The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use

Background We report our preliminary experience with the use of video capsule endoscopy (VCE) in 64 patients with obscure gastrointestinal bleeding (OGIB) and suspected small intestine disease.Methods To be eligible for VCE, patients had to have undergone upper endoscopy, small bowel series, and colonscopy without discovering any source of bleeding. To find the best timing to perform VCE, the patients were retrospectively divided in two groups of 32 cases each: group 1 with patients who had been submitted to VCE within 15 days from OGIB diagnosis, and group 2 with patients who had been submitted to VCE at least 15 days after OGIB diagnosis.Results Lesions were found by VCE in 29 (91%) in group 1: angioectasia-like lesions of the small bowel in 12, some erosions of the ileum without signs of bleeding in 14, a polyp with erosions in 1, and a bleeding site where the surgery showed a tumor of the ileum in 2 patients. In 2 cases, VCE missed showing two small tumors that were revealed by laparoscopy in 1 case and by push enteroscopy in the other. In group 2, lesions were found by VCE in 11 (34%): angioectasia-like lesions of the small bowel in 6, some erosions in 3, a short segmental stenosis in 1, and two polyps in 1. In 1 case, VCE missed showing a small polyp in the jejunum that was revealed by push enteroscopy. In none of these cases was a bleeding site identified. VCE was well tolerated and able to acquire good images in patients with OGIB. It showed lesions in 91% of the patients in group 1 and 34% of cases in group 2.Conclusions Our data suggest that the optimal timing to perform VCE is within a few days after the occurrence of bleeding, possibly within 2 weeks.     

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.     

Best candidates for capsule endoscopy for obscure gastrointestinal bleeding

Background and Aim: Capsule endoscopy (CE) has an important role in the diagnosis of patients with obscure gastrointestinal bleeding. However, there was still controversy regarding the best candidates for CE. The present retrospective study aimed to access the best candidates for CE. Methods: There were 91 consecutive patients referred to the present study for 94 CE examinations from May 2002 to January 2005. They were divided into two groups (41 with active bleeding, and 50 with previous bleeding). Results: The CE findings were positive in 74.7%, suspicious in 11% of cases and negative in 14.3% of cases, respectively. The positive and suspected positive yield of CE were 75.6% and 19.5% in the active bleeding group, 74% and 4% in the previous bleeding group (P = 0.01), 75.7% and 21.6% in the overt bleeding group, 75% and 0% in the occult bleeding group (P = 0.206), 89.7% and 3.4% in patients who bled 2 weeks previously, 52.38% and 4.76% in patients who bled >2 weeks previously (P = 0.003), 75.6% and 19.5% in active bleeding group, 89.7% and 3.4% in patients who bled 2 weeks ago (P = 0.128). Conclusions: The best candidates for the procedure are those with active bleeding, or active bleeding in the previous 2 weeks.     

A prospective, single-blind trial comparing wireless capsule endoscopy and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding

BACKGROUND: Wireless capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are new methods enabling diagnostic endoscopy of the entire small intestine. However, which of the two is superior is unclear. We therefore prospectively compared the clinical efficacy of CE and DBE. METHODS: We prospectively examined 32 patients with obscure gastrointestinal bleeding. CE preceded DBE by 1-7 days, and all patients underwent DBE twice, by antegrade and retrograde approaches, to evaluate the entire small intestine. Physicians evaluating the results of CE and DBE were blind to the results of the other method. We evaluated diagnosis, diagnostic yield of the two methods, and clinical outcomes. RESULTS: CE revealed abnormal findings in 29 (90.6%) of 32 patients. CE definitively or probably detected the sources of bleeding in 23 (71.9%) of the 32 patients, including angioectasias (eight), erosions (seven), ulcers (five), tumor (one), and hemorrhagic polyps (two). DBE definitely or probably detected the sources of bleeding in 21 (65.6%) of the 32 patients, including angioectasias (seven), erosions (four), ulcers (five), tumor (one), hemorrhagic polyps (two) and diverticula (two). CE yielded more abnormal findings than DBE (CE 90.6%, DBE 65.6%) (P = 0.032), although there were no significant differences in diagnostic yield between the methods. We were able to perform additional treatment or biopsy with DBE in 13 patients, including coagulation therapy (ten), endoscopic mucosal resection (one), biopsy (seven), and extraction of retained CE (two). CONCLUSIONS: Our results demonstrate the superiority of CE in detecting abnormal lesions, and the superiority of DBE in endoscopic management.     

Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy

Background and Aim: In patients with obscure gastrointestinal (GI) bleeding, capsule endoscopy is widely used to determine the source of bleeding. However, there is currently no consensus on how to further evaluate patients with obscure GI bleeding with a non‐diagnostic capsule endoscopy examination. This study aims to determine the diagnostic yield of dual‐phase computed tomographic enterography (CTE) in patients with obscure GI bleeding and a non‐diagnostic capsule endoscopy. Methods: Patients with obscure GI bleeding who were referred for capsule endoscopy were prospectively enrolled. Obscure GI bleeding was defined as overt if there was obvious GI bleeding; otherwise it was defined as occult. Patients with a non‐diagnostic capsule endoscopy and no contraindications underwent a CTE. Results: Capsule endoscopy was performed in 52 patients; 26 patients (50%) had occult GI bleeding and 26 patients (50%) had overt GI bleeding. CTE was then performed in 25 of the 48 patients without a definitive source of bleeding seen on capsule endoscopy. The diagnostic yield of CTE was 0% (0/11) in patients with occult bleeding versus 50% (7/14) in patients with overt bleeding (P < 0.01). Using clinical follow up as the gold standard, for the 25 patients with a non‐diagnostic capsule, CTE had a sensitivity of 33% (95% confidence interval 0.15, 0.56) and a specificity of 75% (95% confidence interval 0.22, 0.99). Conclusions: In patients with a non‐diagnostic capsule endoscopy examination, CTE is useful for detecting a source of GI bleeding in patients with overt, but not occult, obscure GI bleeding.     

国产胶囊内镜对不明原因消化道出血的诊断价值

[目的]探讨国产OMOM型智能胶囊(OMOM)在不明原因消化道出血(OGIB)患者中的诊断价值。[方法]对36例OGIB患者进行OMOM检查,总结并分析其临床资料。[结果]36例均完成检查,其中25例发现病变,阳性检出率69.4%;≥60岁患者以小肠血管畸形为主。检查过程中无任何不适及并发症。[结论]OMOM对OGIB诊断具有较高的诊断率及准确性,临床安全性好。     

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.     

A comparison between capsule endoscopy and double balloon enteroscopy using propensity score-matching analysis in patients with previous obscure gastrointestinal bleeding

Background: Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB.

Patients and methods: We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE.

Results: The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p?<?.01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43–12.6; p?<?.01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p?<?.01).

Conclusions: Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.     

胶囊内镜联合多排螺旋CT诊断不明原因消化道出血的临床研究

目的探讨胶囊内镜（capsuleendoscopyCE）联合多排螺旋cT（MSCT）在不明原因消化道出血中的诊断作用和价值。方法收集不明原因消化道出血患者80例,进行胶囊内镜及多排螺旋cT检查,统计两种检查手段病变的检出率及其部位并进行分析。结果80例中CE诊断阳性46例,诊断阳性率为57．5％;MSCT诊断阳性33例,诊断阳性率为41．3％,P〈0．05;CE和MSCT联合诊断的阳性率为63．8％,与CE相比P〉0．05,与MSCT相比P〈0．05;CE和MSCT的诊断一致率为71．3％;另有34例在检查后进行了外科手术,检出病变34种;CE和MSCT均有病变漏诊,但MSCT漏诊更多。结论①cE联合MSCT检查对不明原因消化道出血的诊断阳性率较cE有所提高,但无统计学意义。②CE联合MSCT检查在判断小肠肿瘤的病变性质及肠外情况的了解中具有优势,建议对不明原因消化道出血进行CE和MSCT的联合检查。     

应用胶囊内镜诊断不明原因消化道出血的临床价值探讨

[目的]探讨胶囊内镜(CE)对不明原因消化道出血(OGIB)的诊断价值。[方法]106例OGIB患者依据不同的临床表现分为隐性出血组和显性出血组,均采用CE检查,对诊断结果进行分析总结。[结果]106例OGIB患者中74例获阳性诊断(69.8%),显性出血组占50例(69.5%),隐性出血组占24例(70.6%),2组阳性诊断率比较,差异无统计学意义;阳性诊断结果中以血管病变居多,其次为小肠恶性肿瘤。[结论]CE检查诊断OGIB的价值较高,是一种安全、简便的诊断方法。     

胶囊内镜在不明原因消化道出血中的临床应用

目的探讨胶囊内镜在不明原因消化道出血中的诊断价值、耐受性、并发症。方法对20例不明原因消化道出血患者行OMOM胶囊内镜检查。结果15例胶囊内镜下发现异常,12例明确为出血病灶,诊断率为60%（12/20）,包括克罗恩病5例,间质瘤4例,晚期肿瘤1例,新鲜出血1例,血管瘤1例。20例受检者均耐受良好,2例出现了胶囊滞留。结论胶囊内镜对不明原因消化道出血有较高的诊断率,易耐受,胶囊滞留是其主要并发症,易发生于克罗恩病患者。     

Outcome in obscure gastrointestinal bleeding after capsule endoscopy

AIM: To investigate the clinical impact of capsule endoscopy (CE) after an obscure gastrointestinal bleeding (OGIB) episode, focusing on diagnostic work-up, follow-up and predictive factors of rebleeding.METHODS: Patients who were referred to Hospital del Mar (Barcelona, Spain) between 2007 and 2009 for OGIB who underwent a CE were retrospectively analyzed. Demographic data, current treatment with non-steroid anti-inflammtory drugs or anticoagulant drugs, hemoglobin levels, transfusion requirements, previous diagnostic tests for the bleeding episode, as well as CE findings (significant or non-significant), work-up and patient outcomes were analyzed from electronic charts. Variables were compared by χ² analysis and Student t test. Risk factors of rebleeding were assessed by Log-rank test, Kaplan-Meier curves and Cox regression model.RESULTS: There were 105 patients [45.7% women, median age of 72 years old (interquartile range 56-79)] and a median follow-up of 326 d (interquartile range 123-641) included in this study. The overall diagnostic yield of CE was 58.1% (55.2% and 63.2%, for patients with occult OGIB and overt OGIB, respectively). In 73 patients (69.5%), OGIB was resolved. Multivariate analysis showed that hemoglobin levels lower than 8 g/dL at diagnosis [hazard ratios (HR) = 2.7, 95%CI: 1.9-6.3], patients aged 70 years and above (HR = 2.1, 95%CI: 1.2-6.1) and significant findings in CE (HR = 2.4, 95%CI: 1.1-5.8) were independent predictors of rebleeding.CONCLUSION: One third of the patients presented with rebleeding after CE; risk factors were hemoglobin levels < 8 g/dL, age ≥ 70 years or the presence of significant lesions.     

胶囊内镜在小肠疾病诊断中的作用

目的:小肠疾病很难诊断,现有的诊断技术又不尽如人意,而胶囊内镜能发现整个小肠内的微小病变。为此,我们对胶囊内镜在小肠疾病诊断中的价值进行评估。方法:自2002年5月至2003年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79例疑患小肠疾病、尤其是不明原因消化道出血的患者,进行胶囊内镜检查,其中不明原因的消化道出血患者56例。结果:75例完成最终研究。75例患者中经胶囊内镜检查共发现异常63例,检出率为84％;其中能明确解释临床病因者50例,诊断率为66.6％,包括消化道血管病变21例、小肠炎症性肠病16例、小肠息肉5例、小肠恶性间质肿瘤2例、小肠类癌1例(该患者同时伴升结肠脂肪瘤)、淋巴瘤1例、粘膜下肿瘤3例及憩室1例。所获取的图像质量良好。结论:胶囊内镜对小肠疾病尤其是不明原因消化道出血具有良好的诊断价值。     

Capsule endoscopy for small‐intestinal disorders: Current status

Small‐bowel capsule endoscopy (SBCE) is used widely because of its non‐invasive and patient‐friendly nature. SBCE can visualize entire small‐intestinal mucosa and facilitate detection of small‐intestinal abnormalities. In this review article, we focus on the current status of SBCE. Several platforms for SBCE are available worldwide. Third‐generation SBCE (PillCam^® SB3) has a high‐resolution camera equipped with an adaptive frame rate system. Several software modes have been developed to reduce the reading time for capsule endoscopy and to minimize the possibility of missing lesions. The main complication of SBCE is capsule retention. Thus, the main contraindication for SBCE is known or suspected gastrointestinal obstruction unless intestinal patency is proven. Possible indications for SBCE are obscure gastrointestinal bleeding, Crohn's disease, small‐intestinal polyps and tumors, and celiac disease. Colon capsule endoscopy (CCE) can observe inflamed colonic mucosa non‐invasively, and allows for the continuous and non‐invasive observation of the entire intestinal tract (pan‐endoscopy). Recently, application of CCE as pan‐enteric endoscopy for inflammatory bowel diseases (including Crohn's disease) has been reported. In the near future, reading for CE will be assisted by artificial intelligence, and reading CE videos for long periods will not be required.     

Clinical application of wireless capsule endoscopy

BACKGROUND: Diagnostic modalities for identifying lesions within the small bowel have been quite limited. Wireless capsule endoscopy (WCE) is a new, innovative technique that can detect very small mucosal lesions in the entire small bowel and can be used in the outpatient setting. The present study explored the diagnostic value, tolerance and safety of WCE in the identification of small bowel pathology that was not detected with conventional small bowel imaging studies. METHODS: From May through September 2002, 15 patients with suspected small bowel diseases were prospectively examined, Of them, 12 presented with persistent obscure gastrointestinal bleeding and negative findings on upper endoscopy, colonoscopy, small bowel radiography, and bleeding‐scan scintig‐raphy or mesenteric angiography. RESULTS: Wireless capsule endoscopy identified pathologic small bowel findings in 11 of the 15 patients (73%): angioectasias, Dieulafoy's lesion, polypoid lesion, submucosal mass, Crohn's disease, carcinoid tumor, lipoma, aphthous ulcer, and hemorrhagic gastritis; four of the patients had two lesions. The images displayed were considered to be good. The capsule endoscopes remained in the stomach for an average of 82 min (range 6?311 min) and the mean transit time in the small bowel was 248 min (range 104?396 min). The mean time of recording was 7 h 29 min (from 5 h to 8 h 30 min). The mean time to reach the cecum was 336 min (180?470 min). The average number of the images transmitted by the capsule was 57 919 and the average time the physician took to review the images transmitted by the capsule was 82 min (range 30?120 min). The average time of elimination of the capsule was 33 h (range 24?48 h). All 15 patients reported that the capsule was easy to swallow, painless, and preferable to conventional endoscopy. No complications were observed. CONCLUSIONS: Wireless capsule endoscopy is safe, well tolerated, and useful for identifying occult lesions of the small bowel, especially in patients who present with obscure gastrointestinal bleeding.     

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.     

Wireless capsule endoscopy: Perspectives beyond gastrointestinal bleeding

Wireless capsule endoscopy (CE) is a technology developed for the endoscopic exploration of the small bowel. The first capsule model was approved by the Food and Drug Administration in 2001, and its first and essential indication was occult gastrointestinal (GI) bleeding. Over subsequent years, this technology has been refined to provide superior resolution, increased battery life, and capabilities to view different parts of the GI tract. Indeed, cases for which CE proved useful have increased significantly over the last few years, with new indications for the small bowel and technical improvements that have expanded its use to other parts of the GI tract, including the esophagus and colon. The main challenges in the development of CE are new devices with the ability to provide therapy, air inflation for a better vision of the small bowel, biopsy sampling systems attached to the capsule and the possibility to guide and move the capsule with an external motion control. In this article we review the current and new indications of CE, and the evolving technological changes shaping this technology, which has a promising potential in the coming future of gastroenterology.