Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis

Background and Aim: Uncertainty remains about the best test to evaluate patients with obscure gastrointestinal bleeding (OGIB). Previous meta‐analyses demonstrated similar diagnostic yields with capsule endoscopy (CE) and double balloon enteroscopy (DBE) but relied primarily on data from abstracts and were not limited to bleeding patients. Many studies have since been published. Therefore, we performed a new meta‐analysis comparing CE and DBE focused specifically on OGIB. Methods: A comprehensive literature search was performed of comparative studies using both CE and DBE in patients with OGIB. Data were extracted and analyzed to determine the weighted pooled diagnostic yields of each method and the odds ratio for the successful localization of a bleeding source. Results: Ten eligible studies were identified. The pooled diagnostic yield for CE was 62% (95% confidence interval [CI] 47.3–76.1) and for DBE was 56% (95% CI 48.9–62.1), with an odds ratio for CE compared with DBE of 1.39 (95% CI 0.88–2.20; P = 0.16). Subgroup analysis demonstrated the yield for DBE performed after a previously positive CE was 75.0% (95% CI 60.1–90.0), with the odds ratio for successful diagnosis with DBE after a positive CE compared with DBE in all patients of 1.79 (95% CI 1.09–2.96; P = 0.02). In contrast, the yield for DBE after a previously negative CE was only 27.5% (95% CI 16.7–37.8). Conclusions: Capsule endoscopy and double balloon enteroscopy provide similar diagnostic yields in patients with OGIB. However, the diagnostic yield of DBE is significantly higher when performed in patients with a positive CE.     

Diagnosis of obscure gastrointestinal hemorrhage with capsule endoscopy in combination with multiple-detector computed tomography

Aim:  To demonstrate the clinical efficacy of combination capsule endoscopy (CE) and multiple-detector computed tomography (MDCT) diagnostic imaging in the identification of gastrointestinal hemorrhages.
Methods:  In the present study, 123 patients with gastrointestinal hemorrhages of obscure origin (GHOO) were examined with CE in combination with MDCT. The results were compared with findings of surgical pathology.
Results:  Of the 123 patients, 57.72% (71/123) of the patients exhibited positive CE findings compared with 30.08% (37/123) on MDCT alone ( P  < 0.01). When used in combination, 65.85% (81/123) of patients scored positively. The detection rate due to the combination of diagnostic imaging was significantly higher than that of MDCT alone ( P  < 0.01), but was not significantly higher than that of CE alone ( P  > 0.05). Integrating the two diagnostic platforms improved the diagnosis of stromal tumors, hemangioma, Crohn's disease, vascular anomaly, Meckel's diverticulum, and ancylostomiasis. There was no significant difference in the positive detection rate between CE and MDCT when confirmed by surgical pathology.
Conclusion:  The contribution of CE is critical in the diagnosis of GHOO, given the fact that there is a significant difference in the detection rate between CE and MDCT, but there is no significant difference in the rate between CE plus MDCT and CE alone.     

Comparison of urgent and early endoscopy for acute non-variceal upper gastrointestinal bleeding in high-risk patients

ObjectiveData regarding early (within 24 h) and urgent endoscopy (within 12 h) in non-variceal upper gastrointestinal bleeding (NV-UGIB) revealed conflicting results. This study aimed to investigate the impact of endoscopy timing on the outcomes of high-risk patients with NV-UGIB.Patients and methodsFrom February 2020 to February 2021, consecutive high-risk (Glasgow–Blatchford score ≥12) adults admitted to the emergency department with NV-UGIB were analyzed retrospectively. The primary composite outcome was 30-day mortality from any cause, inpatient rebleeding, need for endoscopic re-intervention, need for surgery or angiographic embolization.Results240 patients were enrolled: 152 (63%) patients underwent urgent endoscopy (<12 h) and 88 (37%) patients underwent early endoscopy (12–24 h). One or more components of the composite outcome were observed in 53 (22.1%) patients: 30 (12.5%) had 30-day mortality, rebleeding occurred in 27 (11.3%), 7 (2.9%) underwent endoscopic re-intervention, and 5 (2.1%) required surgery or angiographic embolization. The composite outcome was similar between the groups. Multivariate analysis showed only hemodynamic instability on admission (OR: 3.05, p = 0.006), and the previous history of cancer (OR: 2.42, p = 0.029) were significant in predicting composite outcome. In terms of secondary outcomes, the endoscopic intervention was higher in the urgent endoscopy group (p = 0.006), whereas the number of transfused erythrocyte suspensions and the length of hospital stay was higher in the early endoscopy group (p = 0.002 and p = 0.040, respectively).ConclusionsUrgent endoscopy leads to a significant reduction in the length of hospitalization and the number of transfused erythrocyte suspensions in NV-UGIB, which can contribute to patient satisfaction, reduce healthcare expenditure, and improve hospital bed availability. The composite outcome and its sub-outcomes were the same among both groups.     

Ultrathin endoscopy for gastrointestinal strictures

Background and Aim: The assessment and treatment of advanced gastrointestinal (GI) strictures, which are defined as the inability to pass through the strictured segment with standard endoscopes, might require radiological work‐up, repeated endoscopies and surgery. The aim of the present study was to assess the role of ultrathin endoscopy (UTE) for the evaluation and treatment of advanced GI strictures. Methods: Patients in whom an initial diagnostic upper or lower endoscopy attempt was incomplete because of a tight stricture underwent a second procedure with a UTE (5.9 mm diameter) in the same session. An interventional endoscopic therapy was also carried out according to the etiology and nature of the stricture using the same UTE. Diagnostic and therapeutic outcomes were recorded and followed up prospectively. The study was conducted in a tertiary endoscopy center. Results: During a one and half year study period, 62 patients (51 at upper and 11 at lower endoscopy) were detected with advanced GI stricture among 8456 diagnostic upper and 3815 lower endoscopy patients. A complete endoscopic examination was successful with UTE in 40 (78%) patients with upper and in nine patients (82%) with lower GI strictures. An interventional procedure was also carried out in 16 patients with the assistance of UTE. Conclusion: UTE is a useful tool for the evaluation of patients with advanced GI strictures. It provides a complete diagnostic endoscopy in most patients and gives an opportunity for therapeutic endoscopic procedures.     

Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage

Background and Aims:  Risk factors for mortality in acute variceal hemorrhage remain incompletely understood. Whether endoscopy timing is associated with risk of mortality has not been investigated. We aimed to investigate risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage, with emphasis on endoscopy timing.
Methods:  Three hundred and eleven (73% male and 23% female) consecutive cirrhotic patients presenting with acute variceal hemorrhage from July 2004 to July 2007 were investigated. The univariate association of endoscopy timing as the predictor for in-hospital mortality was examined. Independent risk factors for mortality were determined by multivariate logistic regression analysis consisting of clinical, laboratory and endoscopic parameters.
Results:  Twenty-five (8.04%) patients died within admission. By plotting the receiver operating curve of endoscopy timing for mortality, we selected 15 h as the optimal cut-off point to define delayed endoscopy. Multivariate regression analysis revealed that independent risk factors predictive for in-hospital mortality included delayed endoscopy performed 15 h after admission (adjusted odds ratio [aOR] = 3.67; 95% confidence interval [CI], 1.27–10.39), every point increment of model for end-stage liver disease (MELD) score (aOR = 1.16; 95% CI, 1.07–1.25), failure of the first endoscopy (aOR = 4.36; 95% CI, 1.54–12.30) and hematemesis as the chief complaint (compared with melena, aOR = 8.66; 95% CI, 1.06–70.94).
Conclusion:  Delayed endoscopy for more than 15 h, high MELD score, failure of the first endoscopy and hematemesis are independent risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.     

Application of artificial intelligence in gastrointestinal endoscopy

With recent significant improvements in artificial intelligence (AI), especially in the field of deep learning, an increasing number of studies have evaluated the use of AI in endoscopy to detect and diagnose gastrointestinal (GI) lesions. The present review summarizes current publications on the use of AI in GI endoscopy and focuses on the challenges and future of AI‐aided systems. We expect AI to provide an effective and practical method for endoscopists in lesion detection and characterization as well as in quality control in endoscopy. However, so far, most studies have remained at the preclinical stage. More attention should be paid in the future to the use of AI in real‐life clinical applications.     

Capsule endoscopy: past,present, and future

A capsule endoscope is a swallowable wireless miniature camera for getting images of the gastrointestinal (GI) mucosa. The initial capsule endoscope model was developed by Given Imaging and approved in Western countries in 2001. Before the introduction of capsule endoscopy (CE) and double-balloon endoscopy (DBE), there was no effective modality for the evaluation and management of patients with obscure GI bleeding. Obscure GI bleeding is defined as bleeding of unknown origin that persists or recurs after a negative initial or primary endoscopy (colonoscopy or upper endoscopy) result. The first capsule endoscope model, which is now regarded as a first-line tool for the detection of abnormalities of the small bowel, was the PillCam SB. It was approved in Japan in April 2007. The main indication for use of the PillCam SB is obscure GI bleeding. Almost the only complication of CE is capsule retention, which is the capsule remaining in the digestive tract for a minimum of 2 weeks. A retained capsule can be retrieved by DBE. There are some limitations of CE in that it cannot be used to obtain a biopsy specimen or for endoscopic treatment. However, the combination of a PillCam SB and DBE seems to be the best strategy for management of obscure GI bleeding. Recently, several new types of capsule endoscope have been developed, such as Olympus CE for the small bowel, PillCam ESO for investigation of esophageal diseases, and PillCam COLON for detection of colonic neoplasias. In the near future, CE is expected to have a positive impact on many aspects of GI disease evaluation and management.     

胶囊内镜下小肠黏膜特征分析53例

目的:回顾性分析胶囊内镜检查患者53例,认识胶囊内镜下小肠正常黏膜特征及小肠病变黏膜特征.方法:2010-08/2011-08,利用Miro Cam胶囊内镜系统对患者53例行胶囊内镜检查.统计患者的年龄、性别、症状、体征等临床资料,将受检者分为不明原因的消化系出血,疑为功能性胃肠病,腹痛、腹泻、腹胀,便秘,体检等共5组;通过查阅病案及电话回访,搜集资料,将胶囊内镜下所见作出最终的临床诊断;分析胶囊内镜下小肠正常及病变黏膜特征.结果:在53例患者中,1例因吞服胶囊后无图像信号,未能顺利完成胶囊内镜检查;1例因患者吞咽胶囊困难而无法进行;其余51例均顺利到达结肠,到达结肠率为96.22%.胃的平均运行时间为69.78 min,小肠的平均运行时间为513.25 min.48例有消化系疾病的阳性结果,3例未见异常,阳性率为90.57%.在所有疑诊小肠疾病的51例患者中,胶囊内镜小肠病变总的诊断率为92.15%(47/51);空肠及回肠阳性诊断率为52.94%,包括炎症12例(1例临床确诊为Crohn’s病),息肉3例,不明肿块3例,淋巴滤泡增生1例,疑似小肠淋巴管扩张7例,钩虫病1例;同时检出反流性食管炎1例;慢性胃炎26例,糜烂性胃炎7例,胃部息肉3例;结肠炎症3例,结肠息肉5例,大肠黑变病2例.胶囊均自然排出体外,无梗阻等并发症的发生.结论:Miro Cam胶囊内镜是一种非侵入性的检查手段,检查安全,顺应性好;在胶囊内镜下,正常小肠黏膜及病变黏膜均呈现出一定的特征.     

Are repeat upper gastrointestinal endoscopy and colonoscopy necessary within six months of capsule endoscopy in patients with obscure gastrointestinal bleeding?

Background and Aim: Medicare reimbursement for capsule endoscopy for the investigation of obscure gastrointestinal bleeding in Australia requires endoscopy and colonoscopy to have been performed within 6 months. This study aims to determine the diagnostic yield of repeating these procedures when they had been non‐diagnostic more than 6 months earlier. Methods: Of 198 consecutive patients who were referred for the investigation of obscure gastrointestinal bleeding, 50 underwent repeat endoscopy and colonoscopy solely to enable reimbursement (35 females and 15 males; mean age 59.4 [range: 21–82] years). The average duration of obscure bleeding was 50.16 (range: 9–214) months. The mean number of prior endoscopies was 3 (median: 2) and 2.8 colonoscopies (median: 2). The most recent endoscopy had been performed 18.9 (median: 14; range: 7–56) months, and for colonoscopy, 19.1 (median 14; range 8‐51) months earlier. Results: A probable cause of bleeding was found at endoscopy in two patients: gastric antral vascular ectasia (1) and benign gastric ulcer (1). Colonoscopy did not reveal a source of bleeding in any patient. Capsule endoscopy was performed in 47 patients. Twenty four (51%) had a probable bleeding source identified, and another five (11%) a possible source. These included angioectasia (17 patients), mass lesion (2), non‐steroidal anti‐inflammatory drug enteropathy (2), Cameron's erosions (2), and Crohn's disease (1). Four patients undergoing repeat capsule endoscopy had a probable bleeding source detected. Conclusion: The yield of repeat endoscopy and colonoscopy immediately prior to capsule endoscopy is low when these procedures have previously been non‐diagnostic. Such an approach is also not cost‐effective.     

急诊内镜联合选择性动脉造影诊治Dieulafoy病4例临床分析

目的探讨急诊内镜联合选择性动脉造影诊治Dieulafoy病的临床价值。方法我院消化内科2009年1月1日～2010年12月31日共收治Dieulafoy病18例,对其中急诊内镜联合选择性动脉造影救治Dieulafoy病所致上消化道大出血4例进行临床分析,通过急诊内镜联合选择性动脉造影的协同应用,观察对出血部位、病因的诊断价值和止血效果。结果 4例患者均在就诊1～24h内胃镜检查确诊Dieulafoy病,其中3例给予镜下钛夹止血或药物喷洒止血后仍有活动性出血随即行选择性动脉造影血管栓塞治疗,1例因镜下出血表现为喷射样,并血压下降,给予病灶旁钛夹标记后随即行选择性动脉造影血管栓塞治疗。本组4例在选择性动脉造影同时结合内镜所见均给予相应病变血管弹簧栓或明胶海绵栓塞止血治疗并成功止血。结论急诊内镜联合选择性动脉造影血管栓塞术协同诊治Dieulafoy病所致消化道出血,两者互为补充,是一种安全、有效、可靠的诊治方法。     

A survey of the practice of after-hours and emergency endoscopy in Canada

OBJECTIVE:

To determine staffing and practice patterns for after-hours endoscopy service in Canada

METHODS:

A link to a web-based survey was sent by e-mail to all clinical members of the Canadian Association of Gastroenterology in February 2011. A priori, it was planned to compare variations in practice among gastroenterologists (GIs) performing endoscopy in different regions of Canada, between pediatric and adult GIs, and between university and community hospitals.

RESULTS:

Of 422 potential respondents, 168 (40%) responded. Of the 139 adult GIs, 61% performed after-hours endoscopy in the endoscopy suite where daytime procedures were performed, 62% had a trained endoscopy nurse available for all procedures, 38% had access to propofol sedation, 12% reprocessed the endoscopes themselves or with the help of a resident, 4% had out-of-hospital patients come directly to their endoscopy suite and 53% were highly satisfied. The adult endoscopists practising at community hospitals were more likely to have an anesthetist attend the procedure. Regional differences were noted, with more involvement of anesthetists (13%) and availability of propofol (50%) in Ontario, more frequent reprocessing of endoscopes in the central reprocessing units in British Columbia (78%) and almost universal availability of a trained endoscopy nurse (96%) with concomitant higher endoscopist satisfaction (84% highly satisfied) in Alberta.

CONCLUSIONS:

More than one-third of surveyed endoscopists across the country do not have a trained endoscopy nurse to assist in after-hours endoscopy – the time period when urgent patients often present and typically require therapeutic endoscopic interventions. There are significant regional differences in the practice of after-hours endoscopy in Canada.     

Original research: National census of UK endoscopy services in 2019

IntroductionThe 2017 Joint Advisory Group on Gastrointestinal (GI) Endoscopy (JAG) census highlighted the pressure endoscopy services were under in meeting national targets and the factors behind this. In 2019, JAG conducted a further national census of endoscopy services to understand trends in activity, workforce and waiting time targets.MethodsIn April 2019, the census was sent to all eligible JAG-registered services. Collated data were analysed through various statistical methods. A further comparative dataset was created using available submissions from the 2017 census matched to services in the current census.ResultsThere was a 68% response rate (322/471). There has been a 12%–15% increase in activity across all GI procedures with largest increases in bowel cancer screening. Fewer services are meeting waiting time targets compared with 2017, with endoscopist, nursing and physical capacity cited as the main reasons. Services are striving to improve capacity: 80% of services have an agreed business plan to meet capacity and the number using insourcing has increased from 13% to 20%. The workforce has increased, with endoscopist numbers increasing by 15%, nurses and allied health professionals by 14% and clerical staff by 30%.ConclusionsThe 2019 JAG census is the most recent and extensive survey of UK endoscopy services. There is a clear trend of increasing activity with fewer services able to meet national waiting time targets than 2 years ago. Services have increased their workforce and improved planning to stem the tide but there remains a continued pressure to deliver high quality, safe endoscopy. In light of the COVID-19 pandemic, JAG recognises that these pressures will be severely exacerbated and waiting time targets for accreditation will need adjustment and tolerance during the evolution and recovery from the pandemic.     

Predictive factors of therapeutic intervention in on-call endoscopy for suspected gastrointestinal bleeding

Background and Aims: Performing an endoscopy out of hours confer significant burdens on limited health-care resources. However, not all on-call endoscopies lead to therapeutic interventions. The purpose of the present study was to analyze predictive factors for performing therapeutic intervention in patients with suspected gastrointestinal bleeding.

Methods: We reviewed and analyzed electronic medical records regarding on-call endoscopy that were prospectively collected for quality control. The subjects were patients with suspected gastrointestinal bleeding who underwent on-call endoscopies at night, on weekends and on holidays between April 2013 and January 2017 in Seoul National University Bundang Hospital. To determine predictive factors for performing therapeutic intervention, the following variables were analyzed: symptoms, patient status, coexisting disease, laboratory findings and medications. To clarify the association between the likelihood of therapeutic intervention in on-call endoscopy and AIMS65 score, the included variables were divided by cutoffs.

Results: A total of 270 patients (male: 72.6%, mean age: 62.6 years) with suspected gastrointestinal bleeding had on-call endoscopies and 153 (56.7%) patients had therapeutic intervention. Gastroscopy, colonoscopy and both endoscopic techniques were performed in 215, 42 and 13 patients, respectively. In the multivariate analysis, hematemesis (p?p?=?.033; OR, 1.958) were correlated with performing therapeutic intervention in on-call endoscopy. AIMS65 score with a cutoff of 2 was associated with the likelihood of intervention (p?=?.043).

Conclusions: Hematemesis and prolonged PT-INR were predictive factors of therapeutic intervention when on-call endoscopy was performed in patients with suspected gastrointestinal bleeding.     

Correlation between predicted and actual consequences of capsule endoscopy on patient management

BACKGROUND: Capsule endoscopy (CE) is a relatively new diagnostic modality in the evaluation of patients with suspected small bowel pathology. It is unclear to what extent physicians are able to predict the clinical consequences of CE on patient management. METHODS: In this prospective study, 180 consecutive CE examinations were analysed. Prior to CE, referring physicians were asked to indicate the consequences of CE according to potential different CE outcomes. The influence of CE on patient management was determined with at least 1 year follow-up. Management consequences were defined as major (surgical or endoscopic intervention, or medical therapy) or minor (nonspecific therapy, including iron supplementation, or no further diagnostic tests). RESULTS: CE led to major management consequences in 32% of cases. Of patients with obscure gastrointestinal bleeding and normal CE findings, 91% were independent of blood transfusions and experienced no further bleeding episodes during a mean follow-up of 33 months. In 78% of 118 cases that were evaluated, the actual consequences of CE matched the consequences predicted by the referring physicians. CONCLUSION: CE had a major impact on patient management in about one third of investigations. In the majority of cases, physicians adequately predicted the clinical consequences of CE.     

胶囊内镜诊断不明原因消化道出血107例

目的:探讨胶囊内镜在不明原因消化道出血中的诊断价值及其与双气囊小肠镜在病因诊断中联合应用的意义。方法:采用M2A胶囊内镜对107例不明原因消化道出血患者进行检查,其中男61例,女46例,平均年龄(51.6±18.9)岁。其中36例患者依据胶囊内镜所观察到的结果,选择经口或经肛行双气囊小肠镜检查和(或)手术探查。结果:107例患者中106例(99.1%)完成胶囊内镜检查,75例(70.8%)胶囊内镜通过回盲瓣。107例中病变检出96例(89.7%)、确诊70例(65.4%)。36例中再经双气囊小肠镜检查和(或)手术后证实胶囊内镜诊断者为26例(72.2%)。2例(1.9%)发生胶囊滞留。结论:胶囊内镜对不明原因消化道出血具有较高的诊断价值,可作为病因诊断的首选筛查手段,与双气囊小肠镜联合应用可大大提高疾病的确诊率。     

胶囊内镜的临床应用

目的 小肠疾病很难诊断，现有的诊断技术又不尽如人意，而胶囊内镜（M2A）能发现整个小肠内的微小病变，且为非侵入性，患者无需住院，因此，对胶囊内镜在小肠疾病诊断中的价值。依从性和安全性进行评估。方法 自2002年5月至9月，我们对经结肠镜，胃镜，X线钡餐造影，小肠钡灌造影，血管造影或核素扫描等检查未发现异常的15例疑患小肠疾病的患者，进行胶囊内镜检查，其中不明原因的消化道出血12例。结果 15例中发现病灶11例（73.3%)，包括血管发育不良，Dieulafoy病，毛细血管扩张征，静脉扩张，息肉样病变，黏膜下肿瘤，脂肪瘤，口疮样小溃疡（Aphthous ulcer)，克罗恩病类癌及出血性胃炎等，其中4例患者同时存在2种病灶，所获取的图像质量良好，胶囊停留于胃内的平均时间为82min(6-311min)，小肠内平均运行时间为248min(104-396min)，平均到达盲肠时间为336min(180-470min)，平均记录时间为449min(300-510min)，医师对胶囊内镜所传输图像的平均读片时间为82min(30-120min)，平均获取照片数为57919张，胶囊平均排出体外时间为33h(24-48h)，整个操作过程患者耐受性甚佳，无任何痛苦，吞咽胶囊无任何困难，检测过程中无任何并发症发生。结论 胶囊内镜是对小肠疾病具有诊断价值的医疗设备，其安全性高，依从性好。