CAPSULE ENDOSCOPY FOR OBSCURE GASTROINTESTINAL BLEEDING IN THE TROPICS: REPORT FROM INDIA

Background: Capsule endoscopy (CE) is useful in patients with obscure gastrointestinal bleeding (OGIB). Experience in CE in OGIB in the tropics is limited. Methods: Eighty‐six patients with OGIB were evaluated clinically and using CE (Given Imaging, Yoqneam, Israel) 89 times (twice in three patients) during a 64‐month period. Images were downloaded and examined by a single investigator using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Patients received specific treatment and were followed up. Intraoperative findings, response to specific treatment and outcome on follow up (10.3 ± 14.1 months) were considered to confirm CE findings. Results: Of 86 patients (aged 54.5 ± 16.3 years, 63 males), 64 and 22 had OGIB‐overt and OGIB‐occult, respectively. Lesions were equally detected in OGIB‐overt and OGIB‐occult patients (48/64, 75% vs 18/22, 81.8%, P = ns). Lesions were detected in 64 of 86 (74.4%) patients [vascular malformations with or without fresh bleeding in 24 (37.5%), tumors in 12 (18.8%), strictures in 15 (23.4%), ulcers in five (7.8%), hookworm in five (7.8%), and more than one lesion in three patients (4.7%)]. Endoscopic insertion of the capsule was required in four patients, and in six it was retained, although none developed intestinal obstruction (surgical removal in two). The sensitivity, specificity, positive and negative predictive values of CE to detect the lesion(s) were 92.9%, 68.2%, 84.8%, and 83.3%, respectively. Conclusion: CE is safe and is equally effective in detecting lesion(s) in occult and overt OGIB. Worm infestation and small bowel tuberculosis are unique and important causes of OGIB in the tropics.     

Yield,etiologies and outcomes of capsule endoscopy in Thai patients with obscure gastrointestinal bleeding

AIM: To investigate the yield, etiologies and impact of capsule endoscopy (CE) in Thai patients with obscure gastrointestinal bleeding (OGIB).METHODS: The present study is a retrospective cohort study. All patients with OGIB who underwent CE in Siriraj Hospital, Bangkok, Thailand during 2005-2009 were included in the study. All the patients’ medical records and results of the CE videos were reviewed. CE findings were classified as significant, suspicious/equivocal and negative. Sites of the lesions were located to duodenum, jejunum, jejunoileum, ileum and diffuse lesions by the localization device of the CE. Impact of CE on the patients’ management was defined by any investigation or treatment given to the patients that was more than an iron supplement or blood transfusion. Patients’ outcomes (rebleeding, persistent bleeding, anemia or requirement of blood transfusion) were collected from chart reviews and direct phone interviews with the patients.RESULTS: Overall, there were 103 patients with OGIB included in the study. Mean age of the patients was 64 ± 16 years (range 9-88 years) and 57 patients (55%) were male. Types of OGIB were overt in 80 (78%) and occult in 23 patients (22%). The median time interval of CE after onset of OGIB was 10 d (range 1-180 d). The median time of follow-up was 19 mo (range 1-54 mo). Capsules reached caecum in 77 patients (74%) and capsule retention was found in 1 patient (1%). The diagnostic yield of CE revealed significant lesions in 37 patients (36%), suspicious/equivocal lesions in 15 patients (15%) and 51 patients (49%) had negative CE result. Among the significant lesions, the bleeding etiologies were small bowel ulcers in 44%, angiodysplasia in 27%, small bowel tumor in 13%, miscellaneous in 8% and active bleeding without identifiable causes in 8%. Patients with small bowel ulcers were significantly associated with the use of non-steroidal anti-inflammatory drugs (48%, P = 0.034), while patients with small bowel tumors were more commonly female (86%, P = 0.043) compared to the other etiologies. The rate of rebleeding, persistent bleeding or anemia in patients with positive, equivocal and negative CE results were 5%, 0% and 18%, respectively (P = 0.078). All the 9 patients with rebleeding after negative CE were subsequently found to be from hematologic disorders (4), colonic diverticulosis (2), colonic Dieulafoy’s (1), hemorrhoid (1) and hemosuccus pancreaticus (1). Results of CE had a positive impact on the patients’ management in 35% of the patients whose results were positive, but none on the patients whose results were equivocal or negative CE (P < 0.001).CONCLUSION: In Thai OGIB patients, CE had low yield and small bowel ulcer was most common. Positive CE impacted managements and outcomes. Negative CE caused low rebleeding.     

64-section multiphase CT enterography as a diagnostic tool in the evaluation of obscure gastrointestinal bleeding

Background and aim

Small bowel follow through (SBFT) and enteroclysis have low sensitivity in picking up lesions in obscure gastrointestinal bleed (OGIB). Computed tomographic enterography (CT-EG), performed with 64-slice multiphase CT system by using large volumes of ingested neutral enteric contrast material, has high spatial and temporal resolution in visualization of the small bowel wall and lumen. The role of 64-slice multiphase CT-EG in the evaluation of OGIB is still evolving, and data on this role are scarce. We evaluated the efficacy of 64-slice multiphase CT-EG using polyethylene glycol (PEG) electrolyte solution as neutral contrast in patients of OGIB.

Methods

CT-EG was performed with 64-slice multiphase CT system using large volume (2,000?mL) of PEG electrolyte solution as oral contrast in patients of OGIB.

Results

Thirty-five patients (21 men, age 41.4 [13.5] y, range 19?C70?year) with OGIB underwent CT-EG; 20 patients had overt OGIB whereas 15 patients had occult OGIB. Among 15 patients with occult OGIB, 10 patients had iron deficiency anemia (IDA) with fecal occult blood test (FOBT) positive and 5 had IDA with FOBT negative. Thirty-two patients (92?%) completed the procedure successfully. The total time taken for the ingestion of 2,000?mL of PEG electrolyte solution was median 64 (range 60?C78) minutes. Adequate luminal distension of small bowel was seen in 29 (90.6?%) patients for successful interpretation of radiological images. Fifteen of 32 (46.9?%) patients had positive findings on CT-EG; 12 of them underwent exploratory laparotomy. The surgical findings were in conformity with CT-EG findings in all patients, which included gastrointestinal stromal tumors (GIST; n?=?6), carcinoid (1), Meckel??s diverticulum (1), small bowel adenocarcinoma (2) and jejunal vascular malformation (2).

Conclusion

64-slice multiphase CT-EG is a useful investigation in the evaluation of both occult and overt OGIB.     

Capsule endoscopy in obscure gastrointestinal bleeding--an Indian experience.

BACKGROUND: Obscure gastrointestinal bleeding (OGIB) is a common indication for capsule endoscopy (CE). Reports on diagnostic yield of CE in this situation show a wide variation. We evaluated the diagnostic yield and clinical impact of CE in patients with OGIB. METHODS: We reviewed the medical records of patients with OGIB who underwent CE at our institution between June 2002 and October 2005. RESULTS: 154 patients (mean age 47 [SD 17] years; 117 men), including 74 with overt OGIB and 80 with occult OGIB, underwent CE. CE yielded positive findings in 57 of 74 patients (77%) with overt OGIB and 22 of 80 (27%) of those with occult OGIB (p < 0.0001); the overall positive diagnostic yield was 52%. NSAID-induced lesions (15%), angiodysplasias (14%) and aphthous ulcers (12%) were the most frequent findings. CE helped in planning further management in 79% of patients with overt OGIB and 26% of those with occult OGIB. CONCLUSION: CE is a useful diagnostic technique in patients with OGIB, especially those with overt OGIB.     

Long-term outcome in patients with obscure gastrointestinal bleeding after negative capsule endoscopy

AIM:To investigate long-term outcome in obscure gastrointestinal bleeding(OGIB) after negative capsule endoscopy(CE) and identify risk factors for rebleeding.METHODS:A total of 113 consecutive patients underwent CE for OGIB from May 2003 to June 2010 at Seoul National University Hospital.Ninety-five patients(84.1%) with a subsequent follow-up after CE of at least 6 mo were enrolled in this study.Follow-up data were obtained from the patients’ medical records.The CE images were reviewed by two board-certified gastroenterologists and consensus diagnosis was used in all cases.The primary outcome measure was the detection of rebleeding after CE,and factors associated with rebleeding were evaluated using multivariate analysis.RESULTS:Of the 95 enrolled patients(median age 61 years,range 17-85 years),62 patients(65.3%) were male.The median duration of follow-up was 23.7 mo(range 6.0-89.4 mo).Seventy-three patients(76.8%) underwent CE for obscure-overt bleeding.Complete examination of the small bowel was achieved in 77 cases(81.1%).Significant lesions were found in 38 patients(40.0%).The overall rebleeding rate was 28.4%.The rebleeding rate was higher in patients with positive CE(36.8%) than in those with negative CE(22.8%).However,there was no significant difference in cumulative rebleeding rates between the two groups(log rank test;P = 0.205).Anticoagulation after CE examination was an independent risk factor for rebleeding(hazard ratio,5.019;95%CI,1.560-16.145;P = 0.007),regardless of CE results.CONCLUSION:Patients with OGIB and negative CE have a potential risk of rebleeding.Therefore,close observation is required and alternative modalities should be considered in suspicious cases.     

A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding

OBJECTIVES: Capsule endoscopy (CE) has revolutionized the evaluation of obscure gastrointestinal bleeding (OGIB) but published literature is limited to small series with heterogeneous indications. The aim of this study was to determine the findings and the diagnostic yield of CE in a large series of patients with overt and occult OGIB. METHODS: Data on 260 patients who underwent CE for overt (N = 126) or occult (N = 134) OGIB were obtained by retrospective chart review and review of an internal database of CE patients and findings. RESULTS: Visualization of the entire small bowel was achieved in 74%. The majority of exams (66%) were rated as having a good or excellent prep. Clinically significant positive findings occurred in 53%. The yield of CE in the obscure-overt group was greater than in the obscure-occult group (60%vs 46%, P= 0.03). Small bowel angioectasias were the most common finding, comprising over 60% of clinically significant lesions. The mean follow-up was 9.6 months, and there were significant reductions in hospitalizations, additional tests/procedures, and units of blood transfused after CE. Both before and after CE, patients in the overt group had more significant GI bleeding than patients in the occult group. Complications occurred in five (1.9%) cases: nonnatural excretion (four) and CE impaction at cricopharyngeus (one). CONCLUSIONS: The yield of clinically important findings on CE in patients with OGIB is 53% and is greater in patients with obscure-overt than obscure-occult GI bleeding. Angioectasias account for the majority of significant lesions in both groups. Compared with pre-CE, patients had clinical improvement post-CE in medical interventions for OGIB. Complications of CE occur in less than 2% of cases.     

Risk factors for small bowel angioectasia: The impact of visceral fat accumulation

AIM: To investigate visceral fat accumulation in association with the risk of small bowel angioectasia.METHODS: We retrospectively investigated 198 consecutive patients who underwent both capsule endoscopy and CT for investigation of obscure gastrointestinal bleeding(OGIB) from January 2009 to September 2013. The visceral fat area(VFA) and subcutaneous fat area were measured by CT, and information on comorbidities, body mass index, and medications was obtained from their medical records.Logistic regression analysis was used to evaluate associations.RESULTS: Capsule endoscopy revealed small bowel angioectasia in 18/198(9.1%) patients with OGIB.Compared to patients without small bowel angioectasia,those with small bowel angioectasia had a significantly higher VFA(96 ± 76.0 cm2 vs 63.4 ±51.5 cm2, P = 0.016) and a higher prevalence of liver cirrhosis(61% vs 22%, P 0.001). The proportion of patients with chronic renal failure was higher in patients with small bowel angioectasia(22% vs 9%,P = 0.11). There were no significant differences in subcutaneous fat area or waist circumference. The prevalence of small bowel angioectasia progressively increased according to the VFA. Multivariate analysis showed that the VFA [odd ratio(OR) for each 10-cm2 increment = 1.1; [95% confidence interval(CI):1.02-1.19; P = 0.021] and liver cirrhosis(OR = 6.1,95%CI: 2.2-18.5; P 0.001) were significant risk factors for small bowel angioectasia.CONCLUSION: VFA is positively associated with theprevalence of small bowel angioectasia, for which VFA and liver cirrhosis are independent risk factors in patients with OGIB.     

Negative capsule endoscopy for obscure gastrointestinal bleeding is closely associated with the use of low-dose aspirin

Abstract

Objective. Capsule endoscopy (CE) is used widely for determining the cause of obscure gastrointestinal bleeding (OGIB). However, negative findings still arise from CE examination. The aim of this study was to determine the factors associated with negative findings on CE in patients with OGIB. Material and methods. A total of 134 patients who underwent CE for overt (n = 104) or occult (n = 30) OGIB between October 2007 and April 2010 were included. The clinical backgrounds of the patients (age; sex; the use of anti-coagulant, anti-platelet drugs or NSAIDs; comorbidity and the timing of CE examination after bleeding) were noted. Results. The overall diagnostic yield of CE in detecting the relevant findings was 50% (n = 67). Multivariate analysis revealed that the use of anti-platelet drug and the timing of CE (≥16 days) were predictive factors for negative findings on CE (odds ratio 2.69 [1.01–7.21], p = 0.048 and odds ratio 2.32 [1.01–5.33], p = 0.047, respectively). Among the patients with the use of low-dose aspirin (LDA, n = 28) as anti-platelet drug, cessation of it before CE was the only predictive factor for negative findings on CE (odds ratio 12.0 [1.72–83.5], p = 0.012). Conclusion. In the patients with OGIB, the use of LDA and the cessation of it before CE made it difficult to detect the cause of bleeding by CE. This might indicate that the source of OGIB related to LDA heals immediately after cessation of the drugs or is a very small lesion that could not be detected by CE.     

Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy

BACKGROUND AND AIMS: Capsule endoscopy (CE) is one of the widely accepted investigations for obscure gastrointestinal bleeding (OGIB), but little is known about the impact of CE on the long-term outcome of patients with OGIB. We studied the long-term outcome of patients with OGIB after CE examination. PATIENTS AND METHODS: Forty-nine consecutive patients (45% men, mean age 58.3 yr) who underwent CE for OGIB were studied. The most clinically relevant finding that was related to bleeding was identified by CE. All patients were followed up for at least 12 months for clinical overt and occult bleeding. RESULTS: The median follow-up was 19 months (range 12 to 31). Possible bleeding lesions were detected by CE in 31 (63.3%) patients, and 15 (30.6%) patients, underwent further interventions including laparotomy and push enteroscopy. The overall long-term rebleeding rate in this cohort was 32.7%. The cumulative rebleeding rate was significantly lower in patients with a negative CE (5.6%) than in patients with a positive CE (48.4%, p=0.03 log-rank test). The sensitivity and negative predictive value of CE in predicting rebleeding were 93.8% and 94.4%, respectively. CONCLUSIONS: Patients with OGIB and negative CE had a very low rebleeding rate, and further invasive investigations can be deferred.     

胶囊内镜在不明原因消化道出血诊断中的应用

背景：胶囊内镜是明确不明原因消化道出血（OGIB）的检查手段之一,其诊断率可能受到检查时机和出血自然病程的影响。目的：探讨胶囊内镜在OGIB诊断中的应用价值和最佳检查时机。方法：收集2010年10月～2012年6月厦门大学附属中山医院46例接受胶囊内镜检查的OGIB患者。回顾性分析胶囊内镜检查诊断OGIB的阳性率、疑诊率、敏感性、特异性、阳性预测值和阴性预测值,比较不同检查时机对OGIB检出率的影响。结果：胶囊内镜检查诊断OGIB的阳性率为71．7％,疑诊率为13．0％,阴性率为15．2％,诊断敏感性、特异性以及阳性预测值、阴性预测值分别为96．3％、75．0％、92．9％、85．7％。活动性出血组的检出率显著高于出血停止组（96．3％对68．4％,P=0．030）,显性出血者的检出率与隐性出血者相比差异无统计学意义（100％对75．0％,P=0．148）。出血停止≤2周者的检出率显著高于出血停止〉2周者（90．9％对37．5％,P=0．041）。结论：胶囊内镜是诊断OGIB的一种安全、有效的检查手段,出血后尽早行胶囊内镜检查可能提高阳性诊断率并为进一步干预创造条件。     

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.     

Diagnostic yield and therapeutic implications of capsule endoscopy in obscure gastrointestinal bleeding

AIM: The main aim of this study was to evaluate efficacy and therapeutic impact of capsule endoscopy (CE) in obscure gastrointestinal bleeding (OGIB). In addition, we evaluated the software of automatic detection of red zones (SBI, Given Imaging). PATIENTS AND METHODS: From June 2002 to June 2003, thirty-five patients with OGIB underwent capsule endoscopy after negative upper and lower digestive endoscopy. Capsule endoscopy was performed following a 12-hour fasting period and some received 2 L of PEG the night before for bowel preparation. RESULTS: CE was performed for occult (N=18) or overt (N=17) OGIB. Potentially bleeding lesions were found in 16/35 patients (45.7%). Lesions were angiodysplasias (N=8), ulcerations (N=4), tumors (N=2) and active bleeding without visible lesion (N=2). Lesions were located in gastric antrum (N=1), duodenum (N=2) and jejuno-ileum (N=13). Endoscopic (N=10), surgical (N=2) or medical (N=1) treatments were performed in 13/35 (37%). SBI was retrospectively evaluated in 24 patients with sensitivity, specificity, positive and negative predictive value of respectively 45%, 73%, 50% and 69%. CE retention during 10 days occurred in a patient with a small bowel NSAID-induced stricture. CONCLUSION: CE is a safe and effective procedure in the management of OGIB and had a therapeutic impact in more than one third of patients.     

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.     

SURVEILLANCE OF SMALL INTESTINAL ABNORMALITIES IN PATIENTS WITH HEPATOCELLULAR CARCINOMA: A PROSPECTIVE CAPSULE ENDOSCOPY STUDY

Background: Patients with hepatocellular carcinoma (HCC) sometimes suffer from obscure gastrointestinal bleeding. Portal hypertension (PH), common in cirrhosis, induces esophagogastric varices. Because of the location, PH also may influence mucosal abnormalities in the small intestine. The objective of this study is to estimate the prevalence of small intestinal mucosal abnormalities in HCC patients using capsule endoscopy (CE). Patients and Methods: We prospectively conducted CE in HCC patients, and analyzed the findings in relation to hepatic function, the number and size of HCC tumor and findings obtained by conventional endoscopy. Results: Thirty‐six patients (aged 66.7 ± 7.5 years, 29 men) underwent CE. Abnormal findings in the small bowel were found in 16 patients (44%), angioectasias in eight patients (22%), erosions in five (14%), varices in four (11%), polyps in four (11%), and submucosal tumor in one (3%). The patients with angioectasia had a larger spleen index than the no abnormal lesions group (85.4 ± 15.8 vs 59.0 ± 24.4, P = 0.02). The former group had been more frequently treated for esophageal varices endoscopically (62% vs 15%, P = 0.02). Large HCC nodules seemed more common in the patients with angioectasia than subjects without abnormal lesions (38% vs 5%, P = 0.06). Small intestinal varices also seemed to have a positive association with large HCC. During the follow up after CE, one patient with small intestinal polyps suffered from obscure gastrointestinal bleeding. Conclusions: CE revealed that HCC patients frequently have small intestinal mucosal lesions. In particular, small intestinal angioectasia, which may cause obscure gastrointestinal bleeding, seems to be associated with portal hypertension.     

A prospective study evaluating emotional disturbance in subjects undergoing defecating proctography

AIM: To investigate the prevalence of psychiatric illness in association with functional gastrointestinal disorders using defecating proctography (DP) and validated questionnaires. METHODS: We prospectively evaluated 45 subjects referred for DP using hospital anxiety and depression scale (HADS), state trait anxiety inventory (STAI), patient health questionnaire 15-item somatic symptom severity scale (PHQ-15), validated questionnaires for sexual or physical abuse; post-traumatic stress disorder questionnaire (PTSD) and ROME-Ⅲ questionnaires for gastrointestinal complaints. DP results were considered negative if levator ani function was normal, rectoceles (if any) were < 4 cm and there was no evidence ofintussusception, rectal prolapse, or other anatomic abnormality demonstrated. Subjects were subsequently divided into those with structural defects seen on DP (DP positive group) and those with a normal defecography study (DP negative group). RESULTS: Forty five subjects were included in the study of which 20 subjects were classified as DP negative (44.4%). There was a striking prevalence of a history of sexual abuse in DP negative group compared to the DP positive group (n = 9, 5 respectively; P = 0.036). Further, subjects in the DP negative group scored significantly higher on the HADS anxiety (6.60 ± 1.00 vs 4.72 ± 0.40, P = 0.04) and depression scales (5.72 ± 1.00 vs 3.25 ± 0.46, P = 0.01). This correlated well with significantly higher scores on the STAI state anxiety scale (42.75 ± 3.16vs 35.6 ± 2.00,P = 0.027), PHQ-15 questionnaire (13.15 ± 0.82 vs 10.76 ± 0.97, P = 0.038) and prevalence of PTSD (20%vs 4%,P = 0.045) among DP negative subjects. There was no difference between the groups in terms of STAI trait anxiety. CONCLUSION: The findings of this prospective study demonstrate a significantly high degree of psychiatric ailments in patients with negative findings on DP who should be appropriately screened for a history of sexual abuse and symptoms of psychosocial distress.     

Single center experience of capsule endoscopy in patients with obscure gastrointestinal bleeding

AIM:To identify optimum timing to maximize diagnostic yield by capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding (OGIB).METHODS:We identified patients who underwent CE at our institution from August 2003 to December 2009.Patient medical records were reviewed to determine type of OGIB (occult,overt),CE results and complications,and timing of CE with respect to onset of bleeding.RESULTS:Out of 385 patients investigated for OGIB,284 (74%) had some lesion detected by CE.In 222 patients (...     

Laparoscopic vs open distal pancreatectomy for solid pseudopapillary tumor of the pancreas

AIM:To compare short-and long-term outcomes of laparoscopic vs open distal pancreatectomy for solid pseudopapillary tumor(SPT)of the pancreas.METHODS:This retrospective study included 28 patients who underwent distal pancreatectomy for SPT of the pancreas between 1998 and 2012.The patients were divided into two groups based on the surgical approach:the laparoscopic surgery group and the open surgery group.The patients’demographic data,operative results,pathological reports,hospital courses,morbidity and mortality,and follow-up data were compared between the two groups.RESULTS:Fifteen patients with SPT of the pancreas underwent laparoscopic distal pancreatectomy(LDP),and 13 underwent open distal pancreatectomy(ODP).Baseline characteristics were similar between the two groups except for a female predominance in the LDP group(100.0%vs 69.2%,P=0.035).Mortality,morbidity(33.3%vs 38.5%,P=1.000),pancreatic fistula rates(26.7%vs 30.8%,P=0.728),and reoperation rates(0.0%vs 7.7%,P=0.464)were similar in the two groups.There were no significant differences in the operating time(171 min vs 178 min,P=0.755)between the two groups.The intraoperative blood loss(149 mL vs 580 mL,P=0.002),transfusion requirement(6.7%vs 46.2%,P=0.029),first flatus time(1.9d vs 3.5 d,P=0.000),diet start time(2.3 d vs 4.9 d,P=0.000),and postoperative hospital stay(8.1 d vs 12.8d,P=0.029)were significantly less in the LDP group than in the ODP group.All patients had negative surgical margins at final pathology.There were no significant differences in number of lymph nodes harvested(4.6 vs6.4,P=0.549)between the two groups.The median follow-up was 33(3-100)mo for the LDP group and 45(17-127)mo for the ODP group.All patients were alive with one recurrence.CONCLUSION:LDP for SPT has short-term benefits compared with ODP.Long-term outcomes of LDP are similar to those of ODP.     

氟比洛芬分散片的制备工艺及质量控制研究

目的:研制氟比洛芬分散片的处方与制备工艺,并建立其质量控制方法。方法:采用正交设计试验的方法来优选处方,并筛选出了最佳处方:崩解剂CMS-Na的用量为8%,加入方法为内、外加法相結合,十二烷基硫酸钠(SDS)的用量为2%。同时采用紫外分光光度法来测定分散片中氟比洛芬的含量。结果:氟比洛芬在1.0-10.0μg/ml的浓度范围内具有良好的线性关系,计算得其平均回收率为100.38%,RSD=2.49%。结论:氟比洛芬分散片的处方设计合理,制备工艺简单,质量控制方法准确、可靠,能够用于该制剂的质量研究。     

Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations

AIM:To examine the predictive factors of capsule endoscopy(CE) completion rate(CECR) including the effect of inpatient and outpatient status.METHODS:We identified 355 consecutive patients who completed CE at Rush University Medical Center between March 2003 and October 2005.Subjects for CE had either nothing by mouth or clear liquids for the afternoon and evening of the day before the procedure.CE exams were reviewed by two physicians who were unaware of the study hypotheses.After retrospective analysis,21 cases were excluded due to capsule malfunction,prior gastric surgery,endoscopic capsule placement or insufficient data.Of the remaining 334 exams [264 out-patient(OP),70 in-patient(IP)],CE indications,findings,location of the patients [IP vs OP and intensive care unit(ICU) vs general medical floor(GMF)] and gastrointestinal transit times were analyzed.Statistical analysis was completed using SPSS version 17(Chicago,IL).Chi-square,t test or fisher exact-tests were used as appropriate.Multivariate logistic regression analysis was used to identify variables associated with incomplete CE exams.RESULTS:The mean age for the entire study population was 54.7 years.Sixty-one percent of the study population was female,and gender was not different between IPs vs OPs(P = 0.07).The overall incomplete CECR was 14% in our study.Overt obscure gastrointestinal bleeding(OGB) was a significantly more common indication for the IP CE(P = 0.0001),while abdominal pain and assessment of IBD were more frequent indications for the OP CE exams(P = 0.002 and P = 0.01,respectively).Occult OGB was the most common indication and arteriovenous malformations were the most common finding both in the IPs and OPs.The capsule did not enter the small bowel(SB) in 6/70 IPs and 8/264 OPs(P = 0.04).The capsule never reached the cecum in 31.4%(22/70) of IP vs 9.5%(25/264) of OP examinations(P 0.001).The mean gastric transit time(GTT) was delayed in IPs compared to OPs,98.5 ± 139.5 min vs 60.4 ± 92.6 min(P = 0.008).Minimal SB transit time was significantly prolonged in the IP compared to the OP setting [IP = 275.1 ±111.6 min vs OP = 244.0 ± 104.3 min(P = 0.037)].CECR was also significantly higher in the subgroup of patients with OGB who had OP vs IP exams(95% vs 80% respectively,P = 0.001).The proportion of patients with incomplete exams was higher in the ICU(n = 7/13,54%) as compared to the GMF(n = 15/57,26%)(P = 0.05).There was only a single permanent SB retention case which was secondary to a previously unknown SB stricture,and the remaining incomplete SB exams were due to slow transit.Medications which affect gastrointestinal system motility were tested both individually and also in aggregate in univariate analysis in hospitalized patients(ICU and GMF) and were not predictive of incomplete capsule passage(P 0.05).Patient location(IP vs OP) and GTT were independent predictors of incomplete CE exams(P 0.001 and P = 0.008,respectively).CONCLUSION:Incomplete CE is a multifactorial problem.Patient location and related factors such as severity of illness and sedentary status may contribute to incomplete exams.     

A prospective study of same day bi-directional endoscopy in the evaluation of patients with occult gastrointestinal bleeding

Objective. Previous studies show conflicting results in the diagnostic yield of oesophagogastroduodenoscopy (OGD) and colonoscopy (bi-directional) in identifying potential bleeding sources (PBS) in patients investigated for occult gastrointestinal bleeding (OGIB). The aims of this study were to evaluate the diagnostic yield of bi-directional endoscopy in patients presenting with OGIB and to assess the factors predictive of a positive yield. Material and methods. Patients with OGIB referred to the gastroenterology unit were prospectively included in the study. Colonoscopy was immediately followed by OGD. Predetermined criteria for the diagnosis of a PBS were used. Potential clinical factors predictive of positive yield were assessed. Results. Of the 219 patients (mean age 65 years, 34% M), 110 (50%) had at least one PBS. Colonoscopy revealed 87 PBS in 73 patients (33%), the most common being adenoma. OGD detected 49 PBS in 48 patients (22%), gastric ulcer being the most common. Of the patients with PBS at OGD, 23% also had a PBS at colonoscopy, including 3 patients with colonic cancers. Patients presenting with either a positive faecal occult blood test (FOBT) or iron-deficiency anaemia (IDA) only had a significantly lower yield for PBS than patients with combined positive FOBT and IDA. The percentages of patients with a PBS increased substantially with age. Conclusions. A PBS was found in only 50% of the patients. Colonoscopy had a slightly higher diagnostic yield, and as expected, resulted in a significantly higher cancer detection rate than OGD. In older patients, colonoscopy should be done irrespective of the findings at OGD. Gastrointestinal-specific symptoms and the use of ASA/NSAIDs were not predictive in finding or localizing PBS.