Can clinical features predict the likelihood of finding abnormalities when using capsule endoscopy in patients with GI bleeding of obscure origin?

BACKGROUND: Capsule endoscopy is becoming the investigation of choice for GI bleeding of obscure etiology. This study examined whether clinical or other features predict an increased likelihood of finding a lesion in patients with this type of bleeding. METHODS: Clinical and other data were collected prospectively for 92 patients undergoing capsule endoscopy for GI bleeding of obscure origin. Patients were divided into two groups: those with overt bleeding (42 patients) and those with anemia alone (50 patients). The relationship between these data and the findings at capsule endoscopy was examined. RESULTS: A definite or probable cause of bleeding was found in 60 patients (angiodysplasias 47, tumor 7, ulcer 3, gastric antral vascular ectasia 2). There was no difference between the two groups with respect to age, gender, mode of presentation, duration of bleeding, or need for transfusion. Lesions were found as often in patients who had only one preceding endoscopy and colonoscopy as in those who had multiple procedures. Colonic cleansing and cecal imaging by the capsule did not influence the result. Hospitalized patients were more likely to have an actively bleeding lesion detected. CONCLUSIONS: Capsule endoscopy is equally useful in patients with overt and occult GI bleeding of obscure origin. Capsule endoscopy should be performed early in the evaluation of these patients.     

Editorial: is there a role for angiography in patients with obscure overt bleeding?

Obscure gastrointestinal hemorrhage remains a challenging but uncommon clinical scenario. Video capsule endoscopy (VCE) has been recommended as the third diagnostic test after normal upper and lower endoscopic examinations. A recent randomized controlled trial comparing immediate VCE to angiography demonstrated a superior diagnostic yield for VCE compared with angiography. However, long-term outcomes, including rebleeding, hospitalization rates, and death, did not differ between the two cohorts. Although VCE appears to be superior to other testing modalities for overall diagnostic yield, the clinical outcomes ultimately depend upon the type of lesion detected. Vascular lesions, mainly small bowel angiodysplasia, can be expected to have the highest rates of rebleeding, despite endoscopic therapy, and have been associated with the presence of comorbid conditions.     

Acute epigastric and low back pain during amiodarone infusion; is it the drug or the vehicle to blame?

Amiodarone is a Class III antiarrhythmic agent used for cardioversion and prevention of recurrences of atrial fibrillation. However, its use is limited due to its side-effects resulting from the drug's long-term administration. We have described acute epigastric pain following treatment with intravenous amiodarone for atrial fibrillation in a previous report. Hereby, we describe a second patient who suffered acute epigastric pain, as well as one who suffered acute low back pain. Intravenous amiodarone has been related to a series of minor and major adverse reactions, indicating other constituents of the intravenous solution as the possible cause, possibly polysorbate-80. A possible correlation between acute epigastric and low back pain after intravenous amiodarone loading is unproven; however it is of crucial importance for clinicians to be aware of this phenomenon, and especially since an acute epigastric pain is implicated in the differential diagnosis of cardiac ischemia.     

Recurrent massive bleeding due to dissecting intramural hematoma of the esophagus： Treatment with therapeutic angiography

Spontaneous or traumatic intramural bleeding of the esophagus, which is often associated with overlying mucosal dissection, constitutes a rare spectrum of esophageal injury called dissecting intramural hematoma of the esophagus (DIHE). Chest pain, swallowing difficulty, and minor hematemesis are common, which resolve spontaneously in most cases. This case report describes a patient with spontaneous DIHE with recurrent massive bleeding which required critical management and highlights a potential role for therapeutic angiography as an alternative to surgery.     

Is endoscopic paravascular injection of sclerosing agents reasonable in the control of GI bleeding?

BACKGROUND: The pharmacologic response and microvascular effects associated with the endoscopic injection of sclerosing agents around vessels (paravascular injection) to stop bleeding from the digestive tract remain to be clarified. METHODS: Using in vivo microscopy, we directly visualized submucosal microvessels of the rat stomach and intestine. We studied differences among sclerosing agents in thrombus formation and vascular diameter change that occur through a pharmacologic response and/or local compression after topical application or paravascular injection of the agents. RESULTS: Except for absolute ethanol, topical application of the agents did not cause constriction or thrombi in either arterioles or venules. Polidocanol topical application and paravascular injection significantly dilated arterioles. Injecting ethanolamine oleate near venules constricted them the longest and most effectively, but vasoconstriction in arterioles was transient. Injecting absolute ethanol formed long-lasting thrombi and caused vasoconstriction in venules, but arteriole thrombi persisted no more than 3 minutes. The vascular response to thrombin did not significantly differ from that to physiologic saline. CONCLUSION: The paravascular injection of ethanolamine oleate, because of its long-lasting vasoconstriction, or of absolute ethanol, because of its thrombogenic effect, is a valid therapeutic approach to treating venous bleeding. The efficacy of paravascular injection of sclerosing agents for treating acute arterial bleeding, however, is not supported in this experimental model.     

Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: The position of capsule endoscopy (CE) relative to push enteroscopy (PE) in the diagnostic algorithm of obscure gastrointestinal bleeding is unclear, as previous studies involved the use of both techniques in all patients. We therefore conducted a trial in which patients were randomized to undergo one or other exploration. METHODS: All consecutive patients referred for obscure gastrointestinal bleeding were randomized between CE and PE as the first-line exploration. The alternative method was only used if the first-line method revealed no definite bleeding source, or if required for clinical reasons during follow-up. RESULTS: CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001). CONCLUSIONS: CE has a higher diagnostic yield than PE in obscure gastrointestinal bleeding, and a strategy based on CE as first-line exploration avoids unnecessary explorations.     

Double-balloon enteroscopy for the diagnosis and treatment of obscure bleeding, inflammatory bowel diseases and polyposis syndromes: we see more but do we know more?

BACKGROUND/AIMS: Our aim was to report our experience with the Fujinon EN-450 T5 therapeutic double-balloon endoscope (DBE) in the diagnosis of small bowel diseases. METHODOLOGY: Between August 2005 and October 2006, 52 DBE procedures were conducted on 47 consecutive patients (M/F: 22/25, age: 51.6 SD 19.5 years) presenting at our tertiary referral hospital (35 and 7 patients from oral and anal route, respectively; 5 patients from both). All procedures were performed using i.v. anesthesia, at our outpatient clinic. RESULTS: Indication suspected small-bowel bleeding in 28 patients, suspected/known inflammatory bowel syndrome (IBD) in 12 and polyposis/suspected neoplasia in 7. In obscure bleeding small-bowel abnormality was found in 18 patients (64.3%) including angiodysplasias/erosions and one polypoid lesion. In suspected IBD, IBD was diagnosed in 2 out of 8 cases. In patients with polyposis syndromes, polyps were in two Peutz-Jeghers patients, while a further patient with suspected stenosis was diagnosed with primary adenocarcinoma. The average insertion length was app. 213cm. No severe complications were observed. CONCLUSIONS: Based on our experience DBE is a safe and useful method for evaluating and treating small bowel disease in selected patients with obscure bleeding, IBD or polyposis syndromes, however the clinical importance of minute lesions still needs to be determined.     

Are there indications for intravenous acid-inhibition in the prevention and treatment of upper GI bleeding?

Administration of acid-inhibiting drugs in the prevention of stress ulcer bleeding is based on the hypothesis that pepsin activity is pH-dependent. In the treatment of peptic ulcer bleeding, acid-inhibition is based on the hypothesis that clot formation and clot lysis depend on intraluminal pH. Medications used in the prophylaxis of stress ulcer bleeding comprise antacids, sucralfate, H2-receptor antagonists and proton pump inhibitors (PPIs). Two studies show that prophylaxis with ranitidine is more effective than prophylaxis with sucralfate. PPIs give a more predictable and sustained pH control during prolonged dosing than ranitidine. Two trials show that patients who receive omeprazole run a significantly lower risk of bleeding than patients receiving ranitidine. The optimal initial treatment for bleeding peptic ulcers in patients with active bleeding or non-bleeding visible vessel is endoscopic therapy. Among patients with non-bleeding visible vessels or adherent clots who do not undergo endoscopic therapy, acid-inhibition with PPIs may significantly reduce rebleeding rate and need for surgery. After endoscopic therapy acid-inhibition with PPIs may have a beneficial effect on hemostasis. One direct comparative trial showed no significant difference in clinical outcomes between patients whether treated with high-dose or low-dose PPI. The use of multiple medications to treat concurrent conditions in ICU patients or bleeding peptic ulcer patients increases the risks of clinically important metabolic drug interactions. More recently developed PPIs are less dependent on CYP2C19 and probably have a lower potential for metabolic drug interactions. For both indications the optimal dose PPI has to be established.