[Diagnostic utility of capsule endoscopy in occult gastrointestinal bleeding]

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% (χ² 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.

Evaluation of iron deficiency anemia in older adults: the role of wireless capsule endoscopy

INTRODUCTION

Anemia although a frequent problem in all age groups, is an important cause of morbidity and mortality in the elderly. Despite standard endoscopic diagnostic evaluations with esophagogastroduodenoscopy (EGD) and colonoscopy, up to 30% of patients with iron deficiency anemia (IDA) are without a definitive diagnosis. Obscure gastrointestinal bleeding (OGIB) (occult or overt) from the small bowel, could be the source of IDA in patients with normal EGD and colonoscopy. Wireless capsule endoscopy (WCE), a relatively new diagnostic modality helps in the detection of small bowel mucosal abnormalities.

AIM

The aim of this study is to report on the diagnostic yield (DY) of WCE for IDA with or without OGIB in older adults and its comparison with younger age groups.

MATERIALS AND METHODS

In this retrospective study, data is based on652 consecutive WCE performed during a 5-year period (2002 to 2007).

RESULTS

Total number ofWCE=652 (males=311, females=341). IDA was the indication for WCE in 424 of 652 cases (65%). Most common finding observed by WCE in patients with IDA without OGIB: group 1 (age<50 y)=small bowel erosion (19%) and ulceration (19%), group 2 (age 50 to 64 y)=small bowel erosion (33%), group 3 (age 65 to 85 y, older adults)=small bowel erosion (30%), and group 4 (age>85 y, the oldest old)=small bowel erosion (38%). Most common finding observed by WCE in patients with IDA with OGIB: group 1=small bowel ulceration (19%), group 2=small bowel erosion (26%), group 3=small bowel erosion (38%), and group 4=angiodysplasia (55%). DY of WCE for IDA without OGIB: group 1=50%, group 2=52%, group 3=56%, and group 4=69%. DY of WCE for IDA with OGIB: group 1=38%, group 2=58%, group 3=63%, and group 4=73%. Active bleeding in the small bowel was seen in 48 of 424 (11%) patients with IDA.

CONCLUSIONS

WCE, a valuable tool for the visualization of entire small bowel mucosa plays a critical role for the evaluation of IDA in patients with negative EGD and colonoscopy. Small bowel erosions, ulcerations, and angiodysplasia observed by WCE are the most frequent findings in patients with IDA. DY of WCE in the evaluation of IDA progressively increases as age advances.

Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability

BACKGROUND

The rapid expansion in use of capsule endoscopy (CE) has led to discussion about training needs and provision. The lesion recognition skills required for CE are ideally suited to computer-based training.

OBJECTIVE

The aim of this study was to prospectively evaluate the educational effectiveness of a computer-based CE training and testing module on trainees with varying experience.

DESIGN

This was a prospective educational evaluation study.

SETTING

Academic endoscopy unit.

PATIENTS

This study involved 28 trainees of varying CE experience (medical students, gastroenterology trainees) and 4 CE experts.

INTERVENTION

Trainees (medical students and gastroenterology trainees) without CE experience completed a 60-question, computer-based test module consisting of 30-second video clips and multiple-choice questions. Without feedback, trainees then completed a comprehensive, menu-driven, computer-based CE training module. The test module was then completed a second time and feedback was given. Expert performance on the test module was benchmarked by 4 CE experts.

MAIN OUTCOME MEASUREMENTS

The first measure was the difference in baseline performance on the test module between trainees and experts (to determine construct validity). The second measure was a change in performance on the test module after training (to determine content validity of the training module).

RESULTS

A significant difference was noted in baseline performance (P < .001) among CE experts (mean 73.8% +/- 8.0%), gastroenterology trainees (49.5% +/- 10.9%), and medical students (29.5% +/- 3.3%). Performance improved significantly (P < .001) in both trainee groups after training (gastroenterology trainees' posttraining score 62.1% +/- 7.7%; medical students' 46.7% +/- 6.8%).

CONCLUSION

Computer-based learning has a potentially significant role in the development of a training syllabus for CE and in CE accreditation.

How should we train capsule endoscopy? A pilot study of performance changes during a structured capsule endoscopy training program

There are no validated training/accreditation guidelines for capsule endoscopy. We assessed the utility of a structured training program on two experienced gastroenterologists and one endoscopy nurse. Validated studies were standardized for difficulty in blocks of three. Trainees completed a standardized data sheet for each study reported (12 studies for the physicians, 22 studies for the nurse). After each block the trainer graded performance and highlighted learning points. Statistical analysis was performed. Physician trainees accurately identified landmarks throughout, while the nurse made errors even at the end of training. Improvement in lesion detection and diagnostic accuracy improved in the nurse, but in only one of the physician trainees, highlighting the variability in learning curves. Overall performance improved in all trainees but was most marked for the nurse trainee (correlation coefficient 0.41, P = 0.06). Improvements in lesion recognition and diagnosis can be demonstrated in senior trainees and nurses following a structured training program; however, there is considerable variability.

Are bowel purgatives and prokinetics useful for small-bowel capsule endoscopy? A prospective randomized controlled study

BACKGROUND

Capsule endoscopy (CE) is limited by incomplete small-bowel transit and poor view quality in the distal bowel. Currently, there is no consensus regarding the use of bowel purgatives or prokinetics in CE.

OBJECTIVE

To evaluate the usefulness of bowel purgatives and prokinetics in small-bowel CE.

DESIGN

Prospective single-blind randomized controlled study.

SETTING

Academic endoscopy unit.

PATIENTS

A total of 150 patients prospectively recruited.

INTERVENTION

Patients were randomized to 1 of 4 preparations: "standard" (fluid restriction then nothing by mouth 12 hours before the procedure, water and simethicone at capsule ingestion [S]); "standard" + 10 mg oral metoclopramide before the procedure (M); Citramag + senna bowel-purgative regimen the evening before CE (CS); Citramag + senna + 10 mg metoclopramide before the procedure (CSM).

MAIN OUTCOME MEASUREMENTS

Gastric transit time (GTT) and small-bowel transit time (SBTT), completion rates (CR), view quality, and patient acceptability.

SECONDARY OUTCOME MEASURES

positive findings, diagnostic yield.

RESULTS

No significant difference was noted among groups for GTT (median [minutes] M, CS, and CSM vs S: 17.3, 24.7, and 15.1 minutes vs 16.8 minutes, respectively; P = .62, .18, and .30, respectively), SBTT (median [minutes] M, CS, and CSM vs S: 260, 241, and 201 vs 278, respectively; P = .91, .81, and .32, respectively), or CRs (85%, 85%, and 88% vs 89% for M, CS, and CSM vs S, respectively; P = .74, .74, and 1.00, respectively). There was no significant difference in view quality among groups (of 44: 38, 37, and 40 vs 37 for M, CS, and CSM, vs S, respectively; P = .18, .62, and .12, respectively). Diagnostic yield was similar among the groups. CS and CSM regimens were significantly less convenient (P < .001), and CS was significantly less comfortable (P = .001) than standard preparation.

CONCLUSIONS

Bowel purgatives and prokinetics do not improve CRs or view quality at CE, and bowel purgatives reduce patient acceptability.

Safety, reliability and limitations of the given patency capsule in patients at risk of capsule retention: a 3-year technical review

INTRODUCTION

The patency capsule may prevent capsule retention in high-risk patients. However data on its use in routine clinical practice is limited.

METHODS

Patients referred to our institution between Feb-04 and Jan-07 were reviewed. The following data was collected: presenting symptoms; medical/surgical history; medication; radiology; patency/video capsule result; subsequent investigations; clinical outcomes.

RESULTS

373 patients were referred. In 315 (84%) 'low-risk' patients (no patency capsule): delayed transit occurred in three, with no cases of capsule retention. In 58 (16%) 'high risk' patients (patency capsule): asymptomatic retention occurred in eight, all with pathology despite normal prior barium studies in six; in four cases patency location was incorrectly assessed radiologically, leading to video capsule retention and surgery in one.

DISCUSSION

Most patients can safely undergo capsule endoscopy without a patency capsule. The patency capsule appears safe and is indicative of pathology when retained. Assessment of patency capsule location post ingestion can be difficult, and if barium radiology is equivocal a limited abdominal computed tomography (CT) scan is suggested.

American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding

This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007.

Bleeding update

Obscure bleeding is a consolidated indication to CE, which when used as a first-line exploration is the most efficient strategy as regards diagnosis in these patients. Patient selection and timing of the procedure are of paramount importance in the high diagnostic yield of CE. When integrated into a global patient care plan, CE is helpful in achieving effective decision-making concerning subsequent investigations and treatments. Although most studies appear to indicate a positive influence of CE diagnosis on clinical outcome of OGIB patients, large prospective trials are warranted to assess what is the most effective therapeutic strategy in patients with vascular lesions.

Diagnosis of small-bowel diseases in the era of capsule endoscopy

Capsule endoscopy is a major breakthrough in gastrointestinal endoscopy and is a first-line tool to detect abnormalities of the small bowel, in up to 50% of patients, intestinal disorders are not associated with any physical findings or positive tests. Indications, yield and impact on patient management of this method of diagnosing small-bowel diseases are analyzed critically in light of current scientific knowledge.