American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding

Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome

OBJECTIVE

Antimicrobial stewardship programs have been shown to help reduce the use of unnecessary antimicrobial agents in the hospital setting. To date, there has been very little data focusing on high-use areas, such as the medical ICU. A prospective intervention was done to assess guideline compliance, antimicrobial expenditure, and healthcare cost when an infectious disease fellow interacts regularly with the medical ICU team.

DESIGN

A 3-month retrospective chart review was followed by a 3-month prospective intervention the following year. Two hundred forty-six total charts were reviewed to assess generally accepted guideline compliance, demographics, and microbiologic results.

SETTING

Twenty-four-bed medical ICU at an 861-bed tertiary care, university teaching hospital in North Carolina.

SUBJECTS

Patients receiving antibiotics in the medical ICU.

INTERVENTION

During the intervention period, the infectious disease fellow reviewed the charts, including physician notes and microbiology data, and discussed antimicrobial use with the medical ICU team.

MEASUREMENTS AND MAIN RESULTS

Antimicrobial use, treatment duration, Acute Physiology and Chronic Health Evaluation II scores, length of stay, mechanical ventilation days, and mortality rates were compared during the two periods.

RESULTS

No baseline statistically significant differences in the two groups were noted (i.e., age, gender, race, or Acute Physiology and Chronic Healthcare Evaluation II scores). Indications for antibiotics included healthcare-associated (53%) and community-acquired pneumonias (17%). Significant reductions were seen in extended-spectrum penicillins (p=0.0080), carbapenems (p=0.0013), vancomycin (p=0.0040), and metronidazole (p=0.0004) following the intervention. Antimicrobial modification led to an increase in narrow-spectrum penicillins (p=0.0322). The intervention group had a significantly lower rate of treatments that did not correspond to guidelines (p<0.0001). There was a reduction in mechanical ventilation days (p=0.0053), length of stay (p=0.0188), and hospital mortality (p=0.0367). The annual calculated healthcare savings was $89,944 in early antibiotic cessation alone.

CONCLUSION

Active communication with an infectious disease practitioner can significantly reduce medical ICU antibiotic overuse by earlier modification or cessation of antibiotics without increasing mortality. This in turn can reduce healthcare costs, foster prodigious education, and strengthen relations between the subspecialties.

Negative capsule endoscopy in patients with obscure gastrointestinal bleeding reliable: Recurrence of bleeding on long-term follow-up

AIM: To assess the rate of recurrent bleeding of the small bowel in patients with obscure bleeding already undergone capsule endoscopy (CE) with negative results.

METHODS: We reviewed the medical records related to 696 consecutive CE performed from December 2002 to January 2011, focusing our attention on patients with recurrence of obscure bleeding and negative CE. Evaluating the patient follow-up, we analyzed the recurrence rate of obscure bleeding in patient with a negative CE. Actuarial rates of rebleeding during follow-up were calculated, and factors associated with rebleeding were assessed through an univariate and multivariate analysis. A P value of less than 0.05 was regarded as statistically significant. The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of negative CE were calculated.

RESULTS: Two hundred and seven out of 696 (29.7%) CE studies resulted negative in patient with obscure/overt gastrointestinal bleeding. Overall, 489 CE (70.2%) were positive studies. The median follow-up was 24 mo (range 12-36 mo). During follow-up, recurrence of obscure bleeding was observed only in 34 out of 207 negative CE patients (16.4%); 26 out of 34 with obscure overt bleeding and 8 out of 34 with obscure occult bleeding. The younger age (< 65 years) and the onset of bleeding such as melena are independent risk factors of rebleeding after a negative CE (OR = 2.6703, 95%CI: 1.1651-6.1202, P = 0.0203; OR 4.7718, 95%CI: 1.9739-11.5350, P = 0.0005). The rebleeding rate (CE+ vs CE-) was 16.4% vs 45.1% (χ² test, P = 0.00001). The sensitivity, specificity, and PPV and NPV were 93.8%, 100%, 100%, 80.1%, respectively.

CONCLUSION: Patients with obscure gastrointestinal bleeding and negative CE had a significantly lower rebleeding rate, and further invasive investigations can be deferred.

Diagnostic value of double balloon endoscopy in obscure gastrointestinal bleeding in elderly patients

AIM: To investigate the diagnostic value of double balloon endoscopy (DBE) in obscure gastrointestinal bleeding (OGIB) in elderly patients.

METHODS: Clinical data for 48 elderly patients with OGIB who underwent DBE from January 2007 to March 2012 were retrospectively reviewed. Meanwhile, 106 cases of young patients were analyzed. The causes of gastrointestinal bleeding were observed by DBE.

RESULTS: The detection rate of gastrointestinal bleeding by DBE was 87.5% (42/48), and the causes of gastrointestinal bleeding were diagnosed in 83.33% (40/48) of cases. Common causes of OGIB in elderly people included small intestinal ulcer, vascular dilatation, small intestinal carcinoma, interstitialoma, mucosal inflammatory changes, small intestinal diverticulum, Crohn's disease, polyps, and melanoma metastasis to small bowel. No significant difference was found in types of diseases between elderly and young patients (P > 0.05).

CONCLUSION: DBE has high diagnostic value in the detection of OGIB in elderly patients. Common reasons for OGIB include small intestinal ulcer, vascular dilatation, small intestinal carcinoma and interstitialoma. There is no significant difference in types of diseases between elderly and young patients.

Endoscopic techniques for small bowel imaging

Advances in small bowel enteroscopy have led to an increase in the endoscopic evaluation and management of small bowel disorders. The entire small bowel can now be visualized in a noninvasive manner by capsule endoscopy, while therapeutic management can be performed with deep enteroscopy techniques, including balloon-assisted and spiral enteroscopy. Each of these enteroscopy tools has its unique advantages and disadvantages, which need to be taken into consideration during selection of the appropriate tool. Capsule endoscopy and deep enteroscopy are often used as complementary tests in the evaluation of small bowel disorders.

MiroCam capsule for obscure gastrointestinal bleeding: a prospective, single centre experience

BACKGROUND

Capsule endoscopy is an established tool for the evaluation of obscure gastrointestinal bleeding but published literature is mostly limited to PillCam SB (Given Imaging, Israel).

AIMS

The aims of this study were to determine the findings, the diagnostic yield and the rebleeding rate in a series of patients with overt or occult obscure gastrointestinal bleeding studied with MiroCam(Intromedic, Seoul, Korea) capsule endoscopy.

METHODS

Data of 118 patients who underwent capsule endoscopy for overt or occult obscure gastrointestinal bleeding were prospectively collected between March 2009 and March 2011.

RESULTS

Evaluation of the entire small bowel (completion rate) was achieved in 96% of cases. Relevant lesions occurred in 58% of patients. Angiodysplasias was the most common finding. Six patients (9% of the positive findings) had a non-small-bowel lesion detected by capsule. The yield of capsule endoscopy in the overt group was greater than in the occult group but without achieving a significant difference (61% vs. 54%, p>0.05). Rebleeding rate was lower in patients with a negative examination (6%) than in patients with a positive one (17%) (p=0.03). Capsule retention was registered in 3 of 118 patients (2.5%).

CONCLUSIONS

MiroCam capsule endoscopy is a safe and effective tool for exploring small bowel with a high completion rate.

CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis

The objective of this article is to provide a comprehensive and update overview of clinical application of CT enterography (CTE) in the evaluation of obscure gastrointestinal bleeding (OGIB). We performed a systematic review of relevant literatures in PubMed, EMBASE and The Cochrane Library and pooled the yield of CTE and the incremental yield (IY) of CTE over an alternate modality. A total of 18 studies (n = 660) reported the yield of CTE in evaluating OGIB and the pooled yield was 40% (95% confidence interval (CI): 33-49%). Seven studies (n = 279) compared the yield of CTE with capsule endoscopy (CE). The yield for CTE and CE for all findings was 34% and 53%, respectively (IY = -19%, 95% CI = -34% to -4%). When considering the types of identified lesions, the yield was significantly different for vascular and inflammatory lesions but not significantly different for neoplastic or other lesions. Two studies (n = 63) compared the yield of CTE with double-balloon enteroscopy (DBE). The yield for CTE and DBE was 38% and 78%, respectively (IY = -40%, 95% CI = -55% to -25%). Three studies (n = 49) compared the yield of CTE with digital subtraction angiography. The yield for CTE and digital subtraction angiography was 64% and 60%, respectively (IY = 4%, 95% CI = -40% to 47%). CTE is an excellent diagnostic tool in patients with OGIB. It may play a complementary role to CE and can be used as a triage tool prior to DBE in evaluating OGIB.

Small-bowel endoscopy core curriculum

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.

Can we improve the detection rate and interobserver agreement in capsule endoscopy?

BACKGROUND

Data about strategies for improving the diagnostic ability of capsule endoscopy readers are lacking.

AIM

(1) To evaluate the detection rate and the interobserver agreement among readers with different experience; (2) to verify the impact of a specific training (hands-on training plus expert tutorial) on these parameters.

METHODS

17 readers reviewed 12 videos twice; between the two readings they underwent the training. The identified small bowel findings were described by a simplified version of Structured Terminology and classifies as clinically significant/non-significant. Findings identified by the readers were compared with those identified by three experts (Reference Standard).

RESULTS

The Reference Standard identified 26 clinically significant findings. The mean detection rate of overall readers for significant findings was low (about 50%) and did not change after the training (46.2% and 46.4%, respectively). There was no difference in the detection rate among readers with different experience. The interobserver agreement with the Reference Standard in describing significant findings was moderate (k = 0.44; CI95%: 0.39-0.50) and did not change after the training (k = 0.44; CI95%: 0.38-0.49) or stratifying readers according to their experience.

CONCLUSIONS

Both the interobserver agreement and the detection rate of significant findings are low, regardless of the readers' experience. Our training did not significantly increase the performance of readers with different experience.

Factors associated with positive findings from capsule endoscopy in patients with obscure gastrointestinal bleeding

BACKGROUND & AIMS

Capsule endoscopy (CE) is used most frequently to identify causes of obscure gastrointestinal bleeding (OGIB). Identifying factors associated with the detection of lesions by CE could improve resource utilization and thereby improve patient selection for CE examination. We sought to identify clinical factors associated with positive findings from CE in patients with OGIB.

METHODS

We analyzed data from 698 CE procedures performed between December 2001 and April 2011 at St Paul's Hospital, Vancouver, Canada (50.3% of patients were female; mean age, 63.4 years). A positive finding was defined as a lesion that was believed to be the source of the bleeding (ulceration, mass lesion, vascular lesion, or visible blood). Univariate and multivariate logistic regression analyses were used to correlate demographic and clinical parameters with positive findings.

RESULTS

A lesion believed to be the cause of bleeding was identified in 42% of cases. In univariate analysis, the number of esophagogastroduodenoscopies (EGDs), the presence of connective tissue disease or diabetes with end-organ damage, Charlson comorbidity index scores, and increasing transfusion requirements were significantly associated with identification of causative pathology from CE (all P < .027). In multivariate analysis, increasing number of EGDs (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.00-1.37), increasing transfusion requirements (3-9 units: OR, 1.70; 95% CI, 1.08-2.66, and ≥10 units: OR, 2.72; 95% CI, 1.69-4.37), and connective tissue disease (OR, 2.24; 95% CI, 1.14-4.41) were all significantly associated with identification of positive findings by using CE (all P < .045).

CONCLUSIONS

Patients with a higher number of precapsule EGDs or transfusions, or connective tissue disease, are superior candidates for analysis of OGIB by CE.

Prospective evaluation of the long-term outcomes after deep small-bowel spiral enteroscopy in patients with obscure GI bleeding

BACKGROUND

Spiral enteroscopy can be safe and effective in the short term for evaluation of obscure GI bleeding, but long-term data are lacking.

OBJECTIVE

To assess the long-term clinical outcomes after deep small-bowel spiral enteroscopy performed for obscure GI bleeding.

DESIGN

Prospective cohort study.

SETTING

Academic referral center.

PATIENTS

This study included 78 patients who underwent antegrade spiral enteroscopy for evaluation of obscure GI bleeding.

INTERVENTION

Diagnostic spiral enteroscopy with hemostatic therapeutic maneuvers applied as indicated.

MAIN OUTCOME MEASUREMENTS

Postprocedure evidence of recurrent overt GI bleeding, blood transfusion requirements, need for iron supplementation, serum hemoglobin values, and the need for additional therapeutic procedures.

RESULTS

Long-term follow-up data (mean [± standard deviation] 25.3 ± 7.5 months; range 12.9-38.8 months) were obtained in 61 patients (78%). Among those with long-term follow-up data, overt bleeding before spiral enteroscopy was present in 62%, compared with 26% in the follow-up period (P < .0001). The mean (± SD) hemoglobin value increased from 10.6 ± 1.8 to 12.6 ± 1.9 g/dL (P < .0001). Blood transfusion requirements decreased by a mean of 4.19 units per patient (P = .0002), and the need for iron supplementation (P = .0487) and additional procedures (P < .0001) decreased in the follow-up period. There were 8 adverse events (9%) (7 mild, 1 moderate).

LIMITATIONS

Single-center study, intervention bias.

CONCLUSION

In patients with obscure GI bleeding, deep small-bowel spiral enteroscopy is safe and effective in reducing the incidence of overt bleeding. An increase in hemoglobin values along with a decrease in blood transfusion requirement, need for iron supplementation, and need for additional therapeutic procedures were found over long-term follow-up. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00861263.).

Prevalence and resolution of anemia with paraesophageal hernia repair

BACKGROUND

Paraesophageal hernias may produce a variety of clinical sequelae including anemia and esophagogastric ulcerations or erosions. We examined the prevalence of anemia in patients with paraesophageal hernias and frequency of anemia resolution with hernia repair.

METHODS

Patients undergoing paraesophageal hernia repairs from July 1996 to September 2010 were included. Data gathered included age, gender, type of hernia, presence of symptomatic anemia, presence of esophagogastric ulcer/erosion, type of repair, and anemia resolution.

RESULTS

One hundred eighty-three patients underwent paraesophageal hernia repair; of these, 68 (37%) were anemic. Of these anemic patients, 39 (57%) were symptomatic from their anemia or specifically referred for anemia, and 20 (29%) had esophagogastric ulceration/erosion. Fifty-eight had documented follow-up. Overall, of these, 35 (60%) had resolution of their anemia. Seventy percent of symptomatic patients had resolution of their anemia, compared to 48% of asymptomatic patients (p = 0.1). Of patients with esophagogastric ulceration/erosion, 85% were symptomatic and 88% had resolution of anemia, compared to 50% of patients without ulceration/erosion (p = 0.015).

CONCLUSIONS

Anemia was a common finding in patients with paraesophageal hernia and most patients were symptomatic because of their anemia. Those patients with esophageal or gastric ulceration/erosion were very likely to have symptomatic anemia, and, interestingly, these patients were more likely to have their anemia resolve with paraesophageal hernia repair.

An unusual endoscopic image of a submucosal angiodysplasia

Obscure gastrointestinal bleeding is responsible for 2-10% of the cases of digestive bleeding. Angiodysplasia is the most common cause. The authors report a case of a 70-year-old female patient admitted to our Gastrointestinal Intensive Care Unit with a significant digestive bleeding. Standard upper and lower endoscopy showed no abnormalities, and we decided to perform a capsule enteroscopy that revealed a submucosal nodule with active bleeding in the jejunum. An intraoperative enteroscopy confirmed the presence of a small submucosal lesion with a central ulceration, and subsequently a segmental enterectomy was performed. Surprisingly, the histopathological diagnosis was angiodysplasia. The patient remains well after a two-year period of follow-up. We present this case of obscure/overt gastrointestinal bleeding to emphasize the role of capsule and intraoperative enteroscopy in the evaluation of these situations, and because of the unusual endoscopic appearance of the angiodysplasia responsible for the hemorrhage.

Double-balloon endoscopy in clinical practice: where are we now?

Double-balloon endoscopy (DBE) was developed in 2000 for the diagnosis and treatment of small bowel diseases. Although use rates still differ between Eastern and Western countries, DBE quickly reached a broad global diffusion. Together with capsule endoscopy (CE), DBE represented 'a revolution' for the management of small bowel diseases because of its therapeutic capabilities. At present, the main indications for DBE in clinical practice are obscure gastrointestinal bleeding, Crohn's disease and familial polyposis. In the setting of obscure gastrointestinal bleeding, DBE seems to have similar diagnostic performances as capsule endoscopy, but it allows for a more definitive diagnosis and the treatment of identified lesions. The main contribution of DBE in the management of Crohn's disease patients is its therapeutic capabilities. Indeed, several recently published studies have suggested that endoscopic dilation of small bowel strictures can delay or, in the near future, could even replace surgical interventions. Also, for patients with familial polyposis syndromes, DBE can represent a viable alternative to small bowel surgery. The complication rate of DBE appears to be low; major complications, such as pancreatitis, bleeding and perforation, have been reported in approximately 1% of all diagnostic DBE whereas the complication rate for therapeutic procedures is about 5%.

Video capsule endoscopy for previous overt obscure gastrointestinal bleeding in patients using anti-thrombotic drugs

BACKGROUND AND AIM

Little is known about the causes of overt obscure gastrointestinal bleeding (OGIB) in patients using anti-thrombotic therapy. We aimed to describe video capsule endoscopy (VCE) findings and to identify factors associated with positive findings in these patients.

METHODS

We carried out a retrospective study of 56 patients who underwent VCE for evaluation of previous overt OGIB during anti-thrombotic therapy. VCE studies were re-evaluated by a gastroenterologist blinded to clinical details. Clinical data included in the multivariate analysis were sex, age, indication for and type of anti-thrombotic therapy, hemodynamic instability on admission, type of blood loss, hemoglobin on admission, use of a proton pump inhibitor, NSAID use, time between bleeding episodes and VCE, and whether or not anti-thrombotic therapy was resumed before the VCE study.

RESULTS

A probable cause for gastrointestinal bleeding was identified in 28 (50%) of the 56 studies. Angiodysplasia was found in 19 patients. Twenty-two studies showed a possible cause in the small bowel. Multivariate logistic regression analysis showed that reinstitution of anti-thrombotic therapy before VCE was carried out was the only independent predictor of positive VCE findings (OR: 8.61, 95% CI: 1.20-60.42, P=0.032).

CONCLUSIONS

Small intestinal angiodysplasia was the most common cause for overt OGIB. Reinstitution of withdrawn anti-thrombotic drugs before the VCE examination was carried out was associated with positive VCE findings in multivariate analysis.

Clinical impact of multidetector computed tomography before double-balloon enteroscopy for obscure gastrointestinal bleeding

AIM: To evaluate the clinical impact of multidetector computed tomography (MDCT) before double-balloon endoscopy (DBE) for patients with obscure gastrointestinal bleeding (OGIB).

METHODS: A retrospective analysis of prospectively collected cases with DBE and MDCT for overt OGIB was conducted from April 2004 to April 2010 at Changhua Christian Hospital. We evaluated the clinical impact of MDCT on the subsequent DBE examinations and the diagnostic yields of both MDCT and DBE respectively.

RESULTS: From April 2004 to April 2010, a total of 75 patients underwent DBE for overt OGIB. Thirty one cases received MDCT followed by DBE for OGIB. The overall diagnostic yields of DBE and MDCT was 93.5% and 45.2%. The MDCT had a high diagnostic yield of tumor vs non-tumor etiology of OGIB (85.7% vs 33.3%, P = 0.014). Additionally, the choice of initial route of DBE was correct in those with a positive MDCT vs negative MDCT (100% vs 52.9%, P = 0.003).

CONCLUSION: This study suggests MDCT as a triage tool may identify patients who will benefit from DBE and aid the endoscopist in choosing the most efficient route.

Resistance to erythropoietin-stimulating agents: etiology, evaluation, and therapeutic considerations

Routine clinical and laboratory assessments facilitate diagnosis of erythropoietin (EPO) resistant anemia by allowing early identification of patients with non-adherence. Any new event that impairs response to EPO (e.g., catheter sepsis) must be promptly controlled. Because of the confounding interaction of its risk factors, initial evaluation should include nutrition, dialysis adequacy, hemorrhage, bone mineral metabolism, and inflammation. Prevention of EPO resistance is more cost effective and should include adequate dialysis and nutritional supplements. Blood loss during hemodialysis (HD) procedures should be minimized. If there is laboratory proof of iron deficit intravenous repletion is most effective. Oxidative stress may be attenuated by vitamins E and C, while optimal control of hyperparathyroidism will enhance EPO stimulation. Contaminated dialysates should be suspected if there is EPO-stimulating agents (ESA) resistance at the same time among most members of a dialysis program. Heavy metal toxicity should be suspected in high-risk patients. The impact of co-morbidities such as hemoglobinopathy, glucose 6 phosphate dehydrogenase (G6PD) deficiency and connective tissue diseases must be excluded in an appropriate setting. In conclusion, given the multiple risk factors of EPO resistance promotion of the overall health status will most likely yield an enduring benefit. Finally, there are experimental trials of gene-based (therapy) to stimulate endogenous EPO synthesis with the goal of avoiding the off-target effect of excessive dosing.

Long-term outcome of patients treated with double balloon enteroscopy for small bowel vascular lesions

OBJECTIVES

Early rebleeding rate after endoscopic therapy with double balloon enteroscopy (DBE) of hemorrhagic small bowel vascular lesions (SBVL) varies between 10 and 50%. In recent reports, long-term follow-up of patients have been described but rebleeding risk factors are still not well established. The aim of the current study was to identify long-term treatment success rate and rebleeding risk factors after DBE therapy in a large cohort.

METHODS

We conducted a single-center, retrospective cohort study in a large French tertiary-referral center between January 2004 and December 2007.

RESULTS

Among 261 patients presenting with obscure gastrointestinal bleeding (OGIB), SBVL was present in 133 patients and was treated successfully in 129 (97%) using mainly argon plasma coagulation. Ninety-eight patients were followed up for a mean period of 22.6±13.9 months (range 1-52). Rebleeding rate was 46% (45/98 patients) at 36 months. On multivariate analysis, the total number of observed lesions (hazard ratio (HR): 1.15, 95% confidence interval (CI): 1.06-1.25, P=0.001) and the presence of a valvular and/or arrhythmic cardiac disease (HR: 2.50, 95% CI: 1.29-4.87, P=0.007) were significantly associated with the risk of rebleeding. Complication rate of therapeutic DBE was 2.3% with no mortality.

CONCLUSIONS

Endoscopic therapy using DBE for SBVL in patients with recurrent OGIB allows a long-term remission in more than half of the patients. Independent rebleeding risk factors after a first endoscopic therapy are an increased number of SBVL and an associated valvular/arrhythmic heart disease.

Assessment of Crohn's disease lesions in wireless capsule endoscopy images

Capsule endoscopy (CE) provides noninvasive access to a large part of the small bowel that is otherwise inaccessible without invasive and traumatic treatment. However, it also produces large amounts of data (approximately 50,000 images) that must be then manually reviewed by a clinician. Such large datasets provide an opportunity for application of image analysis and supervised learning methods. Automated analysis of CE images has only focused on detection, and often only for bleeding. Compared to these detection approaches, we explored assessment of discrete disease for lesions created by mucosal inflammation in Crohn's disease (CD). Our work is the first study to systematically explore supervised classification for CD lesions, a classifier cascade to classify discrete lesions, as well as quantitative assessment of lesion severity. We used a well-developed database of 47 studies for evaluation of these methods. The developed methods show high agreement with ground truth severity ratings manually assigned by an expert, and good precision ( > 90% for lesion detection) and recall ( > 90%) for lesions of varying severity.

Value of fecal occult blood test as a screening test before capsule endoscopy

BACKGROUND

The primary aim was to assess the value of immunochemical and guaiac fecal occult blood test (FOBT) as a screening test before capsule endoscopy (CE) in the setting of obscure gastrointestinal bleeding (OGIB).

METHODS

A prospective study from the St Vincent's Hospital, a tertiary referral hospital in Melbourne, Australia. Sixty-eight patients referred for CE to investigate OGIB underwent two immunochemical/guaiac FOBTs within 2 weeks preceding CE. The correlation between a positive FOBT before CE and clinically significant findings (CSFs) on CE was assessed.

RESULTS

Thirty of 68 (44%) patients with OGIB had significant findings on CE. The accuracy of a combined immunochemical and guaiac FOBT for predicting clinically significant findings on CE was 62% [95% confidence interval (CI): 0.50-0.72]. The sensitivity and specificity were low at 63% (95% CI: 0.50-0.75) and 61% (95% CI: 0.50-0.70), respectively.

CONCLUSION

FOBT has low accuracy as a screening test before CE and thus cannot be recommended for this purpose.

Diagnosis and management of mid-gastrointestinal bleeding by double-balloon endoscopy

The new methods of capsule endoscopy (CE) and double-balloon endoscopy (DBE) have revolutionized the diagnostic approach to middle (mid) gastrointestinal bleeding (MGIB) in recent years. DBE also has therapeutic options and enables us to treat the MGIB endoscopically. In this review, we discuss endoscopic diagnosis and management of three major categories of sources of MGIB - vascular lesions, ulcers/erosions and tumors/polyps.

Do clinical characteristics predict the presence of small bowel angioectasias on capsule endoscopy?

BACKGROUND AND AIMS

Angioectasias (AVMs) are the most common vascular anomaly of the gastrointestinal (GI) tract, and these lesions are often associated with obscure gastrointestinal bleeding (OGIB). It is unknown if the presence of upper and/or lower gastrointestinal AVMs are predictive of small bowel AVMs. The aims of this study are to define the small bowel segmental distribution of AVMs and to identify the factors predicting the presence of small bowel AVMs among a cohort of patients with a known history of AVMs in the upper and/or lower GI tracts who are undergoing capsule endoscopy (CE) for OGIB.

METHODS

We performed a retrospective cohort analysis of 1,125 patients undergoing CE at our institution between 11/1/2001 and 8/31/2007. Inclusion criteria were: (1) complete esophagoduodenoscopy (EGD), CE, and colonoscopy, (2) OGIB indication for CE, and (3) history of ≥ 1 AVM on EGD and/or colonoscopy that was previously treated in the past or deemed not to be a clinically significant source of bleeding. Exclusion criteria were: (1) history of radiation therapy to the GI tract, and (2) presence of a congenital or systemic disease associated with GI AVMs. Data were extracted on: (1) age; (2) gender; (3) presence of diabetes, (4) presence of hypertension, (5) presence of aortic stenosis, (6) history of non-steroidal anti-inflammatory therapy, (7) history of anticoagulant therapy, (8) hemoglobin, platelet, and INR values prior to CE; (9) baseline serum creatinine; and (10) presence and GI tract segmental location of AVMs. Multivariate logistic regression was used to identify independent predictors of small bowel AVMs.

RESULTS

1,125 patients underwent EGD, CE, and colonoscopy. One hundred and fourteen patients had a history of ≥ 1 AVM on EGD and/or colonoscopy and met inclusion and exclusion criteria. The mean age was 69 years, and 63% of patients were women. 37% of patients were found to have ≥ 1 jejunal AVM and 15% were found to have ≥ 1 ileal AVM. In multivariate analysis, age ≥ 65 (OR 2.62, P = 0.05) and the presence of AVMs on EGD (OR 4.61, P = 0.02) were predictive of jejunal AVMs. AVMs on colonoscopy alone were not predictive of jejunal or ileal AVMs. No factors were found to predict the presence of ileal AVMs.

CONCLUSIONS

Patients with AVMs on EGD have an increased risk of jejunal AVMs on CE, particularly if they are elderly. Future studies should validate these findings in a prospective cohort.

Esophago-gastro-duodenoscopy is not indicated in patients with positive immunochemical test and nonexplanatory colonoscopy

OBJECTIVES

Patients with positive fecal occult blood test and unrevealing colonoscopy are often advised to undergo esophago-gastro-duodenoscopy (EGD) to exclude a bleeding source in the upper gastrointestinal tract. In this study, we evaluated EGD findings in patients with positive immunochemical fecal occult blood test (I-FOBT) not explained by colonoscopy.

METHODS

Out of 1221 consecutive patients having total colonoscopy after preparing I-FOBT (OC-MICRO, with threshold of 75 or 100 ngHb/ml), we included only patients without colorectal cancer or advanced adenomatous polyp on colonoscopy, who also underwent EGD within 4 months of the fecal blood testing. Findings on EGD were classified as those lesions which are likely or unlikely to bleed.

RESULTS

EGD was performed in 160 patients after a negative colonoscopy. The procedure was performed 1.6 ± 1.4 months after the I-FOBT. Lesion with a bleeding potential was found in 24 patients (15%). In three (12.5%) and two (8.3%) of these patients I-FOBT was positive at the 75 and 100 ngHb/ml threshold, respectively. In 136 patients EGD was normal, and I-FOBT was similarly positive in 16 (11.7%) and 13 patients (9.5%), respectively. The mean fecal hemoglobin was also similar between the groups.

CONCLUSION

Immunological FOBT positivity was not correlated with the finding of lesions, which are likely to bleed on EGD. Thus, EGD is probably not indicated in patients with positive I-FOBT and unrevealing colonoscopy.

Small bowel capsule endoscopy in clinical practice: a multicenter 7-year survey

BACKGROUND AND AIM

Data about small bowel capsule endoscopy (SBCE) come from studies involving small and highly selected populations. The study aim was to describe extent of use, indications, results, complications, and practical issues of SBCE in clinical practice in a Northern Italian Region (Lombardia).

MATERIALS AND METHODS

Twenty-three out of 29 invited centers fulfilled a specific questionnaire.

RESULTS

Between 2001 and 2008, 2921 procedures were performed and both the number of centers performing SBCE (from 5 to 29) and the number of SBCE (from 7.2 to 69.2 per month) increased steadily. The main indications for SBCE were: obscure gastrointestinal bleeding (OGIB) (43.4%), unexplained anemia (23.9%), suspected Crohn's disease (7.8%) and abdominal pain (5.3%). Overall, SBCE was positive in 50% of cases, negative in 36% and undefined in 14%. The highest diagnostic yields were observed in patients with OGIB (62.5%), polypoid syndromes (74.1%), known (54.8%) or suspected (47.3%) inflammatory bowel disease, while the yields were low in patients examined for chronic diarrhea (27.4%) and abdominal pain (14.9%), 61 patients (2.1%) experienced capsule retention. Thirty-two of them eventually excreted the capsule naturally while endoscopic or surgical retrieval was necessary in 29 (1%) (in two because of obstruction).

CONCLUSION

Over a period of 7 years the use of SBCE in Lombardia increased steadily confirming, in clinical practice, a high diagnostic yield and an acceptable safety profile.

Cost estimation of small bowel capsule endoscopy based on "real world" data: inpatient or outpatient procedure?

BACKGROUND

Although capsule endoscopy is the cornerstone for the evaluation of the small bowel in patients with obscure GI bleeding data about costs are lacking.

AIM

To evaluate, from a third party payer point of view, whether performing capsule endoscopy as an outpatient instead of an inpatient procedure can reduce costs.

MATERIALS AND METHODS

The data source is a multicentre survey collecting data for 2921 patients; 1486 of them underwent capsule endoscopy for obscure GI bleeding or chronic unexplained iron-deficiency anaemia as inpatients (814 with positive, 211 with inconclusive and 461 with negative result). We estimated costs of inpatient procedures based on the diagnosis related groups (DRG) system, while those of outpatient procedures on reimbursement provided in five Italian regions.

RESULTS

We estimated that the cost for each inpatient undergoing capsule endoscopy is about € 1775.90. Assuming that all these patients had undergone the same procedure as outpatients, € 175.00-741.00 per patient (depending on the reimbursement and/or on diagnosis related group codes applied) would have been saved.

CONCLUSIONS

Our estimate suggests that, from the third party payer's perspective and using the diagnosis related group reimbursement system, shifting capsule endoscopy from inpatient to outpatient procedure, would be potentially cost saving at least for patients referred for obscure GI bleeding or chronic unexplained anaemia.

Diagnostic yield of repeat capsule endoscopy and the effect on subsequent patient management

BACKGROUND

Capsule endoscopy (CE) has been shown to produce a high diagnostic yield in patients with obscure gastrointestinal bleeding (OGIB); however, in those with negative studies, management is controversial. Very few studies have reported on repeat CE in the same patient; data regarding this diagnostic strategy are limited.

OBJECTIVE

To determine the diagnostic yield of repeated CE studies and how this yield affects subsequent patient management.

METHODS

A retrospective chart review of all patients who underwent CE at St Paul's Hospital (Vancouver, British Columbia) between December 2001 and June 2009 was conducted. Patients who underwent subsequent repeat CE were identified and divided into one of four subgroups. Findings were classified as positive or negative.

RESULTS

Eighty-two of 676 patients underwent more than one CE study. Group 1 (incomplete study) included 22 patients (27%) and yielded 10 positive findings (45%). Group 2 (screening) comprised four patients (5%) and yielded two positive findings (50%). Group 3 (ongoing symptoms despite previous negative study) totalled 26 patients (32%) and yielded 10 positive findings (38%). Group 4 (previous positive study with treatment/investigation) included 30 patients (37%) and yielded 23 positive findings (77%). Overall, the present study found positive findings in 55% (45 of 82) of repeated CE cases, which resulted in a change in management in 39% (n=32) of the patients.

CONCLUSION

Due to the high diagnostic yield and noninvasive nature of CE, repeat CE appears to be of benefit and should be considered for specific patients before other types of small bowel studies.

Diagnosis and treatment of small bowel diseases are advanced by capsule endoscopy and double-balloon enteroscopy

In 2001, new endoscopic procedures for the small bowel, capsule endoscopy (CE) and double-balloon enteroscopy (DBE), were introduced into regular clinical practice. These methods were significant breakthroughs for imaging examination of the small bowel. The methods have different characteristics with regard to their approach into the target organ; however, common to both is the feature of enabling rapid total observation of the small bowel. CE is the first safe, non-invasive well-tolerated procedure and can be performed in any condition. The examination time is about 8 h and the patient can spend the time freely. CE can demonstrate active bleeding or neoplasm in the small bowel, which other modalities cannot detect. DBE, which was developed by Yamamoto, employs two balloons combined with an overtube and allows deeper insertion into the small bowel, and can be a modality for examination of the entire small bowel with combined oral and anal approaches. This modality enables biopsy specimens to be taken, polyps to be resected and hemostatic procedures to be performed throughout the small bowel. The understanding of small bowel disease is being extended by using CE and DBE for diagnosis. CE is considered to be superior for the first examination of the small bowel and DBE is useful for detailed examination and endoscopic therapy. Further clinical study of unknown small bowel disorders using these two modalities and algorithms for the management of small bowel disorders are required.

Metastatic colorectal cancer to the small bowel-an uncommon cause of obscure GI bleeding: a three-case experience with review of the literature

PURPOSE

Metastatic colorectal cancer to the small intestine is a rare condition presenting with nonspecific symptoms such as obscure gastrointestinal bleeding (OGIB). We report our experience with the use of capsule endoscopy (CE) and double-balloon enteroscopy (DBE) to identify and diagnose the metastatic colorectal cancer to the small bowel. The aim was to demonstrate the approach to the diagnosis of metastatic colorectal cancer to the small bowel including literature review.

METHODS

This is a retrospective case series from an academic tertiary referral center. Three patients with a history of colorectal cancer referred for OGIB underwent CE and subsequent DBE.

RESULTS

All patients underwent evaluation including esophagogastroduodenoscopy and colonoscopy prior to referral. In each case, CE was performed revealing the source of bleeding which was confirmed as metastatic colorectal cancer to the small bowel by DBE. Significant lag time was noted from the initial diagnosis of colorectal cancer to the onset of symptomatic small bowel metastasis in this series (1.3-7 years).

CONCLUSIONS

We found the incidence of metastatic colorectal cancer to the small intestine of those with small intestine tumors to be 6%. Clinicians should be suspicious of this condition in any patient with OGIB and prior history of colorectal cancer. The approach to this diagnosis is varied but one algorithm includes the combined use of CE for tumor localization and balloon-assisted enteroscopy for confirmation.

Obscure gastrointestinal bleeding: preliminary comparison of 64-section CT enteroclysis with video capsule endoscopy

OBJECTIVE

To retrospectively compare the diagnostic capabilities of 64-section CT enteroclysis with those of video capsule endoscopy (VCE) to elucidate the cause of obscure gastrointestinal bleeding.

METHODS

Thirty-two patients who had 64-section CT enteroclysis and VCE because of obscure gastrointestinal bleeding were included. Imaging findings were compared with those obtained at double balloon endoscopy, surgery and histopathological analysis, which were used as a standard of reference.

RESULTS

Concordant findings were found in 22 patients (22/32; 69%), including normal findings (n=13), tumours (n=7), lymphangiectasia (n=1) and inflammation (n=1), and discrepancies in 10 patients (10/32; 31%), including ulcers (n=3), angioectasias (n=2), tumours (n=2) and normal findings (n=3). No statistical difference in the proportions of abnormal findings between 64-section CT enteroclysis (11/32; 34%) and VCE (17/32, 53%) (P=0.207) was found. However, 64-section CT enteroclysis helped identify tumours not detected at VCE (n=2) and definitely excluded suspected tumours (n=3) because of bulges at VCE. Conversely, VCE showed ulcers (n=3) and angioectasias (n=2) which were not visible at 64-section CT enteroclysis.

CONCLUSION

Our results suggest that 64-section CT enteroclysis and VCE have similar overall diagnostic yields in patients with obscure gastrointestinal bleeding. However, the two techniques are complementary in this specific population.

Management of obscure gastrointestinal bleeding based on the classification of capsule endoscopic bleeding findings

BACKGROUND

Double-balloon endoscopy (DBE) and capsule endoscopy (CE) have been useful in managing obscure gastrointestinal bleeding (OGIB). However, DBE is invasive, complex and time-consuming, therefore indications should probably be selective. The aim of this study was to evaluate the usefulness of the classification of the CE bleeding findings for determining the indications and timing of DBE in patients with OGIB.

METHODS

From February 2003 to January 2009, 123 patients with OGIB who underwent CE were included in this study. These CE findings were classified based on the bleeding source. Type CE-I, II, III, IV and 0 indicate active bleeding, previous bleeding, lesions without active bleeding, a lesion outside of the small bowel, and no findings, respectively. We compared diagnostic yield and outcome between the classification and the findings of DBE or enteroclysis.

RESULTS

Comparisons of the positive findings rate with DBE or enteroclysis, the treatment rate and the rebleeding rate with the classification showed: CE-Ia, 100% (6/6), 50% (3/6), 33.3% (2/6); Ib, 66.7% (4/6), 0% (0/6), 16.7% (1/6); IIa, 33.3% (1/3), 33.3% (1/3), 33.3% (1/3); IIb, 53.8% (7/13),15.4% (2/13), 30.8% (4/13); III, 100% (84/84), 9.5% (8/84), 8.3% (7/84); IV, 100% (2/2), 50% (1/2), 0% (0/2); and 0, 0% (0/9), 0% (0/9), 0% (0/9), respectively.

CONCLUSIONS

The proportion of patients requiring treatment, the positive findings rate with DBE or enteroclysis and the rebleeding rates tended to be higher in the higher ranked classification types (CE-I>II>III>IV>0). These findings suggest that the classification can provide useful information on determining the indications and timing of DBE.

Long-acting somatostatin analogue therapy in obscure-overt gastrointestinal bleeding in noncirrhotic portal hypertension: a case report and literature review

We describe a case of obscure gastrointestinal bleeding in a male with noncirrhotic portal hypertension who required multiple admissions and repeated blood transfusions over a 5-month period. Upper and lower gastrointestinal endoscopy failed to establish a cause for bleeding which was eventually ascribed to universal portal hypertensive stigmata in stomach, small bowel and colon, which were not amenable to endoscopic therapy. On account of extensive venous thrombosis, neither surgical shunting nor interventional radiology was an option. Initial management with prothrombotic agents failed. Our patient was successfully stabilized on long-acting somatostatin (SMS) analogue therapy using lanreotide, resulting in avoidance of further admissions and blood transfusion and restoration of his independence and quality of life. The use of short-acting SMS analogues is recognised in acute variceal haemorrhage secondary to portal hypertension in cirrhosis, and long-acting SMS analogue therapy has been described in obscure gastrointestinal bleeding though secondary to angiodysplasia. However, the potential role of long-term SMS analogues in noncirrhotic portal hypertensive bleeding of this type has not been reported earlier. This case supports its use in this scenario in the absence of surgical options and when only palliative approaches are available.

Route selection for double-balloon endoscopy, based on capsule transit time, in obscure gastrointestinal bleeding

BACKGROUND

Double-balloon endoscopy (DBE) utilizes both oral and anal routes. The proper selection of the initial route is important for more rapid management of obscure gastrointestinal bleeding (OGIB). The aim of this retrospective study was to clarify the accuracy of the transit time of video capsule endoscopy (VCE) to the lesion as a predictive indicator for the decision on the initial DBE route.

METHODS

Of 172 patients who underwent both DBE and VCE, 65 who were diagnosed with small-intestinal hemorrhagic lesions by both means were enrolled. The relation between VCE transit time to the lesion and the DBE route by which the lesion was discovered was analyzed, distinguishing between 46 complete and 19 incomplete VCEs.

RESULTS

Among the 46 patients with a complete VCE, the transit time and position of the lesion were strongly correlated. The best cutoff values for route selection by the VCE transit time from capsule intake and from the duodenal bulb to the lesion, determined using a receiver operating characteristic (ROC) curve, were 60% and 50%, respectively, of the transit time to the cecum. At that point, the accuracy of route selection was 90% and 94%, respectively. Positions shown by VCE for ileal lesions tended to be more proximal than those shown by surgery. In the 19 patients with incomplete VCEs, the best cutoff for transit time was 180 min from the duodenal bulb.

CONCLUSIONS

The VCE transit time was useful for determining the route for DBE in OGIB. This parameter was most accurate when the cutoff value for the selection was half of the small-bowel transit time in the complete VCE examination.

Role of wireless capsule endoscopy in inflammatory bowel disease

Capsule endoscopy (CE) offers state-of-the-art imaging of the small bowel. In Crohn’s disease its clinical role is still uncertain. This report analyses the usefulness of CE in patients with suspected Cronh’s disease, in patients with established Crohn’s disease (when assessing severity, occult gastrointestinal bleeding and/or as a guide to therapy), in patients with inflammatory bowel disease unclassified (IBDU), and in individuals with ulcerative colitis. The first item in this group is the most important although there is no strong evidence to establish the position of CE in the diagnostic workup. In patients with established Crohn’s disease, recently developed activity scores are promising tools for an accurate assessment of severity. As a guide to therapy, CE should be focused on patients with unexplained symptoms when other investigations are inconclusive. In postoperative Crohn’s Disease, international consensus recommended considering CE only if ileocolonoscopy is contraindicated or unsuccessful. In the case of IBDU, studies have shown a significant proportion of patients reclassified with Crohn’s disease. In this setting, CE could have a role determining small bowel involvement. The role of CE in ulcerative colitis is limited. Some authors advocate CE before colectomy for refractory cases in order to exclude Crohn’s disease. In summary, CE offers a new horizon in inflammatory bowel disease, and a better knowledge of mucosal abnormalities that could offer a paradigm shift: changing from symptom-based disease activity estimation to direct mucosal healing monitoring. Nevertheless, randomized controlled studies are still needed to provide stronger evidence in this setting.

Antegrade double balloon enteroscopy for continued obscure gastrointestinal bleeding following push enteroscopy: is there a role?

BACKGROUND

The benefit of double balloon endoscopy (DBE) over push enteroscopy (PE) for the proximal small bowel in patients with obscure gastrointestinal bleeding remains unclear.

AIM

To quantify the benefit of DBE if PE fails to benefit patients with obscure gastrointestinal bleeding.

METHODS

This retrospective DBE database review between July 2004 and April 2008 was conducted at a tertiary university hospital in Australia. Thirty-three patients with obscure gastrointestinal bleeding who had undergone PE for proximal small bowel lesions were identified from a DBE database of 280 patients. Mean age was 68.6 (range 30-91) years, and 17 were men. In group A (n = 15) the target lesion was not reached by PE, and in group B (n = 18) an abnormality was found by PE (angioectasia in 17 and red spots in 1) but the patient had ongoing bleeding. Mean follow-up for the cohort was 19.2 (range 5-39) months. DBE interventions were performed as appropriate.

RESULTS

An abnormality was found at DBE in 28/33 (85%) patients. DBE found an abnormality in 12/15 (80%) in group A and 16/18 (89%) in group B. Endoscopic intervention was performed in 23/33 patients (70%). In 27/33 (82%) patients a clinical benefit was seen following DBE. Six patients (18%) had no clinical benefit from DBE.

CONCLUSIONS

In patients with obscure gastrointestinal bleeding and proximal small bowel lesions who fail to benefit from PE, DBE offers a very high benefit in finding and treating lesions with good long-term outcomes.

Negative capsule endoscopy without subsequent enteroscopy does not predict lower long-term rebleeding rates in patients with obscure GI bleeding

BACKGROUND

Capsule endoscopy (CE) is now widely accepted as a first-line diagnostic modality for obscure GI bleeding (OGIB). However, the clinical implications of negative results of CE studies remain unclear.

OBJECTIVE

To investigate long-term (>1 year) outcomes for patients undergoing CE for OGIB and to identify risk factors associated with rebleeding.

DESIGN AND SETTING

Retrospective study in a tertiary care hospital.

METHODS

A total of 57 consecutive patients who had undergone CE for OGIB were enrolled and their pre- and post-CE clinical data were collected. Specific treatments were defined as treatments directly aimed at presumed bleeding causes including hemostasis and disease-specific medical therapy, whereas nonspecific treatments were defined as symptomatic treatments for anemia.

RESULTS

Of the 57 patients, the indication for CE was obscure-overt bleeding in 46 patients and obscure-occult bleeding in 11 patients. Among 51 patients for whom long-term data were available, significant (P2) lesions were found in 23 (45.1%) patients. The overall rebleeding rate was 35.3% during a median follow-up duration of 31.7 months (range 12.8-58.0 months). There was no statistically significant difference in the cumulative rebleeding rate between patients with positive and negative CE results (34.8% vs 35.7%, respectively; P = .989). However, specific treatments after CE (hazard ratio, 0.111; 95% CI, 0.013-0.980; P = .043) significantly decreased rebleeding.

LIMITATIONS

Small number of patients, retrospective study design.

CONCLUSIONS

The rebleeding rate for patients with OGIB and negative CE results was substantial, indicating that these patients should be closely observed. However, specific treatment after CE significantly reduced the incidence of recurrent bleeding.

Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy

BACKGROUND & AIMS

It is often difficult to determine the cause of obscure gastrointestinal bleeding (OGIB). We evaluated the diagnostic yield and long-term outcome of patients with OGIB by using double-balloon endoscopy (DBE).

METHODS

In this large, retrospective cohort study, DBE was performed in 200 consecutive patients with OGIB. Follow-up data were available from 151 patients for 29.7 months (range, 6-78 months), and clinical outcome was assessed.

RESULTS

DBE detected bleeding sources in 155 of 200 patients (77.5%). The most frequent source detected was small intestine ulcers/erosions (64 patients). Patients who underwent DBE within 1 month after the last episode of overt bleeding had a better yield of positive findings than those who did not (84%, 107/128 patients vs 57%, 24/42; P = .002). The overall rate of control of OGIB was 64% (97/151 patients). Patients with vascular lesions of the small intestine had a significantly lower rate of control of OGIB than those with other small intestine lesions (40%, 12/30 patients vs 74%, 52/70; P = .001). A requirement for a large transfusion before DBE (P = .012), multiple lesions (P = .010), and suspicious (not definite) lesions (P = .038) each significantly increased the likelihood of overt rebleeding in patients with vascular lesions of the small intestine.

CONCLUSIONS

DBE is useful for the diagnosis of patients with OGIB and should be performed as soon as possible after overt OGIB. Patients with vascular lesions of the small intestine should be followed with particular care.

Single-center experience of 309 consecutive patients with obscure gastrointestinal bleeding

AIM: To investigate the diagnostic yield of capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding (OGIB), and to determine whether the yield was affected by different bleeding status.

METHODS: Three hundred and nine consecutive patients (all with recent negative gastric and colonic endoscopy results) were investigated with CE; 49 cases with massive bleeding and 260 cases with chronic recurrent overt bleeding. Data regarding OGIB were obtained by retrospective chart review and review of an internal database of CE findings.

RESULTS: Visualization of the entire small intestine was achieved in 81.88% (253/309) of cases. Clinically positive findings occurred in 53.72% (166/309) of cases. The positivity of the massive bleeding group was slightly higher than that of the chronic recurrent overt bleeding group but there was no significant difference (59.18% vs 52.69%, P > 0.05) between the two groups. Small intestinal tumors were the most common finding in the entire cohort, these accounted for 30% of clinically significant lesions. In the chronic recurrent overt bleeding group angioectasia incidence reached more than 29%, while in the massive bleeding group, small intestinal tumors were the most common finding at an incidence of over 51%. Increasing patient age was associated with positive diagnostic yield of CE and the findings of OGIB were different according to age range. Four cases were compromised due to the capsule remaining in the stomach during the entire test, and another patient underwent emergency surgery for massive bleeding. Therefore, the complication rate was 1.3%.

CONCLUSION: In this study CE was proven to be a safe, comfortable, and effective procedure, with a high rate of accuracy for diagnosing OGIB.

Capsule endoscopy in suspected small bowel Crohn's disease: economic impact of disease diagnosis and treatment

AIM

To model clinical and economic benefits of capsule endoscopy (CE) compared to ileo-colonoscopy and small bowel follow-through (SBFT) for evaluation of suspected Crohn's disease (CD).

METHODS

Using decision analytic modeling, total and yearly costs of diagnostic work-up for suspected CD were calculated, including procedure-related adverse events, hospitalizations, office visits, and medications. The model compared CE to SBFT following ileo-colonoscopy and secondarily compared CE to SBFT for initial evaluation.

RESULTS

Aggregate charges for newly diagnosed, medically managed patients are approximately $8295. Patients requiring aggressive medical management costs are $29,508; requiring hospitalization, $49,074. At sensitivity > 98.7% and specificity of > 86.4%, CE is less costly than SBFT.

CONCLUSION

Costs of CE for diagnostic evaluation of suspected CD is comparable to SBFT and may be used immediately following ileo-colonoscopy.

Preliminary estimate of triphasic CT enterography performance in hemodynamically stable patients with suspected gastrointestinal bleeding

OBJECTIVE

The objective of our study was to retrospectively evaluate the performance of triphasic CT enterography and identify causes of false-negative CT results in hemodynamically stable patients with suspected gastrointestinal bleeding.

MATERIALS AND METHODS

A retrospective review of 48 patients (male-female ratio, 22:26) with suspected gastrointestinal bleeding (first-episode gastrointestinal bleed, n = 19; obscure gastrointestinal bleed, n = 29) who underwent triphasic CT enterography was performed. All patients had endoscopic, pathologic, or other imaging confirmation within 3 months of triphasic CT enterography. The sensitivity and specificity of triphasic CT enterography were calculated using pathology, endoscopy, or other imaging confirmation as the reference standard. Results were retrospectively reviewed to determine the cause of missed findings at triphasic CT enterography.

RESULTS

The overall sensitivity and specificity of triphasic CT enterography for detecting gastrointestinal bleeding was 33% (7/21) and 89% (24/27), respectively. Sensitivity and specificity were higher in first-episode gastrointestinal bleed cases (42% and 100%, respectively) than in obscure gastrointestinal bleed cases (22% and 85%). In the subset of patients undergoing capsule endoscopy (n = 17), only triphasic CT enterography identified two of three bleeding sources. Triphasic CT enterography did not identify six ulcers, four vascular malformations, two hemorrhoids, a duodenal mass, and a bleeding colonic diverticulum. The missed findings at triphasic CT enterography were attributed to being CT occult (n = 9), perception errors (n = 4), and technical errors (n = 1). If perception errors are excluded, the sensitivity of triphasic CT enterography increases to 52% (11/21).

CONCLUSION

Triphasic CT enterography can be a useful and complementary test in the evaluation of clinically stable patients with suspected gastrointestinal bleeding by identifying the bleeding source in one third to one half of patients. Because of the potential for perception errors, radiologists should familiarize themselves with the appearance of bleeding sources at CT enterography.

Recurrent obscure gastrointestinal bleeding: dilemmas and success with pharmacological therapies. Case series and review

The present article describes three difficult cases of recurrent bleeding from obscure causes, followed by a review of the pitfalls and pharmacological management of obscure gastrointestinal bleeding. All three patients underwent multiple investigations. An intervening complicating diagnosis or antiplatelet drugs may have compounded longterm bleeding in two of the cases. A bleeding angiodysplasia was confirmed in one case but was aggravated by the need for anticoagulation. After multiple transfusions and several attempts at endoscopic management in some cases, long-acting octreotide was associated with decreased transfusion requirements and increased hemoglobin levels in all three cases, although other factors may have contributed in some. In the third case, however, the addition of low-dose thalidomide stopped bleeding for a period of at least 23 months.

Occult and obscure gastrointestinal bleeding: Causes and diagnostic approach in 2009

Gastrointestinal bleeding can be obscure or occult (OGIB), the causes and diagnostic approach will be discussed in this editorial. The evaluation of OGIB consists on a judicious search of the cause of bleeding, which should be guided by the clinical history and physical findings. The standard approach to patients with OGIB is to directly evaluate the gastrointestinal tract by endoscopy, abdominal computed tomography, angiography, radionuclide scanning, capsule endoscopy. The source of OGIB can be identified in 85%-90%, no bleeding sites will be found in about 5%-10% of cases. Even if the bleedings originating from the small bowel are not frequent in clinical practice (7.6% of all digestive haemorrhages, in our casuistry), they are notoriously difficult to diagnose. In spite of progress, however, a number of OGIB still remain problematic to deal with at present in the clinical context due to both the difficulty in exactly identifying the site and nature of the underlying source and the difficulty in applying affective and durable diagnostic approaches so no single technique has emerged as the most efficient way to evaluate OGIB.

Evaluation of iron deficiency anemia in older adults: the role of wireless capsule endoscopy

INTRODUCTION

Anemia although a frequent problem in all age groups, is an important cause of morbidity and mortality in the elderly. Despite standard endoscopic diagnostic evaluations with esophagogastroduodenoscopy (EGD) and colonoscopy, up to 30% of patients with iron deficiency anemia (IDA) are without a definitive diagnosis. Obscure gastrointestinal bleeding (OGIB) (occult or overt) from the small bowel, could be the source of IDA in patients with normal EGD and colonoscopy. Wireless capsule endoscopy (WCE), a relatively new diagnostic modality helps in the detection of small bowel mucosal abnormalities.

AIM

The aim of this study is to report on the diagnostic yield (DY) of WCE for IDA with or without OGIB in older adults and its comparison with younger age groups.

MATERIALS AND METHODS

In this retrospective study, data is based on652 consecutive WCE performed during a 5-year period (2002 to 2007).

RESULTS

Total number ofWCE=652 (males=311, females=341). IDA was the indication for WCE in 424 of 652 cases (65%). Most common finding observed by WCE in patients with IDA without OGIB: group 1 (age<50 y)=small bowel erosion (19%) and ulceration (19%), group 2 (age 50 to 64 y)=small bowel erosion (33%), group 3 (age 65 to 85 y, older adults)=small bowel erosion (30%), and group 4 (age>85 y, the oldest old)=small bowel erosion (38%). Most common finding observed by WCE in patients with IDA with OGIB: group 1=small bowel ulceration (19%), group 2=small bowel erosion (26%), group 3=small bowel erosion (38%), and group 4=angiodysplasia (55%). DY of WCE for IDA without OGIB: group 1=50%, group 2=52%, group 3=56%, and group 4=69%. DY of WCE for IDA with OGIB: group 1=38%, group 2=58%, group 3=63%, and group 4=73%. Active bleeding in the small bowel was seen in 48 of 424 (11%) patients with IDA.

CONCLUSIONS

WCE, a valuable tool for the visualization of entire small bowel mucosa plays a critical role for the evaluation of IDA in patients with negative EGD and colonoscopy. Small bowel erosions, ulcerations, and angiodysplasia observed by WCE are the most frequent findings in patients with IDA. DY of WCE in the evaluation of IDA progressively increases as age advances.

Enteroscopy: an overview

Although the small intestine has long been considered the final frontier of endoscopy, a vast amount of progress has led to increased diagnostic and therapeutic capabilities. With the increasing prevalence of capsule endoscopy, the need for enteroscopy also continues to increase. The endoscopic options currently available include double and single balloon-assisted enteroscopy, spiral enteroscopy, and lastly, intraoperative enteroscopy. The majority of published literature has focused on double balloon enteroscopy, but further studies have to provide information on the safety and yield of the newer techniques. Although intraoperative enteroscopy may be practiced less frequently, it has a role in the management of lesions that may not be approachable by other endoscopic means and a role in the guidance of surgical management.