The role of endoscopy in the management of suspected small-bowel bleeding

Interventional Algorithm in Gastrointestinal Bleeding-An Expert Consensus Multimodal Approach Based on a Multidisciplinary Team

The approach to the patient with gastrointestinal bleeding (GIB) can be very complex. A multidisciplinary panel of physicians with expertise in Gastroenterology, Anesthesiology, and Transfusion Medicine worked together to provide the best knowledge and guide clinical practitioners in the real setting of health institutions, characterized by disparate availability of human and technical resources. The authors propose a global and personalized approach according to different clinical scenarios to improve the outcomes of patients with GIB, for whom the reduction of inappropriate transfusions is crucial. The goal of this document is to provide clear and objective guidance through interventional algorithms toward a goal-directed approach according to the clinical situation and supported by the latest available scientific data on GIB management in different settings.

Computed tomography versus lower endoscopy as initial diagnostic method for evaluating patients with hematochezia at emergency room

For acute lower gastrointestinal bleeding (LGIB), lower gastrointestinal endoscopy is the preferred initial diagnostic test. However, it is difficult to perform urgently. Computed tomography (CT) is a convenient alternative.This study aimed to determine the diagnostic performance of CT compared to lower endoscopy as an initial test for evaluating acute LGIB.The medical records of 382 patients who visited our emergency department with hematochezia between January 2012 and January 2017 were retrospectively analyzed. Of them, 112 underwent CT, 65 underwent colonoscopy, and 205 underwent sigmoidoscopy as an initial test. For each method, sensitivity, specificity, positive predictive value, and negative predictive value were calculated upon active bleeding site detection and LGIB etiology diagnosis.The sensitivity, specificity, positive predictive value, and negative predictive value of CT for active bleeding site detection were 85.7%, 100%, 100%, and 96.9%, respectively, while those for identifying the etiology of LGIB were 87.4%, 40.0%, 83.5, and 47.6%, respectively.CT was not inferior to lower endoscopy for active bleeding site detection. Early localization and the exclusion of active bleeding were possible with CT. Etiology was diagnosed with high sensitivity and PPV by CT. Thus, CT can be an alternative initial diagnostic tool for evaluating acute LGIB.

Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review

Left ventricular assist devices (LVAD) are increasingly become common as life prolonging therapy in patients with advanced heart failure. Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps. Unfortunately, continuous flow LVADs are fraught with complications such as gastrointestinal (GI) bleeding that are primarily attributed to the formation of arteriovenous malformations. With frequent GI bleeding, antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events. Small bowel bleeds account for 15% as the source and patients often undergo multiple endoscopic procedures. Treatment strategies include resuscitative measures and endoscopic therapies. Medical treatment is with octreotide. Novel treatment options include thalidomide, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based hormonal therapies, doxycycline, desmopressin and bevacizumab. Current research has explored the mechanism of frequent GI bleeds in this population, including destruction of von Willebrand factor, upregulation of tissue factor, vascular endothelial growth factor, tumor necrosis factor-α, tumor growth factor-β, and angiopoetin-2, and downregulation of angiopoetin-1. In addition, healthcare resource utilization is only increasing in this patient population with higher admissions, readmissions, blood product utilization, and endoscopy. While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages, these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.

Prospective multicenter study to evaluate capsule endoscopy competency using a validated assessment tool

BACKGROUND AND AIMS

Capsule endoscopy (CE) is an established, noninvasive modality for examining the small bowel. Minimum training requirements are based primarily on guidelines and expert opinion. A validated tool to assess the competence of CE is lacking. In this prospective, multicenter study, we determined the minimum number of CE procedures required to achieve competence during gastroenterology fellowship; validated a capsule competency test (CapCT); and evaluated any correlation between CE competence and endoscopy experience.

METHODS

We included second- and third-year gastroenterology fellows from 3 institutions between 2013 and 2018 in a structured CE training program with supervised CE interpretation. Fellows completed the CapCT with a maximal score of 100. For comparison, expert faculty completed the same CapCT. Trainee competence was defined as a score ≥90% compared with the mean expert score. Fellows were tested after 15, 25, and 35 supervised CE interpretations. CapCT was validated using expert consensus and item analysis. Data were collected on the number of previous endoscopies.

RESULTS

A total of 68 trainees completed 102 CapCTs. Fourteen CE experts completed the CapCT with a mean score of 94. Mean scores for fellows after 15, 25, and 35 cases were 83, 86, and 87, respectively. Fellows with at least 25 interpretations achieved a mean score ≥84 in all 3 institutions. CapCT item analysis showed high interobserver agreement among expert faculty (k = 0.85). There was no correlation between the scores and the number of endoscopies performed.

CONCLUSION

After a structured CE training program, gastroenterology fellows should complete a minimum of 25 supervised CE interpretations before assessing competence using the validated CapCT, regardless of endoscopy experience.

Quality indicators in enteroscopy. Enteroscopy procedure

Within the project "Quality Indicators in Gastrointestinal Endoscopy," under the leadership of the Sociedad Española de Patología Digestiva (SEPD), our goal is to propose the procedures and the structure, process, and outcome indicators required for the application and assessment of quality in enteroscopy. To this end a search was performed for quality indicators in enteroscopy. Quality of evidence was measured by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, and classified as high, moderate, low, and very low. A total of 10 process indicators (one preprocedure, eight procedure, one postprocedure) were identified for enteroscopy, with appropriate indication and choice of most efficient route being most significant.

Emergent Double Balloon Enteroscopy in Overt Suspected Small Bowel Bleeding: Diagnosis and Therapy

Background

Double balloon enteroscopy (DBE) is a diagnosis and therapy method for suspected small bowel bleeding (SSBB). The data for emergent DBE is limited in overt SSBB cases. The aim of this study was to investigate the role of diagnosis and therapy of emergent DBE in patients with overt SSBB.

Material/Methods

The clinical and endoscopic data for patients with overt SSBB undergoing DBE in a single center from January 2010 to December 2017 were collected and analyzed. Emergent DBE was defined as DBE performed less than 3 days of last bleeding onset.

Results

A total of 265 DBEs in 265 patients with overt SSBB were enrolled (mean age, 44.7±17.3 years; 66.8% males). The patients were divided into 3 groups according to the timing of DBE: less than 3 days (n=32), more than 3 days and less than 7 days (n=146), and more than 7 days (n=87) (first group was the emergent group, the latter 2 groups were the non-emergent groups). The diagnosis yield for the emergent group was significantly higher than the non-emergent groups (84.4% versus 65.1% or 59.8%, respectively, P<0.05), but was not different between the 2 non-emergent groups (P>0.05). The top 3 diagnoses were angioectasias (19.6%), diverticulum (16.2%), and tumor (12.1%). For therapy yield, there was a remarkable reducing trend in the emergent group (<3 days), and the 2 non-emergent groups (3 to 7 days group and >7 days group: 78.1%, 58.2% and 39.1%, respectively, P<0.05. The top 3 endoscopic treatments were hemostatic clips (21.9%), argon plasma coagulation (15.8%), and epinephrine injection (14.0%).

Conclusions

The emergent DBE had the highest yields for diagnosis and therapy. The study finding showed a pivotal role of emergent DBE in overt SSBB.

Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Undisclosed payments by pharmaceutical and medical device manufacturers to authors of endoscopy guidelines in the United States

BACKGROUND AND AIMS

Payments from pharmaceutical and medical device manufacturers to authors of clinical practice guidelines (CPGs) may influence practice recommendations. It is therefore important to evaluate the completeness of financial conflict of interest (FCOI) declarations among CPG authors.

METHODS

We performed a cross-sectional analysis of industry payments to authors of endoscopy guidelines published by 5 GI societies between 2014 and 2017. For each author we identified payments using the disclosure section of CPGs and the Centers for Medicare & Medicaid Services Open Payments (CMS-OP) database. We calculated the prevalence, monetary value, and type of declared and undeclared payments among authors. Payments were assessed for the calendar year of and before publication.

RESULTS

Thirty-seven CPGs were included in the analysis comprising 569 author entries (91 unique individuals; 66.43% men, 92.6% physicians, 66.4% academically affiliated). Four hundred fifty-one episodes (79%) involved FCOIs, 451 (79%) had undisclosed FCOIs in the CMS-OP, and 445 (77%) had FCOIs relevant to a CPG recommendation. The median undisclosed payment value was $4807.26 (interquartile range, $334.84-$20,579.75). Male authors (odds ratio, 2.23; 95% confidence interval, 1.47-3.39) and academically affiliated authors (odds ratio, 8.87; 95% confidence interval, 5.57-14.13) were significantly more likely to have undeclared payments (P < .001). No CPGs met all National Academy of Medicine criteria.

CONCLUSIONS

Recognizing concerns about the accuracy of the CMS-OP, there are substantial discrepancies between industry-reported payments and author self-disclosure. Additionally, there is a high prevalence of undisclosed payments by pharmaceutical and medical device manufacturers to these authors. Given the potential impact of these discrepancies and undisclosed payments on CPGs, more accurate reporting and alternative strategies for managing FCOI are needed.

Bowel Preparation With Polyethylene Glycol 3350 or Fasting Only Before Peroral Single-balloon Enteroscopy: A Randomized European Multicenter Trial

BACKGROUND

Although bowel preparation before colonoscopy and capsule endoscopy is widely evaluated and usually follows established guidelines, a standard preparation regime for peroral small bowel enteroscopy is yet to be defined.The aim of the present study was to compare small bowel preparation with polyethylene glycol (PEG) and "fasting only" (FO) before peroral single-balloon enteroscopy (SBE).

STUDY

We compared small bowel preparation with PEG versus "FO" for peroral SBE in a randomized European multicenter trial. Patients' and procedural characteristics were documented and carefully analyzed. Primary endpoint was the oral intubation depth of the small bowel. A modified Boston preparation scale was used to assess bowel cleansing as a secondary endpoint.

RESULTS

In total, 43 patients were enrolled in this study (FO group: n=25; PEG group: n=18). In both groups, patients' characteristics were comparable. The indications for oral enteroscopy were equally distributed in both groups (P=0.894). The oral intubation depth was significantly higher in the PEG versus the FO group (261±87 vs. 203±66 cm; P=0.019; mean±SD), while the quality of bowel preparation was equally sufficient in both groups [complete visualization of the mucosa (Boston preparation scale) 83% versus 76% (P=1.000)].

CONCLUSIONS

Small bowel preparation with PEG for SBE yields significantly deeper intubation as compared with "FO" preparation. As patient comfort and safety was similar in both groups, PEG preparation might be favored, especially if deep intubation of the small bowel is desired. For patients requiring visualization of the proximal jejunum, a FO preparation seems to be sufficient.

The Predicament of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device: Pathophysiology, Evaluation, and Management

Heart failure affects over 5 million Americans, with numbers expected to rise. While heart transplantation is the most effective long-term strategy for end-stage heart failure, there is a limited cardiac donor pool, and these organs are often unavailable at the time of need. Left ventricular assist devices, therefore, continue to be used to bridge this gap. Originally implanted as a bridge to transplant, these devices are now additionally utilized as destination therapy for patients ineligible for transplant. With the widespread applicability of these devices for not just temporary measures, but also for prolonged use, the short- and long-term impact on other organ systems has become more evident. For example, gastrointestinal (GI) bleeding, with an incidence approaching 30%, is one such complication post-continuous-flow left ventricular assist device implantation. This high incidence of GI bleeding is thought to stem from a combination of factors, including the need for concomitant anticoagulant and antiplatelet therapy, and intrinsic device-related properties resulting in acquired Von Willebrand disease and arteriovenous malformations. Due to the significant morbidity associated with these GI bleeding events, a standardized protocol optimizing medical and endoscopic management, alongside close coordination between the gastroenterology and cardiology services, should be advocated for and ultimately employed.

Management of Multiple Arteriovenous Malformations of the Small Bowel

A 62-year-old Japanese female was referred to our hospital with gastrointestinal bleeding. Although small-bowel bleeding was suspected, no bleeding source was identified by enhanced computed tomography (CT), video capsule endoscopy (VCE), and double-balloon enteroscopy (DBE). Five years later, the patient had recurrent intermittent bloody stools with a significant decrease in hemoglobin levels. Although no active bleeding was observed on antegrade DBE, we detected a pulsatile submucosal uplift accompanied by a small red patch on the top of the uplift in the jejunum. Arteriovenous malformation (AVM) was suspected as the cause of small-bowel bleeding. Multiple-phase CT showed a number of small vascular ectasias during the arterial phase in the jejunum, and we confirmed the presence of multiple AVMs in the jejunum by selective angiography. To identify the location of the lesions and determine the minimal surgical margins, we performed intraoperative selective angiography with indocyanine green (ICG) injection. This technique allowed us to clearly observe the region and perform segmental small-bowel resection with minimal surgical margin. The patient reported that she has had no gastrointestinal bleeding at the two years follow-up visit.

Endoscopic ultrasonography and small-bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small-bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device-assisted enteroscopy have quickly become the reference standard for the diagnosis of small-bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up-to-date overview of the latest advances in endoscopic ultrasonography and small-bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.

Capsule endoscopy for the study of small bowel disorders: Experience at a private institution in Mexico

INTRODUCTION AND AIMS

Capsule endoscopy has revolutionized the study of small bowel disorders. Its diagnostic yield, reasons for referral, and frequency of significant endoscopic findings at our institution are unknown. The aims of our study were to describe the reasons for referral, the frequency of significant endoscopic findings, and the diagnostic yield of capsule endoscopy in patients that underwent the procedure for the study of small bowel disorders.

MATERIAL AND METHODS

A retrospective study was conducted that included all patients that underwent capsule endoscopy for small bowel disorder evaluation at our institution. The diagnostic yield for significant endoscopic findings, the frequency of significant endoscopic findings, and the reasons for referral for capsule endoscopy were determined.

RESULTS

A total of 134 patients were included in the study and 143 capsule endoscopies were performed. Women made up 48.5% of the sample and the mean patient age was 63 years (18.7 standard deviation). The main reasons for referral were suspicion of overt small bowel bleeding (55.9%) and suspicion of occult small bowel bleeding (28.6%). The overall diagnostic yield was 66.4%. The most common significant findings were small bowel angioectasias (52.6%) and small bowel ulcers (38.9%). There were two adverse events (1.3%): one capsule retention that required enteroscopic removal and one asymptomatic bronchoaspiration of the capsule that resolved spontaneously.

CONCLUSIONS

The frequency of significant endoscopic findings with capsule endoscopy at our institution was different from that reported in other Mexican studies, but the reasons for referral and the diagnostic yield were similar.

Impact of Urgent Double-Balloon Enteroscopy on the Short-Term and Long-Term Outcomes in Overt Small Bowel Bleeding

BACKGROUND

Double-balloon enteroscopy (DBE) is a safe and useful procedure for managing small bowel bleeding. However, there are limited studies regarding the preferable timing of DBE and its impact on long-term outcomes.

AIM

We aimed to evaluate the association between the timing of DBE and the long-term outcomes of patients suspected of having overt small bowel bleeding who underwent DBE.

METHODS

We retrospectively reviewed a prospectively collected database of patients who underwent DBE procedures between May 2004 and April 2016. The electronic medical records were reviewed, and interviews were conducted via mail and telephone.

RESULTS

One-hundred sixty-five patients could be followed up. The bleeding source was detected during the initial DBE (DBE-positive group) for 102 patients. Sixty-three patients had no definite lesion during the initial DBE (DBE-negative group). Urgent DBE (DBE within 24 h after the last bleeding episode) was performed more often for the DBE-positive group (50/102; 49.0%) than for the DBE-negative group (10/63; 16.1%) (p < 0.0001). Nine patients in the DBE-positive group underwent curative surgery after diagnosis. Among the remaining DBE-positive patients, 38 of 93 (40.9%) had recurrent bleeding during 2675 days of follow-up. Twenty-one of 63 patients (33.3%) in the DBE-negative group had recurrent bleeding during 2490 days of follow-up. There was no significant difference between the two groups in terms of intervals without rebleeding (p = 0.17).

CONCLUSION

Urgent DBE at the initial bleeding episode was useful for detecting lesions. However, the rebleeding rate was not dependent on the initial DBE results.

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.

Obscure gastrointestinal bleeding resulting from small bowel neoplasia; A case series

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Obscure GI bleeding can be a challenging diagnosis and is well acknowledged.

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Perseverance is required to achieve the correct diagnosis in obscured GI bleeding.

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Diagnostic overshadowing can halt investigations and delay diagnosis.

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Multidisciplinary team input is important in the diagnosis of obscured GI bleeding.

Introduction

Undiagnosed gastrointestinal bleeding may originate in the small bowel. This presents a diagnostic challenge despite the advancement in contemporary imaging. We report two cases which highlight the limitations of routine investigation for obscure gastrointestinal bleeding.

Presentation of case

Patient A presented with a history of rectal bleeding, treated with interventional embolisation of caecal angiodysplasia. A diagnosis of neuroendocrine tumour (NET) was reached two years after presentation following intraoperative right hemicolectomy resection of a presumed recurrent angiodysplastic bleed. Patient B presented with recurrent melaena labelled as non-steroidal anti-inflammatory drug (NSAID) induced gastritis. After multiple endoscopic and radiological investigations, a 4.5 cm mass was visualised on imaging after three years, which was histologically proven as gastrointestinal stromal tumour (GIST) of the small bowel. Both patients experienced a delayed diagnosis despite multiple investigations and careful follow-up.

Discussion

Our case series discusses the benefits and limitations of investigation for gastrointestinal bleeding and suggests a need for continued multidisciplinary input in situations where the patient presumed diagnosis remains in question.

Conclusion

OGIB remains a diagnostic challenge and is attributable to small bowel pathology in 75% of cases. This suggests a need for continued investigation in situations where the patient presents multiple times despite adequate treatment for the presumed underlying condition.

Optimal management of the patient presenting with small bowel bleeding

The management of small bowel bleeding, also known as obscure gastrointestinal bleeding, has changed substantially over the past two decades due to revolutionary technological advances in small intestinal endoscopy. This clinical review will summarize the evolving definition of small bowel bleeding, how to perform a detailed initial assessment of patients with the condition, the strengths and limitations of small bowel endoscopy, and the treatment of small bowel bleeding.

Diagnosis of chronic anaemia in gastrointestinal disorders: A guideline by the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP)

Anaemia is a common pathologic condition, present in almost 5% of the adult population. Iron deficiency is the most common cause; other mechanisms can be involved, making anaemia a multi-factorial disorder in most cases. Anaemia being a frequent manifestation in the diseases of the gastrointestinal tract, patients are often referred to gastroenterologists. Furthermore, upper and lower endoscopy and enteroscopy are pivotal to the diagnostic roadmap of anaemia. In spite of its relevance in the daily clinical practice, there is a limited number of gastroenterological guidelines dedicated to the diagnosis of anaemia. For this reason, the Italian Association of Hospital Gastroenterologists and Endoscopists and the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition commissioned a panel of experts to prepare a specific guideline on anaemia and its diagnostic roadmap in the gastroenterological scenario. The panel also discussed about the potential involvement of gastroenterologists and endoscopists in the management of patients with anaemia, with particular attention to the correct use of investigations. The panel paid particular attention to practical issues with the aim to support gastroenterologists in their clinical practice when dealing with patients with anaemia.

The Clinician's Guide to Suspected Small Bowel Bleeding

Small bowel bleeding accounts for 5-10% of gastrointestinal bleeding. With the advent of capsule endoscopy, device-assisted enteroscopy, and multiphase CT scanning, a small bowel source can now be found in many instances of what has previously been described as obscure gastrointestinal bleeding. We present a practical review on the evaluation and management of small bowel bleeding for the practicing clinician.

CapsoCam SV-1 Versus PillCam SB 3 in the Detection of Obscure Gastrointestinal Bleeding: Results of a Prospective Randomized Comparative Multicenter Study

BACKGROUND AND STUDY AIM

Newer capsule with a panoramic viewing mode is available and might increase the detection rate of bleeding lesions in patients with obscure gastrointestinal bleeding (OGIB). Furthermore, an improved patient acceptance rate is expected.

MATERIALS AND METHODS

In a randomized prospective comparative multicenter study, patients with OGIB were included and examined either with CapsoCam SV-1 or with PillCam SB 3. Detection of bleeding lesions, transit, and evaluation time and adverse events were evaluated. Physicians were interviewed about their experience with both capsules and the evaluation software. A detailed subject questionnaire analyzed acceptance of each capsule. Follow-up was 3 months.

RESULTS

In total, 181 patients with OGIB were recruited into the study. After exclusion of 28 patients 153 patients were randomized and CapsoCam SV-1 (n=78) or PillCam SB 3 (n=75) was administered. CapsoCam SV-1 detected more cases of bleeding (31/79, diagnostic yield 39.7%) compared with PillCam SB 3 (26/75, diagnostic yield 34.6%, NS). Transit time of both capsules was not different. Evaluation time with PillCam SB 3 was superior to CapsoCam SV-1 (27 vs. 40 min, P=0.01). In total, 95% of the physicians were satisfied with each capsule system and evaluation software. The acceptance rate of the patients to retrieve the CapsoCam SV-1 was high. Adverse events/serious adverse events were 17.9%/1.3% with CapsoCam SV-1 and 16%/0% with PillCam SB 3. Rebleeding rate was 28.75% within 3 months.

CONCLUSIONS

CapsoCam SV-1 detected more lesions; however, relevant bleeding sources were visualized by both capsules. Physician's satisfaction was high with both capsule systems and evaluation software. Patient's acceptance with CapsoCam SV-1 was unexpectedly high. Serious adverse events were 0% with PillCam SB 3 and 1.3% with CapsoCam SV-1.

The impact of inpatient capsule endoscopy on the need for therapeutic interventions in patients with obscure gastrointestinal bleeding

BACKGROUND/AIM

There are limited data evaluating the impact of inpatient video capsule endoscopy (VCE) on the need for therapeutic interventions in hospitalized patients with obscure gastrointestinal bleeding (OGIB). The objective of this study was to determine the impact of inpatient VCE on the need for therapeutic interventions and rehospitalization for recurrent bleeding.

PATIENTS AND METHODS

Hospitalized patients who underwent VCE for OGIB indication were retrospectively included. Clinical data were collected including therapeutic interventions performed after VCE. Specific therapeutic interventions were defined as the medical, endoscopic, or surgical treatment directly targeting the cause of OGIB. Patients were followed up to determine the rate of rehospitalization.

RESULTS

A total of 48 inpatient VCE were identified, of which 43 VCE were performed for OGIB indication and were included for analysis. The completion rate and the diagnostic yield were 78.5% and 55.8%, respectively. Subsequent specific therapeutic interventions were performed in 65.2% and 5.8% of patients with positive and negative VCE, respectively (P < 0.001). After a median follow up of 30 months (minimum 12, maximum 58), rehospitalization for recurrent bleeding occurred in 30.4% and 17% of patients with positive and negative VCE, respectively. Patients with angiodysplasia on VCE were significantly more likely to be readmitted (P = 0.02). Throughout the course of the follow-up, only 2 (11.7%) patients with negative VCE underwent specific therapeutic interventions.

CONCLUSION

Inpatient VCE is an effective tool to identify patients who need specific therapeutic interventions. Patients with negative VCE are unlikely to be readmitted or require specific therapeutic interventions in the index admission.

Early timing of single balloon enteroscopy is associated with increased diagnostic yield in patients with overt small bowel bleeding

BACKGROUND/PURPOSE

Although performing balloon enteroscopy soon after the onset of small bowel bleeding appeared to enhance diagnostic rate, the optimal timing was unclear.

METHODS

A retrospective cohort study in a single referral center. Patients with overt, suspected small bowel bleeding who underwent primary single-balloon enteroscopy (SBE) were evaluated to determine the association between procedure timing and diagnostic yield rates.

RESULTS

A total of 220 patients were enrolled (47.7% males; mean age, 65.6 ± 18.1 years). They were stratified into four groups based on the timing of SBE: emergency (<24 h after onset or continued bleeding, n = 64), 24-72 h (n = 28), 3-7 days (n = 41), and >7 days (n = 87). A significant trend of decreasing diagnostic yields was observed across the groups (90.6%, 67.9%, 68.3%, and 44.8%, respectively, P < 0.0001). Diagnostic yield rates were different between emergency and 24-72 h groups (P < 0.0001), and between 3 and 7 days and >7 days groups (P < 0.05), but not between 24 and 72 h and 3-7 days groups (P = 0.97). In multivariate regression analysis, emergency, ≤ 3 days, and ≤7 days SBEs had greater yield rates than SBEs at later timings.

CONCLUSION

The likelihood of diagnostic yield was highest when SBE was performed during continued bleeding or within 24 h of onset, and gradually declined as waiting time increased. We therefore recommend that SBE should be performed as soon as possible, preferably no later than seven days.

Diagnostic Value and Safety of Emergency Single-Balloon Enteroscopy for Obscure Gastrointestinal Bleeding

BACKGROUND

This study assesses the diagnostic performance of emergency single-balloon enteroscopy (SBE) for obscure gastrointestinal bleeding (OGIB) under general anesthesia versus conscious sedation.

STUDY

The data of 102 OGIB in-patients from June 2015 to June 2018 were retrospectively analyzed. The diagnosis and detection rates and adverse events were calculated overall and in relation to age, gender, type of operation and anesthesia, bleeding type, different times of examination, and SBE route. All statistical analyses were performed using SPSS 24.0, and the diagnosis and detection rates were compared using the Chi-square test.

RESULTS

Among the 102 patients, 66 patients had positive findings, while 11 patients had suspected positive findings, and the diagnosis and detection rates were 64.7% and 75.5%, respectively. Ulcers (19.6%) and tumors (16.7%) were the most common causes of OGIB. There were no statistical differences in diagnosis and detection rates between the ages of ≥60 and <60 and between different genders. Patients with emergency SBE had higher diagnosis and detection rates (68.6% vs. 35.3%, P = 0.023; 80.0% vs. 47.1%, P = 0.016, respectively), when compared with nonemergency SBE patients. The diagnosis rate at 24 hours was higher than that at 2-7 days and one week (88.0% vs. 61.5%, P = 0.030; 88.0% vs. 53.8%, P = 0.007). For overt bleeding, the difference in diagnosis rates at 24 hours, 2-7 days, and one week was statistically significant (100.0% vs. 57.1%, P = 0.006; 100.0% vs. 57.1%, P = 0.006). For occult bleeding, the pairwise comparison revealed no statistical difference. Patients with general anesthesia had a higher detection rate, when compared to patients with conscious sedation (87.9% vs. 63.9%, P = 0.004). In addition, adverse events under general anesthesia were lower, when compared to adverse events under conscious sedation (28.8% vs. 69.4%, P = 0.020). There was no significant difference in adverse events at the different time points (P > 0.05).

CONCLUSION

Emergency SBE under general anesthesia achieves higher diagnosis and detection rates, and fewer adverse events under conscious sedation, when compared to nonemergency SBE, regardless of the route. For patients with overt bleeding, it is easier to find lesions by emergency SBE within 24 hours.

Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease

Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.

Experiencia con videocápsula endoscópica en el estudio y diagnóstico de enfermedades del intestino delgado en un hospital de alta complejidad en Medellín, Colombia

Introducción: el intestino delgado (ID) es un órgano difícil de estudiar debido a su gran tamaño y ubicación anatómica; los estudios endoscópicos convencionales (esofagogastroduodenoscopia y colonoscopia) no logran evaluarlo en su totalidad y la enteroscopia con balón es más invasiva, con mayores efectos adversos y tasas de complicaciones. La videocápsula endoscópica (VCE) es una tecnología mínimamente invasiva que permite visualizar de forma dinámica y completa la mucosa del ID; es el método directo más seguro y con menos tasas de complicaciones.Metodología: se realizó un estudio descriptivo de corte transversal, para describir la experiencia clínica en la utilización de la VCE en un hospital de alta complejidad en Medellín, Colombia; asimismo, determinar las indicaciones, síntomas más comunes y hallazgos anormales.Resultados: se realizaron 374 VCE en el período de estudio: 282 ambulatorias (75,4 %) y 92 hospitalizados (24,6 %). En ambos grupos la indicación más frecuente fue sangrado digestivo oscuro (38,65 % y 53,26 %, respectivamente), seguidos por anemia crónica en el 27,65 % de ambulatorios y por enfermedad inflamatoria intestinal (EII) en 21,74 % de los hospitalizados. Los hallazgos anormales fueron más frecuentes en el yeyuno y las lesiones más comunes fueron angiodisplasias y lesiones inflamatorias.Conclusiones: en las indicaciones más frecuentes (sangrado digestivo oscuro y anemia) se documentaron potenciales fuentes de sangrado en más del 70 % de los casos; siendo las lesiones vasculares e inflamatorias los hallazgos más comunes. En seguimiento o evaluación de EII se documentaron en más del 50 % lesiones inflamatorias. La VCE es muy segura, no se presentó ninguna complicación relacionada con la VCE.

Clinical approach to the patient with acute gastrointestinal bleeding

Gastrointestinal bleeding (GIB) is a very common condition at all ages, with high rates of morbidity and mortality, especially in case of acute presentation. The optimal management of acute GIB requires a timely overview of vital signs and clinical presentation to stabilize the patient if necessary and set up the most adequate diagnostic and therapeutic approach, based on the suspected etiology. Endoscopy plays a major role both in diagnosis and treatment of acute GIB, as allows the application of several hemostasis techniques during the diagnostic session, which should preferably be performed within 24 hours from the acute event. The hemostasis technique should be chosen based on type, etiology of the bleeding and the operator preference and expertise. Nevertheless, several challenging cases need the cooperation of radiology especially in the diagnostic phase, and even in the therapeutic phase for those bleedings in which medical and endoscopic techniques have failed. Imaging diagnostic techniques include mainly CT angiography, scintigraphy with labeled erythrocytes and arteriography. This last technique plays also a therapeutic role in case arterial embolization is needed. Only those patients in which the previous techniques have failed, both in diagnosis and treatment, are candidates for emergency surgery. (www.actabiomedica.it)

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: A systematic review and meta-analysis

AIM

To compare the diagnostic accuracy of video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) in cases of obscure gastrointestinal bleeding (OGIB) of vascular origin.

METHODS

MEDLINE (via PubMed), LILACS (via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.

RESULTS

In the per-patient analysis, 17 studies (1477 lesions) were included. We identified 3150 exams (1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864 (58.5%) were diagnosed by VCE, and 613 (41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84% (95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was 92% (95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29 (95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20 (95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to 90%.

CONCLUSION

The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Gastrointestinal Vascular Malformations in Patients with Turner's Syndrome: A Systematic Review of Case Reports

BACKGROUND/AIM

There is a paucity of data on gastrointestinal (GI) vascular abnormalities in patients with Turner's syndrome (TS). Therefore, this literature review aimed to characterize the nature of GI vascular malformations in patients with TS, their localization in the GI tract, and their clinical and laboratory manifestations.

METHODS

A systematic search for articles was conducted using Medline and Embase (until August 2017). A manual search of the references of the included papers was performed to identify any potential additional references. We also conducted a retrospective chart review of all patients with TS and GI bleeding who were hospitalized at our institution.

RESULTS

A total of 29 articles published between 1947 and 2015 that described 39 cases were reviewed. Additionally, we included 2 patients who were hospitalized at our institution. The median age of patients with TS was 15 years (range: 0.1-57 years). Iron deficiency anaemia (35/40), haematochezia (15/37), and melaena (14/36) were the most common symptoms. Abnormal GI vessels occurred throughout the entire bowel, with a predilection for the small intestine (72%, 29/40). The most common abnormal vessels (65%, 24/37) were telangiectasias and dilated veins.

CONCLUSION

Telangiectasias and dilated veins of the small intestine were the most commonly seen abnormal GI vessels in patients with TS.

Meckel’s diverticulum diagnosis by video capsule endoscopy: A case report and review of literature

BACKGROUND

Meckel’s diverticulum (MD) occurs predominantly in children and adolescents. It is rarely diagnosed in adults. Preoperative diagnosis is difficult due to low sensitivity of the radiological imaging studies. The role of video capsule endoscopy (VCE) in the diagnosis of MD is unknown, and the endoscopic patterns are not defined. We will describe four of our cases of MD evaluated with VCE and make a review of the literature focusing on the endoscopic characteristics.

CASE SUMMARY

We present four cases of MD confirmed by surgery. They were all adult males with ages going from 18 to 50 years, referred to our service from 2004 to 2018, due to obscure gastrointestinal bleeding (OGIB). They had a history of 1 mo to 10 years of overt and occult bleeding episodes. Laboratory blood test showed an iron-deficiency anemia from 4 to 9 g/dL of hemoglobin that required multiple hospitalizations and blood transfusions in all cases. Repeated upper digestive endoscopies and colonoscopies were negative. Small bowel was examined with VCE, which revealed double lumen images in all cases, one with polyps and three with circumferential ulcers in the diverticulum. However, based on VCE findings, preoperative diagnosis of MD was suggested only in two patients. Capsule was retained in one patient, which was recovered with surgery. The anatomopathological report revealed ulcerated ectopic gastric mucosa in all cases.

CONCLUSION

VCE is useful for the diagnosis of MD. However, endoscopic characteristics must be recognized in order to establish preoperative diagnosis.

False-negative double-balloon enteroscopy in overt small bowel bleeding: long-term follow-up after negative results

BACKGROUND AND AIM

Double-balloon enteroscopy (DBE) performed to investigate overt small bowel bleeding can miss the source of bleeding. We investigated the clinical outcomes of patients with negative DBE results for suspected overt small bowel bleeding, which is defined in the current guidelines as obscure gastrointestinal bleeding.

METHODS

We reviewed the prospectively collected medical records of patients who underwent DBE at our hospital between May 1, 2004 and April 30, 2016. During this period, 297 patients underwent DBE for suspected overt small bowel bleeding. The first DBE yielded negative results for 83 patients (27.9%). Written interviews, telephone interviews, and medical records of these patients were reviewed in April 2017. Follow-up data were collected for 63 patients (75.9%).

RESULTS

During a mean follow-up period of 83.5 months, re-bleeding occurred in 21 of 63 patients (33.3%) after a mean of 23.0 months after the first DBE yielded negative results. The bleeding source was identified in 19 of 21 patients (90.5%). In 15 of these 19 patients (78.9%), the source was the small intestine. Among these 15 patients, 14 (93.3%) had bleeding sites within reach of the first DBE and 3 (20%) experienced their first incidence of re-bleeding more than 3 years after the first DBE. The need for transfusion for the first bleeding episode was a predictor of re-bleeding (odds ratio 7.5; 95% confidence interval 1.7-33.0).

CONCLUSIONS

False-negative DBE results for overt small bowel bleeding are not rare, and the first re-bleeding episode can occur 3 years later. Repeat DBE when re-bleeding occurs should be considered, even if the first DBE results were negative.

Effect of Double-Balloon Enteroscopy on Diagnosis and Treatment of Small-Bowel Diseases

Background:

The diagnosis and treatment of small-bowel diseases is clinically difficult. The purpose of this study was to evaluate the diagnostic and therapeutic value of double-balloon enteroscopy in small-bowel diseases.

Methods:

The history and outcomes of 2806 patients who underwent double-balloon enteroscopy from July 2004 to April 2017 were reviewed, which included 562 patients with obscure digestive tract bleeding, 457 patients with obscure diarrhea, 930 patients with obscure abdominal pain, 795 patients with obscure weight loss, and 62 patients with obscure intestinal obstruction. Examinations were performed through the mouth and/or anus according to the clinical symptoms and abdominal images. If a lesion was not detected through one direction, examination through the other direction was performed as necessary. Eighty-four patients with small-bowel polyps, 26 with intestinal obstruction caused by enterolith, and 18 with bleeding from Dieulafoy's lesions in the small intestine were treated endoscopically.

Results:

A total of 2806 patients underwent double-balloon enteroscopy, and no serious complications occurred. An endoscopic approach through both the mouth and anus was used in 212 patients. Lesions were detected in 1696 patients, with a detection rate of 60.4%; the rates for obscure digestive tract bleeding, diarrhea, abdominal pain, weight loss, and intestinal obstruction were 85.9% (483/562), 73.5% (336/457), 48.2% (448/930), 49.1% (390/795), and 62.9% (39/62), respectively. For patients with small-bowel polyps who underwent endoscopic therapy, no complications such as digestive tract bleeding and perforation occurred. Intestinal obstruction with enteroliths was relieved with endoscopic lithotripsy. Among the 18 patients with bleeding from small-bowel Dieulafoy's lesions, 14 patients were controlled with endoscopic hemostasis.

Conclusion:

Double-balloon enteroscopy is useful for diagnosing and treating some small-bowel disease.

A Deeper Look at the Small Bowel: Training Pathways in Video Capsule Endoscopy and Device-Assisted Enteroscopy

BACKGROUND

Although there are guidelines for video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), little is known about fellowship training in these technologies.

AIMS

The aims were to better characterize current small bowel endoscopy training in 3-year GI fellowship programs and 4th-year advanced endoscopy programs in the U.S.

METHODS

We developed an online multiple-choice survey to assess current GI fellowship program training in small bowel endoscopy. The survey was distributed via email to GI fellowship program directors in the U.S.

RESULTS

Of the 168 program directors contacted, 59 responded (response rate = 35.1%). There was no statistically significant difference in the availability of VCE or DAE between respondents and non-respondents. VCE training was universally available in 3-year training programs, with 84.8% (50/59) requiring it for fellows. The majority of 3-year GI fellows graduated with independence in VCE: 83.1% (49/59) of programs reported "most" or "all" graduates were able to read independently. DAE techniques were available in 86.4% of training programs (51/59). Training in DAE was more limited and shared between 3-year and 4th-year programs: 12.1% (7/58) of 3-year programs required training in DAE and 22.9% (8/35) of 4th-year programs required training in DAE .

CONCLUSIONS

Training in VCE is widely available in U.S. GI fellowship programs, although programs have different ways of incorporating this training into the curriculum and of measuring competency. While DAE technology was available in the majority of programs, training was less frequently available, and training is shared between 3-year fellowship programs and 4th-year advanced endoscopy programs .

Enteroscopy in children

INTRODUCTION

Device-assisted enteroscopy is a new endoscopic technique for the evaluation of small bowel in adults and children. Data in pediatric population are limited. This review aims to identify diagnostic and therapeutic benefits of enteroscopy in children.

METHODS

We have analysed paediatric literature on device-assisted enteroscopy focusing on indications, technical aspects and complications, with attention given to adult publications that may be applicable to the paediatric population.

RESULTS

Obscure gastrointestinal bleeding, Crohn's disease and small bowel polyps are the main indications of enteroscopy in children. Device-assisted enteroscopy has high diagnostic yield for the main paediatric indications, but MR-enterography and capsule endoscopy should be used beforehand in diagnostic work-up to better identify candidates for enteroscopy and to improve its diagnostic and therapeutic yield. Major complications are rare and mostly related to therapeutic procedures.

CONCLUSION

Despite limited data in the paediatric population, device-assisted enteroscopy represents a useful and safe endoscopic technique in children. Its use, combined with MR-enterography and capsule endoscopy, allows identification and treatment of many of the small bowel paediatric diseases with a low risk of complications.

Unusual Cause of Gastrointestinal Bleeding in a Patient with Turner Syndrome

Turner syndrome is an exclusively female genetic disease caused by complete or partial absence of the second X chromosome. It is classically characterized by congenital lymphedema, short stature, and gonadal dysgenesis. In addition, the syndrome is associated with several other abnormalities. One of them is gastrointestinal bleeding, which is frequently associated with inflammatory bowel disease, but it can also be caused by vascular lesions such as hemangioma, vascular ectasia, and telangiectasia. We report the case of a patient with Turner syndrome with an episode of gastrointestinal bleeding, outlining our pathway for the investigation and treatment of this condition.

Diagnostic Benefit of Simultaneous Capsule Endoscopy Using Two Different Systems

Background/Aims

Capsule endoscopy (CE) is a noninvasive test for diagnosing small bowel disorders. However, several studies reported that the CE-based visualization is suboptimal. This study, the first to use two CEs simultaneously, aimed at evaluating the diagnostic ability of dual CE.

Methods

Dual CE procedures were prospectively conducted. All patients completed bowel cleansing 2 hours before examination. Subsequently, they simultaneously swallowed two capsules: MiroCam (IntroMedic, Seoul, Korea) and PillCam SB3 (Medtronic, Minneapolis, USA). We assessed the completeness and feasibility of small bowel examination and the detection rate of duodenal papilla and diagnostic yield.

Results

Twenty consecutive patients who underwent complete small bowel examination with dual CE were enrolled in the study. The mean time of small bowel passage was 245 ± 99 min. Dual CE examination increased the duodenal papilla detection rate to up to 75% (versus PillCam SB3 alone (P = 0.031) and MiroCam alone (P = 0.063)) and overall diagnostic yield to up to 70% (P = 0.063) in comparison to single CE. Adverse events or electrical interference during data transmission between the two capsule endoscopes were not detected.

Conclusions

In this study, we found that dual CE enhances diagnostic accuracy and could increase the diagnostic power of existing CE systems using simply applicable methods. This trial is registered with KCT0002541.

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.

Emergent single-balloon enteroscopy for overt bleeding of small intestinal vascular malformation

A 28-year-old man presented with anemia symptoms and intermittent tarry stool passage for three days. No stigmata of hemorrhage were identified using esophagogastroduodenoscopy, ileocolonoscopy, and contrast-enhanced computed tomography. He then developed massive tarry stool passage with profound hypovolemic shock and hypoxic respiratory failure. Emergent angiography revealed active bleeder, probably from the jejunal branches of the superior mesenteric artery, but embolization was not performed due to possible subsequent extensive bowel ischemia. His airway was secured via endotracheal intubation with ventilator support, and emergent antegrade single-balloon enteroscopy was performed at 8 h after clinical overt bleeding occurrence; the procedure revealed a 2-cm pulsating subepithelial tumor with a protruding blood plug at the distal jejunum. Laparoscopic segmental resection of the jejunum with end-to-end anastomosis was performed after emergent endoscopic tattooing localization. Pathological examination revealed a vascular malformation in the submucosa with an organizing thrombus. He was uneventfully discharged 5 d later. This case report highlights the benefit of early deep enteroscopy for the treatment of small intestinal bleeding.

Evaluation of scoring systems without endoscopic findings for predicting outcomes in patients with upper gastrointestinal bleeding

Background

Risk scoring systems are used to evaluate patients with upper gastrointestinal bleeding (UGIB). We compared Glasgow-Blatchford score (GBS), modified GBS (mGBS), and Pre-endoscopy Rockall score (Pre-E RS) for immediate application without endoscopic findings in predicting the need of interventions and the 30-day mortality in patients with UGIB.

Methods

Patients who visited the emergency room with UGIB from January 2007 to June 2016 were included. GBS, mGBS, and Pre-E RS were obtained for all patients. The area under the receiver-operating characteristic curves (AUC) was used to assess the accuracy of the scoring systems to determine the need for interventions and 30-day mortality. Also, we investigated the potential cutoff scores for predicting 30-day mortality and the need for interventions.

Results

In predicting the need for interventions, GBS (AUC = 0.727) and mGBS (AUC = 0.733) outperformed Pre-E RS (AUC = 0.564, P < 0.0001). In predicting 30-day mortality, Pre-E RS (AUC = 0.929) outperformed GBS (AUC = 0.664, P < 0.0001) and mGBS (AUC = 0.652, P < 0.0001). Based on AUC analyses of sensitivities and specificities, the optimal cutoff mGBS and GBS for the need for interventions was 9 (70.71% sensitivity, 89.35% specificity) and 9 (73.57% sensitivity, 82.90% specificity) respectively, and optimal cutoff Pre-E RS for 30-day mortality was 4 (88.0% sensitivity, 97.52% specificity).

Conclusions

GBS and mGBS are considered to be moderately accurate in making an early decision about the need of interventions in patients with UGIB. Pre-E RS is considered to be highly accurate in early detection of patients at high risk for 30-day mortality without endoscopic findings. In addition, we suggested potential cutoff scores to predict the need of interventions for GBS and mGBS, and 30-day mortality for Pre-E RS. Further studies are needed to confirm the clinical applicability of results.

Long-term effects of video capsule endoscopy in the management of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) accounts for approximately 5% of all gastrointestinal (GI) hemorrhages. It usually arises from a small bowel lesion beyond the reach of conventional endoscopy including esophagogastroduodenoscopy and colonoscopy. Video capsule endoscopy (VCE) revolutionized the evaluation of OGIB patients since it allows reliable and noninvasive visualization of the small bowel mucosal surface. Since 2001, VCE has evolved into an efficient technology integrated in clinical practice. It is the cornerstone in the algorithm of OGIB investigation given its high diagnostic yield, which compares favorably to that of double-balloon enteroscopy (DBE). In terms of outcomes, a positive index VCE examination usually correlates to a high re-bleeding rate, while a negative one provides adequate evidence of low re-bleeding risk, suggesting a wait and watch approach in this subset of patients. Additionally, a variety of factors has been acknowledged as significant predictors of re-bleeding episodes. While research data regarding immediate endoscopic findings have matured, data concerning the clinical utility of VCE in patients with OGIB on the long-term remain sparse. This manuscript reviews the current literature, aiming to highlight the role of VCE in the long-term management of OGIB.