor factors of rebleeding in a population with angioectasias diagnosed by SBCE.

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.

Arteriosclerosis Is a Major Predictor of Small Bowel Vascular Lesions

BACKGROUND

Most studies have focused on evaluating the association between the presence of small bowel vascular lesions (SBVLs) and patients' comorbidities.

AIMS

We sought to uncover a more fundamental indicator that may predict the presence of SBVLs by considering atherosclerosis qualitatively and quantitatively.

METHODS

We enrolled 79 consecutive patients with obscure gastrointestinal bleeding who had undergone computed tomography (CT) and capsule endoscopy or double-balloon endoscopy from January 2015 to June 2017. The SBVL frequency, type, and location, and the relationship between the presence of SBVLs and the patients' clinical characteristics were evaluated. Arterial wall calcification was assessed on unenhanced CT images, and a modified Agatston scoring system was used to determine the abdominal aorta calcium scores.

RESULTS

Of the 27 (34%) patients with SBVLs, 15 (19%) had type 1a, 12 (15%) had type 1b, and 2 (3%) had type 2a SBVLs. Most of the lesions were located in the jejunum. Cardiovascular disease (P = .017), chronic kidney disease (P = .025), and arteriosclerosis (P = .0036) were associated with the presence of SBVLs. Subsequent multivariate analysis revealed that arteriosclerosis (odds ratio [OR] 7.29; 95% confidence interval [CI] 1.13-143.9) and superior mesenteric artery calcification (OR 16.3; 95% CI 3.64-118.6) were independent predictors of the presence of SBVLs. The modified Agatston score was significantly higher in SBVL cases than in non-SBVL cases (6384 vs. 2666, P = .0023).

CONCLUSIONS

Arteriosclerosis, especially increased superior mesenteric artery calcification, is associated with an increased likelihood of SBVLs.

Overview of small bowel angioectasias: clinical presentation and treatment options

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

Small Intestinal Angioectasia: Characterization, Risk Factors, and Rebleeding

BACKGROUND

Gastrointestinal angioectasias (AEs) represent the most common vascular malformation within the gastrointestinal tract. This study sought to characterize epidemiologic/comorbid risk factors for AEs, rebleeding, and patterns of anatomic distribution within the small intestine.

STUDY

This retrospective observational cohort study included 158 patients with AEs on capsule endoscopy (CE) from 2007 to 2015. Epidemiologic/comorbid data were collected and incorporated into final analysis. Each AE was categorized by location using a small bowel transit time-based quartile system. Rebleeding was evaluated following CE. Multivariate logistic regression was applied to statistically significant factors on univariate analysis to determine independent risk factors for rebleeding.

RESULTS

Most lesions were found in the first quartile (67.1%). Rebleeding occurred in 46 (29.7%) of the 156 patients for whom data were available. Rates of rebleeding were significantly higher among older patients (74.4 vs. 67.7 y, P=0.001), those with active bleeding on CE (41.3% vs. 16.5%, P=0.001), those with a history of aortic stenosis (21.7% vs. 9.2%, P=0.033), and those with AEs presents in quartile 3 (26.1% vs. 8.3%, P=0.003). Age, active bleeding on CE, and AE presence in quartile 3 were independently associated with rebleeding in multivariate analysis (P=0.009, 0.023, and 0.008, respectively).

CONCLUSIONS

These data help improve our knowledge of AEs regarding risk factors for rebleeding, and utilizes a novel small bowel transit time-based quartile localization method that may simplify future research and comparisons of anatomic distribution and behavior of small bowel AEs.

Proton pump inhibitor therapy did not increase the prevalence of small-bowel injury: A propensity-matched analysis

Background

Previous studies have reported that the suppression of acid secretion by using proton pump inhibitors (PPIs) results in dysbiosis of the small-bowel microbiota, leading to exacerbated small-bowel injuries, including erosions and ulcers. This study was designed to assess the association between PPI therapy and small-bowel lesions after adjustment for the differences in baseline characteristics between users and non-users of PPIs.

Methods

We retrospectively studied patients suspected to be suffering from small-bowel diseases, who underwent capsule endoscopy between 2010 and 2013. We used propensity matching to adjust for the differences in baseline characteristics between users and non-users of PPIs. The outcomes included the prevalence of small-bowel lesions: erosion, ulcer, angioectasia, varices, and tumor.

Results

We selected 327 patient pairs for analysis after propensity matching, and found no significant differences in the prevalence of small-bowel injuries, including erosions and ulcers, between users and non-users of PPIs. Two subgroup analyses of the effect of the type of PPI and the effect of PPI therapy in users and non-users of nonsteroidal anti-inflammatory drugs indicated no significant differences in the prevalence of small-bowel injuries in these two groups.

Conclusion

PPI therapy did not increase the prevalence of small-bowel injury, regardless of the type of PPI used and the use of nonsteroidal anti-inflammatory drugs.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Re-bleeding events in patients with small intestinal vascular malformation: Risk factors and effect of treatment with thalidomide

AIM

To investigate the risk factors for re-bleeding events in patients with small intestinal vascular malformation and assess the influence of thalidomide on the re-bleeding rate.

METHODS

This study involved patients with gastrointestinal bleeding referred to the First Affiliated Hospital of Zhengzhou University for capsule endoscopy (CE) and enteroscopy between January 2012 and December 2014. Only patients with small intestinal vascular malformation were included in the study. Follow-up data were obtained through medical records review, telephone interviews or follow-up clinic visits to identify the risk factors associated with re-bleeding. Based on the follow-up data, the re-bleeding rate was compared between patients who had been treated with thalidomide and those who had not.

RESULTS

A total of 156 patients were included in the study, and all of them completed the follow-up, with a mean follow-up duration of 10.78 ± 7.64 mo. Multiple regression analysis identified that presence of hypertension (HR = 1.994, 95%CI: 1.236-3.125, P = 0.005), multiple lesions (≥3) (HR = 1.644, 95%CI: 1.002-2.703, P = 0.049) and liver cirrhosis (HR = 2.116, 95%CI: 1.063-4.212, P = 0.033) were significant independent predictors of re-bleeding, while treatment with thalidomide was a protecting factor (HR = 0.497, 95%CI: 0.303-0.816, P = 0.006). The cumulative re-bleeding rates in patients who were treated with thalidomide and those who were not were 35.71% and 54.65%, respectively, and the difference reached statistical significance (P < 0.05).

CONCLUSION

The re-bleeding rate in patients with small bowel vascular malformation is relatively high, especially those with hypertension, multiple lesions (≥3) and liver cirrhosis. Repeated CE or enteroscopy is recommended for those patients with risk factors for re-bleeding within 2 years. Treatment with thalidomide for patients without contraindication can reduce the re-bleeding rate.