Frequency and risk factors for rebleeding events in patients with small bowel angioectasia

Endoscopic injection sclerotherapy for treating recurrent bleeding of small bowel angioectasias

BACKGROUND

There is still no consensus on the preferred endoscopic therapy for small bowel angioectasias (SBAs). The aim of this study was to evaluate effectiveness and safety of endoscopic injection sclerotherapy (EIS) for treating recurrent bleeding of SBAs.

METHODS

Sixty-six adult patients diagnosed with SBAs by capsule endoscopy (CE) or double-balloon enterscopy (DBE) examinations were enrolled in this retrospective study from September 2013 to September 2021. The patients were divided into an EIS group (35 cases) and a control group (31 cases) according to whether they underwent EIS treatment. Clinical characteristics, medical histories, lesion characteristics, main laboratory indicators, treatments, and outcomes were collected. The rates of re-bleeding, re-admission, and red blood cell (RBC) transfusion were compared between different groups after discharge. The rates of hospitalization and RBC transfusion were compared between before admission and after discharge in both groups. Odds ratios (ORs) and 95% confidence intervals (CIs) were used in the multivariate logistic regression analysis to assess relative factors for re-bleeding.

RESULTS

All the rates of re-bleeding, re-admission and RBC transfusion after discharge in the EIS group were significantly lower than those in the control group (all P < 0.05). The rates of hospitalization and RBC transfusion after discharge were significantly lower than those before admission in the EIS group (both P < 0.05), while those did not reach significant differences in the control group (both P > 0.05). Multivariate logistic regression analysis showed that RBC transfusion before admission (OR, 5.655; 95% CI, 1.007-31.758, P = 0.049) and multiple lesions (≥ 3) (OR, 17.672; 95% CI, 2.246-139.060, P = 0.006) were significant risk factors of re-bleeding, while EIS treatment (OR, 0.037; 95% CI, 0.005-0.260, P < 0.001) was a significant protective factor. No endoscopic adverse events were observed during hospitalization and none of the enrolled patients died within 12 months after discharge.

CONCLUSION

EIS treatment had good effectiveness and safety for treating recurrent bleeding of SBAs, which could be considered as one of the first-line endoscopic treatment options for SBAs.

Application of validated bleeding risk scores for atrial fibrillation in obscure gastrointestinal bleeding patients increases videocapsule endoscopy's diagnostic yield: a retrospective monocentric study

BACKGROUND

Videocapsule endoscopy (VCE) is considered the gold standard for overt and obscure gastrointestinal bleeding (OGIB), after negative upper and lower endoscopy. Nonetheless, VCE's diagnostic yield is suboptimal, and it represents a costly, time-consuming, and often not easily available technique. In order to evaluate bleeding risk in patients with atrial fibrillation, several scoring systems have been proposed, but their utilization outside the original clinical setting has rarely been explored. The aim of the study is to evaluate potential role of bleeding risk scoring systems in predicting the occurrence of positive findings at VCE examination, and therefore in increasing VCE diagnostic yield.

METHODS

Data from consecutive patients undergoing VCE between April 2015 and June 2020 were retrospectively retrieved, and clinical and demographic characteristics were collected. HAS-BLED, ATRIA, and ORBIT scores were calculated, and patients were considered at low or high risk of bleeding accordingly. Discriminative ability of the scores for positive VCE findings has been evaluated by area under receiver operator characteristic curve (AUC) calculation. Diagnostic yield of scores in high- and low-risk patients was calculated.

RESULTS

A total of 413 patients underwent VCE examination, among which 368 (89%) for OGIB. Positive findings were observed in 246 patients (67%), with angiodysplasias being the most frequent lesion (92%). The three scores displayed similar consistent discriminative ability for positive VCE findings (mean AUC = 0.69), and identified high-risk group of patients in which VCE has a higher diagnostic yield.

CONCLUSIONS

In the present retrospective study, bleeding scores accurately discriminated patients with higher probability of positive findings at VCE examination. Bleeding scores utilization may help in the management of patients with OGIB, with a potential consistent resource optimization and cost-saving.

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

INTRODUCTION

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of Rebleeding in Patients with Small Bowel Vascular Lesions

Objective With recent advances in endoscopic modalities, small bowel vascular lesions (SBVLs) are often now detected in patients with gastrointestinal bleeding. Given the high invasiveness of endoscopic treatment, it is important to select patients at high risk for bleeding. To assess the risk of rebleeding in patients with SBVLs as a systemic disease rather than a gastrointestinal disease in relation to their general health. Methods We retrospectively analyzed the clinical data of 55 patients with SBVLs among patients with obscure gastrointestinal bleeding. The possible association between the clinical findings and the updated Charlson comorbidity index with rebleeding was evaluated. Results Gastrointestinal rebleeding occurred in 20 patients (36.4%) during the follow-up period. The presence of multiple comorbidities as indicated by an updated Charlson comorbidity index of ≥4 was a risk factor for rebleeding (hazard ratio, 3.64; p=0.004). Other risk factors were arteriosclerosis of the superior mesenteric artery and multiple SBVLs. Endoscopic hemostasis and the discontinuation of antithrombotic medications were not significantly associated with rebleeding. Patients with a high updated Charlson comorbidity index had a high risk of death of causes other than gastrointestinal rebleeding. Conclusion Gastrointestinal rebleeding is not a rare condition among patients with SBVLs. Patients with poor general health may therefore have a higher risk of rebleeding.

A comprehensive systematic review and meta-analysis of risk factors for rebleeding following device-assisted enteroscopy therapy of small-bowel vascular lesions

INTRODUCTION

the aim of this study was to determine the risk factors for rebleeding following device-assisted enteroscopy therapy of small bowel vascular lesions.

METHODS

this is a systematic review and meta-analysis. A literature search was performed from January 2003 to October 2019. All studies reporting on at least one risk factor for bleeding recurrence after endoscopic therapy of small bowel vascular lesions were included. A meta-analysis of those risk factors reported in at least three studies was performed to assess their association with rebleeding. The OR and 95 % CI were used for binary outcome data. Heterogeneity analysis was performed using the Tau and I2 index. If I2 > 20 %, potential sources of heterogeneity were identified by sensitivity analyses and a random-effect model was used.

RESULTS

the search identified a total of 572 articles and 35 full-text records were assessed for eligibility after screening. Finally, eight studies that included 548 patients were selected. The overall median rebleeding rate was 38.5 % (range: 10.9-53.3 %) with a median follow-up of 24.5 months. Female sex (OR: 1.96, 95 % CI: 1.14-3.37, p = 0.01, I2 = 0 %), Osler-Weber syndrome (OR: 4.35, 95 % CI: 1.22-15.45, p = 0.02, I2 = 0 %) and cardiac disease (OR: 1.89, 95 % CI: 1.12-2.97, p = 0.005, I2: 0 %) were associated with rebleeding. According to the sensitivity analysis, overt bleeding (OR: 2.13, 95 % CI: 1.22-3.70, p = 0.007, I2 = 0 %), multiple lesions (OR: 4.57, 95 % CI: 2.04-10.22, p < 0.001, I2 = 0 %) and liver cirrhosis (OR: 2.61, 95 % CI: 1.11-6.13, p = 0.03, I2 = 0 %) were also predictors for rebleeding.

CONCLUSIONS

patient characteristics and comorbidities should be considered for follow-up patient management after effective device-assisted endoscopic therapy, as they can predict rebleeding.

Scoring systems in clinical small-bowel capsule endoscopy: all you need to know!

Capsule 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.

Superselective transcatheter arterial embolization for acute small bowel bleeding: clinical outcomes and prognostic factors for ischemic complications

BACKGROUND

Small bowel bleeding (SBB) accounts for 5%-10% of all cases of acute gastrointestinal bleeding. Transcatheter arterial embolization (TAE) plays an important role in the treatment of SBB.

PURPOSE

To evaluate the safety and efficacy of superselective TAE exclusively for SBB and to assess factors associated with clinical outcomes.

MATERIAL AND METHODS

From January 2006 to April 2017, 919 patients were admitted with signs and symptoms of gastrointestinal bleeding; 74 patients (mean age = 57.5 years; age range = 14-82 years) with positive angiographic findings for SBB were retrospectively analyzed. The technical success of TAE and clinical outcomes, including recurrent bleeding, major complications, and in-hospital mortality were evaluated. The associations of various clinical and technical factors with clinical outcomes were analyzed.

RESULTS

The bleeding foci were in the ileum in 48 (65%) patients and the jejunum in 26 (35%). Technical success was achieved in 72 (97%) patients. The rates of recurrent bleeding, major complications, and in-hospital mortality were 12% (7/57), 21% (15/71), and 25% (18/72), respectively. Superselective embolization was a significant prognostic factor associated with fewer major complications (OR = 0.069; P = 0.003). The increased number of embolized vasa recta was significantly associated with a higher probability of major complications (OR = 2.64; P < 0.001). The use of N-butyl cyanoacrylate was associated with lower rates of major complication (OR = 0.257; P = 0.027).

CONCLUSION

TAE is a safe and effective treatment modality for SBB. In addition, whenever possible, TAE should be performed in a superselective manner to minimize ischemic complications.

Systemic manifestations - do not forget the small bowel

PURPOSE OF REVIEW

Systemic diseases can afflict the small bowel (SB) but be challenging to diagnose. In this review, we aim to provide a broad overview of these conditions and to summarise their management.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is an important modality to investigate pathology in the SB. SB imaging can be complementary to SBCE for mural and extramural involvement and detection of multiorgan involvement or lymphadenopathy. Device assisted enteroscopy provides a therapeutic arm, to SBCE enabling histology and therapeutics to be carried out.

SUMMARY

SB endoscopy is essential in the diagnosis, management and monitoring of these multi-system conditions. Collaboration across SB centres to combine experience will help to improve the management of some of these rarer SB conditions.

Contribution of Capsule Endoscopy Early in a Bleeding Episode to Treatment of Small Bowel Angioectasia: A Case Report

Background: Recent advances in endoscopic devices such as small bowel capsule endoscopy and balloon-assisted endoscopy have improved the level of medical care for small bowel bleeding. However, treating small bowel angioectasia remains challenging because repeated intermittent bleeding can occur from the multiple minute lesions (about 1 mm in size) that develop in a synchronous and metachronous manner. Here, we report a case of small bowel angioectasia in which capsule endoscopy performed early in a bleeding episode contributed to treatment. Case Summary: A 66-year-old man with suspected small bowel bleeding underwent small bowel capsule endoscopy and balloon-assisted endoscopy with argon plasma coagulation hemostasis for a small intestinal angioectasia. Because small bowel bleeding recurred intermittently after the treatment, small bowel capsule endoscopy and balloon-assisted endoscopy were repeated when there was no bleeding, but no abnormalities were found. Subsequent small bowel capsule endoscopy during a bleeding episode revealed bloody intestinal fluid in the proximal small intestine. Peroral balloon-assisted endoscopy was performed 2 days after SBCE for detailed observation of the small intestinal mucosa at the suspected bleeding site, and there a 1-mm Dieulafoy’s lesion with no active bleeding was identified. We performed argon plasma coagulation, and no bleeding was observed thereafter. Conclusions: Small bowel capsule endoscopy immediately after bleeding onset can identify the bleeding source of multiple minute lesions in small bowel angioectasia.

Gastrointestinal bleeding from angiodysplasia in von Willebrand disease: Improved diagnosis and outcome prediction using videocapsule on top of conventional endoscopy

BACKGROUND

Despite a high prevalence of angiodysplasia, no specific guidelines are available for the modalities of endoscopic exploration of gastrointestinal (GI) bleeding in von Willebrand disease (VWD). Whether VWD patients could benefit from video capsule endoscopy (VCE) looking for angiodysplasia eligible to endoscopic treatment or at high risk of bleeding is unknown.

OBJECTIVES

To assess the diagnostic efficacy for angiodysplasia and the prognostic value of VCE on top of conventional endoscopy in VWD patients with GI bleeding.

PATIENTS/METHODS

A survey was sent to the 30 centers of the French-network on inherited bleeding disorders to identify VWD patients referred for endoscopic exploration of GI bleeding from January 2015 to December 2017. Data obtained included patient characteristics, VWD phenotype/genotype, GI bleeding pattern, results of endoscopic investigations, and medical management applied including endoscopic therapy. We assessed by Kaplan-Meier analysis the recurrence-free survival after the first GI bleeding event according to endoscopic categorization and, in patients with angiodysplasia, to the presence of small-bowel localizations on VCE exploration.

RESULTS

GI bleeding source localization was significantly improved when including VCE exploration (P < .01), even in patients without history of angiodysplasia (P < .05). Patients with angiodysplasia had more GI bleeding recurrences (P < .01). A lower recurrence-free survival was observed in patients with angiodysplasia (log-rank test, P = .02), and especially when lesions were located in the small bowel (log-rank test, P < .01), even after endoscopic treatment with argon plasma coagulation (log-rank test, P < .01).

CONCLUSION

VCE should be more systematically used in VWD patients with unexplained or recurrent GI bleeding looking for angiodysplasia eligible to endoscopic treatment or at high risk of relapse.

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.

Does urgent balloon-assisted enteroscopy impact rebleeding and short-term mortality in overt obscure gastrointestinal bleeding?

BACKGROUND AND AIMS

The diagnostic yield (DY) and therapeutic yield (TY) of balloon-assisted enteroscopy (BAE) in overt obscure gastrointestinal bleeding (OGIB) is higher in the first 72 h. This study aimed to evaluate if this higher DY and TY after urgent BAE impacted the rebleeding rate, time to rebleed and short-term mortality.

METHODS

Retrospective cohort-study, which consecutively included all patients submitted to BAE for overt OGIB, between 2010 and 2019. Patients were distributed in 2 groups: (1) Urgent BAE; (2) Non-urgent BAE. Rebleeding was defined as an Hb drop >2 g/dL, need for transfusional support or presence of melena/hematochezia.

RESULTS

Fifty-four patients were included, of which 17 (31.5%) were submitted to BAE in the first 72 h. DY and TY of urgent BAE (DY 88.2%; n = 15; TY 94.1%; n = 16) was higher compared to non-urgent BAE (DY 59.5%; n = 22; TY 45.9%; n = 17) (DY p = .03) (TY p = .001). The rebleeding rate at 1, 2, and 5 years was 32.0%, 34.0%and 37.0%, respectively. Rebleeding was lower after urgent BAE (17.6%; n = 3) compared to non-urgent BAE (45.9%; n = 17) (p = .04). Rebleeding tended to occurr earlier in non-urgent BAE, being at 6-months (32.5%) and 36 months (41.3%) (p = .05). OGIB related 30-day mortality was 5.4% (n = 2) for non-urgent BAE and 0% for urgent BAE (p = .5).

CONCLUSION

Urgent BAE might be associated with higher DY and TY with lower rebleeding and trend toward higher rebleeding-free time.

Diagnosis and therapeutic strategies for small bowel vascular lesions

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds

BACKGROUND

Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease.

AIMS

To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias.

METHODS

We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size.

RESULTS

Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3).

CONCLUSIONS

This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.

Diagnostic and therapeutic yields of urgent balloon-assisted enteroscopy in overt obscure gastrointestinal bleeding

BACKGROUND AND AIMS

Balloon-assisted enteroscopy (BAE) is one of the diagnostic and therapeutic procedures in the algorithm for the evaluation of overt obscure gastrointestinal bleeding (OGIB). There is currently no consensus regarding the role of urgent BAE in overt OGIB. The aims of this study were to compare the diagnostic and therapeutic yields of urgent and nonurgent BAE in patients with overt OGIB.

PATIENTS AND METHODS

We conducted a retrospective, single-center study that included patients who underwent BAE for overt OGIB between January 2010 and December 2017. Urgent BAE was defined as an enteroscopy performed within 72 h of clinical presentation. Demographic, clinical, laboratory, and technical data were reviewed and the diagnostic and therapeutic yields evaluated and compared.

RESULTS

Seventy BAEs were performed in 57 patients with overt OGIB [29 (50.9%) females, mean age: 68.0±11.1 years]. The diagnostic yield of urgent BAE was significantly higher than nonurgent BAE (84.5 vs. 50.0%, P<0.01). The most common diagnosis were angiodysplasias (30%), tumors (15.7%), erosions/ulcers (4.3%), and diverticula (4.3%). Endoscopic therapy was more frequently performed in urgent BAE patients (57.7 vs. 31.8%, P=0.03). The most commonly used endoscopic therapies were argon plasma coagulation (30.0%), hemostatic clips (5.7%), epinephrine injection (5.7%), and polypectomy (2.9%). In terms of urgent BAE, the diagnostic yield was similar when enteroscopy was performed at less than or equal to 24, 48, or 72 h (P>0.05), but the therapeutic yield was higher the earlier the enteroscopy was performed (100, 76.9, and 57.7% at ≤24, ≤48, and ≤72 h respectively; P=0.03).

CONCLUSION

The diagnostic and therapeutic impact of BAE was higher in an urgent setting. These data support an important role for urgent BAE in overt OGIB.

Small bowel bleeding: cause and the role of endoscopy and medical therapy

PURPOSE OF REVIEW

The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias.

SUMMARY

SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.

Meta-analysis shows similar re-bleeding rates among Western and Eastern populations after index video capsule endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (VCE) is the first-line diagnostic procedure for investigating obscure gastrointestinal bleeding (OGIB). Different re-bleeding rates following index VCE have been reported among Western and Eastern studies.

METHODS

We conducted a comprehensive literature search to identify studies examining re-bleeding rates after VCE for OGIB. Meta-analysis assessed the pooled proportion of re-bleeding events after VCE for OGIB according to study's origin (Western vs. Eastern) and according to the length of follow-up (≥24 months vs. <24 months). We also calculated the re-bleeding odds ratios (OR; 95% CI) after positive vs. negative index VCE, overt vs. occult initial presentation of bleeding and after interventional treatment for positive index cases, according to the study's origin.

RESULTS

We included 46 (30 Western and 16 Eastern) studies with 5796 patients. Significant heterogeneity was detected among meta-analyzed studies. Overall, the pooled re-bleeding rate was similar between Western (29%; 95% CI: 23-34) and Eastern (21%; 95% CI: 15-27) populations, irrespective of the length of follow-up. The odds of re-bleeding was significantly higher after positive as compared to negative index VCE in Eastern studies (OR: 1.77; 95% CI: 1.07-2.94). Application of specific treatment after positive index VCE was associated with lower re-bleeding odds in both Western (OR: 0.37; 95% CI: 0.16-0.87) and Eastern (OR: 0.39; 95% CI: 0.21-0.72) populations.

CONCLUSIONS

Patients undergoing VCE for OGIB have similar re-bleeding rates in the East and the West, regardless of the length of follow-up. However, increased re-bleeding odds after positive index VCE is observed in Eastern studies.

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.

Lanreotide in the management of small bowel angioectasias: seven-year data from a tertiary centre

BACKGROUND AND AIMS

Haemorrhage from small bowel angioectasias (SBAs) can be debilitating to patients who are very often elderly and have multiple comorbidities. Our aim was to assess the use of lanreotide in addition to endotherapy in patients with SBAs.

METHOD

Patients with SBAs on capsule endoscopy (CE) who received lanreotide injections from January 2010 to till the present day at the Royal Hallamshire Hospital in Sheffield were included. Baseline demographics were recorded. Efficacy was evaluated in terms of improvement in mean haemoglobin, transfusion requirements and bleeding episodes.

RESULTS

Twelve patients (67% males, mean age 74 SD ± 15.5 years) were included. All patients had multiple comorbidities. Lanreotide was given at a dosage of 60 mg (42%), 90 mg (33%) or 120 mg (25%). It was given at a four-week interval in 75% of patients and at a six-week interval in 17% of patients. One patient (8%) received a single dose. The mean duration of treatment was 19 months SD ± 14.5. Only 17% of patients had their lanreotide stopped due to cholelithiasis. There was a significant improvement in mean haemoglobin: 86.8 versus 98.0 (131-166 g/L, p = .012). The mean number of bleeding episodes (4.18 versus 1.09, p = .010) and packed red cells (323 versus 152, p = .006) received improved. Patients required less DBEs ± APCs after starting lanreotide (19 versus 11 p = .048).

CONCLUSION

Lanreotide is a useful adjuvant treatment to therapeutic enteroscopy in patients with refractory obscure gastrointestinal bleeding due to SBAs. It improves haemoglobin levels, reduces transfusion requirements, bleeding episodes and number of DBEs. Overall, it has a good safety profile.

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.

A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9mg/dL: A prospective cohort study

BACKGROUND

Anemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation.

METHODS

To elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9g/dL and no extraintestinal bleeding.

RESULTS

4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3]g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2]g/dL, P<0.001).

CONCLUSION

Not only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9g/dL.

Investigation of Small Bowel Abnormalities in HIV-Infected Patients Using Capsule Endoscopy

HIV infection is reportedly associated with an increased permeability of the intestinal epithelium and can cause HIV enteropathy, which occurs independently of opportunistic infections. However, the characteristics of small bowel abnormalities attributable to HIV infection are rarely investigated. In the present study, we assessed the intestinal mucosal changes found in HIV-infected patients and compared them with the mucosa of healthy control subjects using capsule endoscopy (CE). Three of the 27 HIV-infected patients harbored gastrointestinal opportunistic infections and were thus excluded from subsequent analyses. The endoscopic findings of CE in HIV-infected patients were significantly higher than those in control subjects (55% versus 10%, P = 0.002); however, most lesions, such as red spots or tiny erosions, were unlikely to cause abdominal symptoms. After validating the efficacy of CE for the diagnosis of villous atrophy, we found that the prevalence of villous atrophy was 54% (13/24) among HIV-infected patients. Interestingly, villous atrophy persisted in patients receiving long-term antiretroviral therapy, though most of them exhibited reconstituted peripheral blood CD4+ T cells. Although we could not draw any conclusions regarding the development of small bowel abnormalities in HIV-infected patients, our results may provide some insight regarding the pathogenesis of HIV enteropathy.

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.

Clinical outcome after enteroscopy for small bowel angioectasia bleeding: A Korean Associateion for the Study of Intestinal Disease (KASID) multiceter study

BACKGROUND AND AIMS

Angioectasias are the most common sources of bleeding in the small bowel. They can be treated using balloon-assisted enteroscopy (BAE). This study aimed to identify the rebleeding rate and associated factors after BAE in patients with small bowel angioectasia bleeding.

METHODS

We retrospectively analyzed the records of patients with bleeding due to small bowel vascular lesion in a multicenter enteroscopy database including 1108 BAEs. Finally, in rebleeding analysis, we analyzed 66 patients with angioectasia on the basis of the Yano-Yamamoto classification. Patients who had undergone endotherapy (ET) were divided into ET (n = 45) and non-ET (n = 21) groups. Rebleeding was defined as evidence of bleeding at least 30 days after BAE.

RESULTS

Fifty-three patients (80.4%) underwent only one-side enteroscopy. The most common ET was argon plasma coagulation (87.2%). During a mean follow-up duration of 24.5 months, ET and non-ET groups had rebleeding rates of 15.6% and 38.1% (P = 0.059), respectively. Median rebleeding time of ET and non-ET groups was 32.5 and 62 months, respectively. Liver cirrhosis (LC), low platelet count (< 10⁵ /μL), and transfusions were the rebleeding-associated factors in the univariate analysis. In the multivariate analysis, the presence of LC (HR 4.064, 95% CI 1.098-15.045; P = 0.036) was the only independent rebleeding-associated risk factor.

CONCLUSIONS

ET using BAE did not significantly affect the rebleeding rate in patients with small bowel angioectasia bleeding. An independent rebleeding risk factor was the presence of LC. Regardless of ET, careful long-term follow-up may be needed, especially in LC patients with small bowel angioectasia bleeding.

Overview of technical solutions and assessment of clinical usefulness of capsule endoscopy

The paper presents an overview of endoscopic capsules with particular emphasis on technical aspects. It indicates common problems in capsule endoscopy such as: (1) limited wireless communication (2) the use of capsule endoscopy in the case of partial patency of the gastrointestinal tract, (3) limited imaging area, (4) external capsule control limitations. It also presents the prospects of capsule endoscopy, the most recent technical solutions for biopsy and the mobility of the capsule in the gastrointestinal tract. The paper shows the possibilities of increasing clinical usefulness of capsule endoscopy resulting from technological limitations. Attention has also been paid to the current role of capsule endoscopy in screening tests and the limitations of its effectiveness. The paper includes the author's recommendations concerning the direction of further research and the possibility of enhancing the scope of capsule endoscopy.

Overview of technical solutions and assessment of clinical usefulness of capsule endoscopy

The paper presents an overview of endoscopic capsules with particular emphasis on technical aspects. It indicates common problems in capsule endoscopy such as: (1) limited wireless communication (2) the use of capsule endoscopy in the case of partial patency of the gastrointestinal tract, (3) limited imaging area, (4) external capsule control limitations. It also presents the prospects of capsule endoscopy, the most recent technical solutions for biopsy and the mobility of the capsule in the gastrointestinal tract. The paper shows the possibilities of increasing clinical usefulness of capsule endoscopy resulting from technological limitations. Attention has also been paid to the current role of capsule endoscopy in screening tests and the limitations of its effectiveness. The paper includes the author's recommendations concerning the direction of further research and the possibility of enhancing the scope of capsule endoscopy.