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Akiki K, Mahmoud T, Alqaisieh MH, Sayegh LN, Lescalleet KE, Abu Dayyeh BK, Wong Kee Song LM, Larson MV, Bruining DH, Coelho-Prabhu N, Buttar NS, Sedlack RE, Chandrasekhara V, Leggett CL, Law RJ, Rajan E, Gleeson FC, Alexander JA, Storm AC. A novel blood-sensing capsule for rapid detection of upper GI bleeding: a prospective clinical trial. Gastrointest Endosc 2024; 99:712-720. [PMID: 38065512 DOI: 10.1016/j.gie.2023.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/07/2023] [Accepted: 11/23/2023] [Indexed: 04/24/2024]
Abstract
BACKGROUND AND AIMS Upper GI bleeding (UGIB) is a common medical emergency associated with high resource utilization, morbidity, and mortality. Timely EGD can be challenging from personnel, resource, and access perspectives. PillSense (EnteraSense Ltd, Galway, Ireland) is a novel swallowed bleeding sensor for the detection of UGIB, anticipated to aid in patient triage and guide clinical decision-making for individuals with suspected UGIB. METHODS This prospective, open-label, single-arm comparative clinical trial of a novel bleeding sensor for patients with suspected UGIB was performed at a tertiary care center. The PillSense system consists of an optical sensor and an external receiver that processes and displays data from the capsule as "Blood Detected" or "No Blood Detected." Patients underwent EGD within 4 hours of capsule administration; participants were followed up for 21 days to confirm capsule passage. RESULTS A total of 126 patients were accrued to the study (59.5% male; mean age, 62.4 ± 14.3 years). Sensitivity and specificity for detecting the presence of blood were 92.9% (P = .02) and 90.6% (P < .001), respectively. The capsule's positive and negative predictive values were 74.3% and 97.8%, and positive and negative likelihood ratios were 9.9 and .08. No adverse events or deaths occurred related to the PillSense system, and all capsules were excreted from patients on follow-up. CONCLUSIONS The PillSense system is safe and effective for detecting the presence of blood in patients evaluated for UGIB before upper GI endoscopy. It is a rapidly deployed tool, with easy-to-interpret results that will affect the diagnosis and triage of patients with suspected UGIB. (Clinical trial registration number: NCT05385224.).
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Affiliation(s)
- Karl Akiki
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Mohammad H Alqaisieh
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Lea N Sayegh
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Kristin E Lescalleet
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mark V Larson
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | | | - Navtej S Buttar
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Robert E Sedlack
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan J Law
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA.
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Bajer L, Ryou M, C. Thompson C, Drastich P. Novel upper gastrointestinal bleeding sensor capsule: a first human feasibility and safety trial. Clin Endosc 2024; 57:203-208. [PMID: 38229441 PMCID: PMC10984735 DOI: 10.5946/ce.2023.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND/AIMS Upper gastrointestinal bleeding (UGIB) is the most common GI condition requiring hospitalization, and can be diagnosed by direct visualization. The present study aimed to evaluate the safety and feasibility of using the PillSense system (EnteraSense Ltd.), a novel diagnostic tool designed for the rapid in vivo detection of UGIB, in human volunteers. METHODS In the present study, 10 volunteers swallowed a PillSense capsule, followed by 2 servings of an autologous blood preparation. Participants were monitored for capsule passage, overall tolerability of the procedure, and adverse events. RESULTS The procedure was completed per the protocol established in the present study in 9/10 cases. In 9 of the subjects, after capsule ingestion, the device indicated the absence of blood with sensor output values of 1. After the ingestion of the first blood mixture, the sensor outputs of all devices increased from 2.8 to 4, indicating that each camera detected blood. The sensor output remained within that range after the ingestion of the second mixture; however, in one case, the baseline capsule signal was positive, because of a preexisting condition. The passage of the capsule was verified in all patients, and no adverse events were reported. CONCLUSION The first trial of the PillSense system in human subjects demonstrated the feasibility, safety, and tolerability of utilizing this product as a novel, noninvasive, and easy-to-use triage tool for the diagnosis of patients suspected of having UGIB.
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Affiliation(s)
- Lukas Bajer
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | | | - Pavel Drastich
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Meltzer AC, Limkakeng AT, Gentile NT, Freeman JQ, Hall NC, Vargas NM, Fleischer DE, Malik Z, Kallus SJ, Borum ML, Ma Y, Kumar AB. Risk stratification with video capsule endoscopy leads to fewer hospital admissions in emergency department patients with low-risk to moderate-risk upper gastrointestinal bleed: A multicenter clinical trial. J Am Coll Emerg Physicians Open 2021; 2:e12579. [PMID: 34723247 PMCID: PMC8544929 DOI: 10.1002/emp2.12579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE In US emergency departments (EDs), the physician has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Although many bleeding lesions are self-limited, the majority of these patients require emergency hospitalization for upper endoscopy (EGD). We conducted a clinical trial to determine if ED risk stratification with video capsule endoscopy (VCE) reduces hospitalization rates for low-risk to moderate-risk patients with suspected upper GI bleeding. METHODS We conducted a randomized controlled trial at 3 urban academic EDs. Inclusion criteria included signs of upper GI bleeding and a Glasgow Blatchford score <6. Patients were randomly assigned to 1 of the following 2 treatment arms: (1) an experimental arm that included VCE risk stratification and brief ED observation versus (2) a standard care arm that included admission for inpatient EGD. The primary outcome was hospital admission. Patients were followed for 7 and 30 days to assess for rebleeding events and revisits to the hospital. RESULTS The trial was terminated early as a result of low accrual. The trial was also terminated early because of a need to repurpose all staff to respond to the coronavirus disease 2019 pandemic. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital, and in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (P = 0.012). There was no difference in safety on day 7 and day 30 after the index ED visit. CONCLUSIONS VCE is a potential strategy to decrease admissions for upper GI bleeding, though further study with a larger cohort is required before this approach can be recommended.
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Affiliation(s)
- Andrew C. Meltzer
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | | | - Nina T. Gentile
- School of MedicineTemple UniversityPhiladelphiaPennsylvaniaUSA
| | - Jincong Q. Freeman
- Milken Institute School of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Nicole C. Hall
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Nataly Montano Vargas
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | | | - Zubair Malik
- School of MedicineTemple UniversityPhiladelphiaPennsylvaniaUSA
| | - Samuel J. Kallus
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Marie L. Borum
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Yan Ma
- Milken Institute School of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Anita B. Kumar
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
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Brunk T, Schmidt A, Hochberger J, Wedi E, Meier B, Braun G, Neser F, Schneider M, Kandler J, Bauerfeind P, Repp M, Weingart V, Brand M, Caca K, Wannhoff A, Messmann H, Karpynec S, Kubisch I, Albert J, Neuhaus H, Schmitz L, Allescher HD, Meining A, Kuellmer A. Telemetric capsule-based upper gastrointestinal tract - blood detection - first multicentric experience. MINIM INVASIV THER 2021; 31:704-711. [PMID: 34342252 DOI: 10.1080/13645706.2021.1954534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill® acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine. MATERIAL AND METHODS Sixty-one consecutive patients in whom the HemoPill® had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course. RESULTS The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur. CONCLUSION HemoPill®-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.
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Affiliation(s)
- Thomas Brunk
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - Edris Wedi
- Department of Gastroenterology, Sana Hospital Offenbach, Offenbach, Germany
| | - Benjamin Meier
- Department of Gastroenterology and Oncology, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Georg Braun
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Frank Neser
- Department of Gastroenterology, Chemnitz Hospital, Chemnitz, Germany
| | | | - Jennis Kandler
- Department of Internal Medicine and Gastroenterology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany
| | - Peter Bauerfeind
- Division of Gastroenterology, Triemli Hospital, Zurich, Switzerland
| | - Michael Repp
- Department of Gastroenterology, Hospital Altenburger Land, Altenburg, Germany
| | - Vincens Weingart
- Department of Gastroenterology, Hospital Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany
| | - Markus Brand
- Interventional and Experimental Endoscopy (InExEn), Internal Medicine II, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Karel Caca
- Department of Gastroenterology and Oncology, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Andreas Wannhoff
- Department of Gastroenterology and Oncology, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Symon Karpynec
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Ilja Kubisch
- Department of Gastroenterology, Chemnitz Hospital, Chemnitz, Germany
| | - Joerg Albert
- Department of Gastroenterology, Robert Bosch Hospital, Stuttgart, Germany
| | - Horst Neuhaus
- Department of Internal Medicine and Gastroenterology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany
| | - Lukas Schmitz
- Department of Internal Medicine and Gastroenterology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany
| | - Hans-Dieter Allescher
- Department of Gastroenterology, Hospital Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany
| | - Alexander Meining
- Interventional and Experimental Endoscopy (InExEn), Internal Medicine II, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Armin Kuellmer
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Wu RM, Fisher LR. Role of Video Capsule in Small Bowel Bleeding. Gastrointest Endosc Clin N Am 2021; 31:277-306. [PMID: 33743926 DOI: 10.1016/j.giec.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Video capsule endoscopy has an essential role in the diagnosis and management of small bowel bleeding and is the first-line study recommended for this purpose. This article reviews the risk factors for small bowel bleeding, optimal timing for video capsule endoscopy testing, and algorithms recommended for evaluation. Used primarily for the assessment of nonacute gastrointestinal blood loss, video capsule endoscopy has an emerging role for more urgent use in emergency settings and in special populations. Future software incorporation of neural networks to enhance lesion detection will likely result in an augmented role of video capsule endoscopy in small bowel bleeding.
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Affiliation(s)
- Richard M Wu
- Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania Health System, 4th Floor GI Department, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Laurel R Fisher
- Small Bowel Imaging Program, Division of Gastroenterology and Hepatology, University of Pennsylvania Health System, 3400 Civic Center Drive, PCAM 7S, Philadelphia, PA 19104, USA.
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Abstract
Video capsule endoscopy has been proven to be a beneficial tool to inspect the gastrointestinal lumen but its true impact may lie in utilization outside of traditional gastroenterology settings such as in the emergency room, the intensive care unit, and outpatient settings. Some advantages of video capsule endoscopy are that its administration does not require special training, patients do not require anesthesia, and videos can be shared with off-site consultants.
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Jawaid S. The Cost-Effectiveness of Video Capsule Endoscopy. Gastrointest Endosc Clin N Am 2021; 31:413-424. [PMID: 33743935 DOI: 10.1016/j.giec.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The development of video capsule endoscopy (VCE) has allowed for visualization of parts of the gastrointestinal tract generally not readily accessible by noninvasive means. Its ease of use has proved useful in diagnosing and managing various small bowel inflammatory disorders. Continued technological evolution of VCE has paved the way for use in small intestinal bleeding and in patients with acute gastrointestinal bleeding. A detailed analysis of costs associated with VCE has demonstrated its ability to promote efficient allocation of health care resources. Further work is needed regarding development of a universal infrastructure to handle the widespread use of VCE technology.
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Affiliation(s)
- Salmaan Jawaid
- Gastroenterology-Advanced Endoscopy, Baylor College of Medicine, 7200 Cambridge Street, Suite 8B, MSBCM 901, Houston, TX 77030, USA.
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8
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Jiang XL, Wang JS, He JH. Summary of The Third Capsule Endoscopy Global Summit. Shijie Huaren Xiaohua Zazhi 2021; 29:210-216. [DOI: 10.11569/wcjd.v29.i4.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In order to emphasize the epidemic prevention during capsule endoscopy examinations, exhibit the latest achievements of capsule endoscopy, and strengthen international exchanges and cooperation in capsule endoscopy products, quality control, R&D, clinical applications, and talents, The Third Capsule Endoscopy Global Summit was held in Chongqing, China. The summit invited foreign experts to live online and remotely broadcast special academic speeches. The invited domestic experts brought the latest academic reports on the spot. A total of 17 medical experts presented a number of latest technologies and academic achievements in the field of capsule endoscopy from five levels. Professor Xue-Liang Jiang, President of the World Chinese Digestive Society and Editor-in-Chief of the World Chinese Journal of Digestology, was invited to give a report on the clinical application of capsule endoscopy.
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Affiliation(s)
- Xue-Liang Jiang
- Digestive Center of the Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250001, Shandong Province, China
| | - Jin-Shan Wang
- Jinshan Science & Technology Limited Company, Chongqing 404100, China
| | - Jian-Hua He
- Jinshan Science & Technology Limited Company, Chongqing 404100, China
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Shah N, Chen C, Montano N, Cave D, Siegel R, Gentile NT, Limkakeng AT, Kumar AB, Ma Y, Meltzer AC. Video capsule endoscopy for upper gastrointestinal hemorrhage in the emergency department: A systematic review and meta-analysis. Am J Emerg Med 2020; 38:1245-1252. [PMID: 32229221 DOI: 10.1016/j.ajem.2020.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/06/2020] [Accepted: 03/08/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The assessment of the severity of upper gastrointestinal hemorrhage in emergency department (ED) patients is difficult to assess with commonly available diagnostic tools. Small studies have shown that video capsule endoscopy (VCE) is a promising risk-stratification method and may be better than current clinical decision rules such as the Rockall score and the Glasgow Blatchford score. This review aims to assess the accuracy of VCE to detect active upper gastrointestinal hemorrhage compared to a reference standard. METHODS The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology was used to perform a review of studies that have measured the diagnostic accuracy of VCE. Studies were included if they measured ED use of VCE for upper GI hemorrhage as compared to a reference standard of an esophagogastroduodenoscopy (EGD). A meta-analysis was performed on select patients using a fixed effects and random-effects model to determine the primary outcome of diagnostic test accuracy. RESULTS 40 studies were screened for eligibility and five studies representing 193 patients met the inclusion and exclusion criteria. All patients received both a VCE and an EGD. The sensitivity and specificity of VCE were 0.724 and 0.748, respectively. The diagnostic odds ratio was 6.29 (95% CI: 3.23-12.25) and the summary receiver operating characteristic curve was 0.782. CONCLUSIONS VCE demonstrated high accuracy for detecting upper GI hemorrhage in this meta-analysis of existing studies. In light of the potential advantages of VCE in the ED, further research is warranted to further establish its role.
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Affiliation(s)
- Nidhi Shah
- The George Washington University School of Medicine and Health Sciences, Department of Emergency Medicine, The Department of Emergency Medicine, 2120 L Street NW, Suite 450, Washington, DC 20037, USA.
| | - Chen Chen
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology and Biostatistics, 950 New Hampshire Ave NW, 5th Floor, Washington, DC 20052, USA.
| | - Nataly Montano
- The George Washington University School of Medicine and Health Sciences, Department of Emergency Medicine, The Department of Emergency Medicine, 2120 L Street NW, Suite 450, Washington, DC 20037, USA.
| | - David Cave
- University of Massachusetts, UMass Memorial Medical Center, University Campus, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Rebecca Siegel
- The George Washington University School of Medicine and Health Sciences, Department of Emergency Medicine, The Department of Emergency Medicine, 2120 L Street NW, Suite 450, Washington, DC 20037, USA
| | - Nina T Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Medicine Education and Research Building (MERB), 3500 N. Broad Street, Philadelphia, PA 19140, USA.
| | - Alexander T Limkakeng
- Division of Emergency Medicine, Duke University School of Medicine, 2301 Erwin Road, Box 3096, Durham, NC 27710, USA.
| | - Anita B Kumar
- The George Washington University School of Medicine and Health Sciences, Department of Medicine, Division of Gastroenterology, The Department of Emergency Medicine, 2120 L Street NW, Suite 450, Washington, DC 20037, USA.
| | - Yan Ma
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology and Biostatistics, 950 New Hampshire Ave NW, 5th Floor, Washington, DC 20052, USA.
| | - Andrew C Meltzer
- The George Washington University School of Medicine and Health Sciences, Department of Emergency Medicine, The Department of Emergency Medicine, 2120 L Street NW, Suite 450, Washington, DC 20037, USA.
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Alzoubaidi D, Lovat LB, Haidry R. Management of non-variceal upper gastrointestinal bleeding: where are we in 2018? Frontline Gastroenterol 2019; 10:35-42. [PMID: 30651955 PMCID: PMC6319149 DOI: 10.1136/flgastro-2017-100901] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/10/2018] [Accepted: 01/21/2018] [Indexed: 02/04/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies in the UK. Despite advancement in technology the management of AUGIB remains a challenge. The clinical community recognise the need for improvement in the treatment of these patients. AUGIB has a significant impact on resources. Endoscopic therapy is the gold standard treatment. The mortality in AUGIB is rarely related to the presenting bleed but significantly associated with concurrent comorbidities. The cost of blood transfusion in the management of patients with AUGIB is significant and misuse of blood products has been documented nationally. Risk stratification tools such as Glasgow-Blatchford Score, Rockall Score and the AIMS65 score have allowed clinicians to triage patients appropriately in order to deliver endoscopic therapy within a suitable time frame. Endoscopic therapeutic modalities such as epinephrine injection, heat thermocoagulation and mechanical clips have had a positive impact on patient's management. However, in order to continue to improve patient's outcomes, further developments are needed.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London, London, UK
- GI Services, University College London Hospital, London, UK
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11
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Lower Endoscopic Diagnostic Yields Observed in Non-hematemesis Gastrointestinal Bleeding Patients. Dig Dis Sci 2018; 63:3448-3456. [PMID: 30136044 DOI: 10.1007/s10620-018-5244-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/06/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Location of bleeding can present a diagnostic challenge in patients without hematemesis more so than those with hematemesis. AIM To describe endoscopic diagnostic yields in both hematemesis and non-hematemesis gastrointestinal bleeding patient populations. METHODS A retrospective analysis on a cohort of 343 consecutively identified gastrointestinal bleeding patients admitted to a tertiary care center emergency department with hematemesis and non-hematemesis over a 12-month period. Data obtained included presenting symptoms, diagnostic lesions, procedure types with diagnostic yields, and hours to diagnosis. RESULTS The hematemesis group (n = 105) took on average 15.6 h to reach a diagnosis versus 30.0 h in the non-hematemesis group (n = 231), (p = 0.005). In the non-hematemesis group, the first procedure was diagnostic only 53% of the time versus 71% in the hematemesis group (p = 0.02). 25% of patients in the non-hematemesis group required multiple procedures versus 10% in the hematemesis group (p = 0.004). Diagnostic yield for a primary esophagogastroduodenoscopy was 71% for the hematemesis group versus 50% for the non-hematemesis group (p = 0.01). Primary colonoscopies were diagnostic in 54% of patients and 12.5% as a secondary procedure in the non-hematemesis group. A primary video capsule endoscopy yielded a diagnosis in 79% of non-hematemesis patients (n = 14) and had a 70% overall diagnostic rate (n = 33). CONCLUSION Non-hematemesis gastrointestinal bleeding patients undergo multiple non-diagnostic tests and have longer times to diagnosis and then compared those with hematemesis. The high yield of video capsule endoscopy in the non-hematemesis group suggests a role for this device in this context and warrants further investigation.
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12
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Kim SH, Yang DH, Kim JS. Current Status of Interpretation of Small Bowel Capsule Endoscopy. Clin Endosc 2018; 51:329-333. [PMID: 30078306 PMCID: PMC6078920 DOI: 10.5946/ce.2018.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 07/18/2018] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy (CE) has revolutionized direct small bowel imaging and is widely used in clinical practice. Remote visualization of bowel images enables painless, well-tolerated endoscopic examinations. Small bowel CE has a high diagnostic yield and the ability to examine the entire small bowel. The diagnostic yield of CE relies on lesion detection and interpretation. In this review, issues related to lesion detection and interpretation of CE have been addressed, and the current status of automated reading software development has been reviewed. Clinical significance of an external real-time image viewer has also been described.
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Affiliation(s)
- Su Hwan Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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13
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Wortman JR, Landman W, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90:20170076. [PMID: 28362508 DOI: 10.1259/bjr.20170076] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute gastrointestinal (GI) bleeding is a common cause of both emergency department visits and hospitalizations in the USA and can have a high morbidity and mortality if not treated rapidly. Imaging is playing an increasing role in both the diagnosis and management of GI bleeding. In particular, CT angiography (CTA) is a promising initial test for acute GI bleeding as it is universally available, can be performed rapidly and may provide diagnostic information to guide management. The purpose of this review was to provide an overview of the uses of imaging in the diagnosis and management of acute GI bleeding, with a focus on CTA.
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Affiliation(s)
- Jeremy R Wortman
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
| | - Wendy Landman
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
| | - Urvi P Fulwadhva
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
| | - Salvatore G Viscomi
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,3 Department of Radiology, Cape Cod Hospital, Hyannis, MA, USA
| | - Aaron D Sodickson
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
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14
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Abstract
Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.
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15
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Yung DE, Sykes C, Koulaouzidis A. The validity of suspected blood indicator software in capsule endoscopy: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2017; 11:43-51. [PMID: 27842442 DOI: 10.1080/17474124.2017.1257384] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Software tools have been developed as capsule endoscopy (CE) reading aids. The suspected blood indicator (SBI) tags possible areas of haemorrhage in the gastrointestinal (GI) tract. This meta-analysis aims to investigate the diagnostic accuracy of SBI in CE. Areas covered: A systematic literature search was conducted for studies on the use of SBI in CE. Sensitivity, specificity and diagnostic odds ratio (DOR) of SBI in diagnosing GI bleeding was evaluated. 2040 patients from 16 studies underwent 2049 CE examinations. The overall sensitivity of SBI for bleeding or potentially bleeding lesions was 0.553, specificity 0.578, DOR 12.354. The sensitivity of SBI for active bleeding was 0.988, specificity 0.646, DOR 229.89. Expert commentary: Currently, SBI has limited validity in CE reading. However, in active GI bleeding, it has good sensitivity, supporting its use in the acute setting.
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Affiliation(s)
- Diana E Yung
- a Centre for Liver & Digestive Disorders , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Catherine Sykes
- a Centre for Liver & Digestive Disorders , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Anastasios Koulaouzidis
- a Centre for Liver & Digestive Disorders , The Royal Infirmary of Edinburgh , Edinburgh , UK
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16
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Klein A, Gralnek IM. Video capsule endoscopy for triage of patients with acute upper GI hemorrhage: Is seeing believing? Gastrointest Endosc 2016; 84:914-916. [PMID: 27855797 DOI: 10.1016/j.gie.2016.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Rappaport Family Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Ha'Emek Medical Center, Afula, Israel; Rappaport Family Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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17
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Schostek S, Zimmermann M, Keller J, Fode M, Melbert M, Schurr MO, Gottwald T, Prosst RL. Telemetric real-time sensor for the detection of acute upper gastrointestinal bleeding. Biosens Bioelectron 2016; 78:524-529. [DOI: 10.1016/j.bios.2015.11.073] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 11/19/2015] [Accepted: 11/24/2015] [Indexed: 01/24/2023]
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18
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Abstract
PURPOSE OF REVIEW Acute, nonvariceal upper gastrointestinal bleeding (UGIB) is a common medical emergency encountered worldwide. Despite medical and technological advances, it remains associated with significant morbidity and mortality. RECENT FINDINGS Rapid patient assessment and management are paramount. When indicated, upper endoscopy in patients presenting with acute UGIB is effective for both diagnosis of the bleeding site and provision of endoscopic hemostasis. Endoscopic hemostasis significantly reduces rebleeding rates, blood transfusion requirements, length of hospital stay, surgery, and mortality. Furthermore, early upper endoscopy, defined as being performed within 24 h of patient presentation, improves patient outcomes. SUMMARY A structured approach to the patient with acute UGIB that includes early hemodynamic resuscitation and stabilization, preendoscopic risk stratification using validated instruments, pharmacologic and endoscopic intervention, and postendoscopy therapy is important to optimize patient outcome and assure efficient use of medical resources.
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19
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Simon TG, Travis AC, Saltzman JR. Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:429-42. [PMID: 26142029 DOI: 10.1016/j.giec.2015.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Acute nonvariceal upper gastrointestinal bleeding remains an important cause of hospital admission with an associated mortality of 2-14%. Initial patient evaluation includes rapid hemodynamic assessment, large-bore intravenous catheter insertion and volume resuscitation. A hemoglobin transfusion threshold of 7 g/dL is recommended, and packed red blood cell transfusion may be necessary to restore intravascular volume and improve tissue perfusion. Patients should be risk stratified into low- and high-risk categories, using validated prognostic scoring systems such as the Glasgow-Blatchford, AIMS65 or Rockall scores. Effective early management of acute, nonvariceal upper gastrointestinal hemorrhage is critical for improving patient outcomes.
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Affiliation(s)
- Tracey G Simon
- Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA
| | - Anne C Travis
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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20
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Promise and potential of video capsule endoscopy in the emergency department. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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21
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Upper gastrointestinal bleeding: patient presentation, risk stratification, and early management. Gastroenterol Clin North Am 2014; 43:665-75. [PMID: 25440918 DOI: 10.1016/j.gtc.2014.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The established quality indicators for early management of upper gastrointestinal (GI) hemorrhage are based on rapid diagnosis, risk stratification, and early management. Effective preendoscopic treatment may improve survivability of critically ill patients and improve resource allocation for all patients. Accurate risk stratification helps determine the need for hospital admission, hemodynamic monitoring, blood transfusion, and endoscopic hemostasis before esophagogastroduodenoscopy (EGD) via indirect measures such as laboratory studies, physiologic data, and comorbidities. Early management before the definitive EGD is essential to improving outcomes for patients with upper GI bleeding.
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22
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Meltzer AC, Ward MJ, Gralnek IM, Pines JM. The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the ED. Am J Emerg Med 2014; 32:823-32. [PMID: 24961149 PMCID: PMC4108573 DOI: 10.1016/j.ajem.2013.11.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/05/2013] [Accepted: 11/07/2013] [Indexed: 12/29/2022] Open
Abstract
STUDY OBJECTIVE Acute upper gastrointestinal (GI) hemorrhage is a common presentation in hospital-based emergency departments (EDs). A novel diagnostic approach is to use video capsule endoscopy to directly visualize the upper GI tract and identify bleeding. Our objective was to evaluate and compare the relative costs and benefits of video capsule endoscopy compared to other strategies in low- to moderate-risk ED patients with acute upper GI hemorrhage. METHODS We constructed a model using standard decision analysis software to examine the cost-effectiveness of 4 available strategies for a base-case patient who presents to the ED with either mild- or moderate-risk scenarios (by Glasgow-Blatchford Score) for requiring invasive hemostatic intervention (ie, endoscopic, surgical, etc) The 4 available diagnostic strategies were (1) direct imaging with video capsule endoscopy performed in the ED; (2) risk stratification using the Glasgow-Blatchford score; (3) nasogastric tube placement; and, finally, (4) an admit-all strategy. RESULTS In the low-risk scenario, video capsule endoscopy was the preferred strategy (cost $5691, 14.69 quality-adjusted life years [QALYs]) and was more cost-effective than the remaining strategies including nasogastric tube strategy (cost $8159, 14.69 QALYs), risk stratification strategy (cost $10,695, 14.69 QALYs), and admit-all strategy (cost $22,766, 14.68 QALYs). In the moderate-risk scenario, video capsule endoscopy continued to be the preferred strategy (cost $9190, 14.56 QALYs) compared to nasogastric tube (cost $9487, 14.58 QALYs, incremental cost-effectiveness ratio $15,891) and more cost effective than admit-all strategy (cost, $22,584, 14.54 QALYs.) CONCLUSION Video capsule endoscopy may be cost-effective for low- and moderate-risk patients presenting to the ED with acute upper GI hemorrhage.
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Affiliation(s)
- Andrew C Meltzer
- Department of Emergency Medicine, George Washington University, Washington, DC, USA.
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, USA
| | - Ian M Gralnek
- Bruce and Ruth Rappaport Faculty Of Medicine, Technion-Israel Institute Of Technology, GI Outcomes Unit, Department Of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Jesse M Pines
- Department of Emergency Medicine, George Washington University, Washington, DC, USA
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23
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Abstract
Acute gastrointestinal (GI) bleeding is a common cause of hospitalization, resulting in about 400,000 hospital admissions annually, with a mortality rate of 5-10%. It is estimated that 5% of acute GI bleedings are of obscure origin with a normal esophagogastroduodenoscopy and ileocolonoscopy. Capsule endoscopy is the state-of-the-art procedure for inspection of the entire small bowel with a high sensitivity for the detection of causes of bleeding. In recent years, many studies have addressed the sensitivity and outcome of capsule-endoscopy procedures in patients with acute GI bleeding. This review looks at the role of capsule endoscopy in the evaluation of patients with acute GI bleeding from either the upper GI tract or small bowel.
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Affiliation(s)
- Moshe Nadler
- Department of Gastroenterology, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, 5265601, Israel
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24
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Meltzer AC, Ali MA, Kresiberg RB, Patel G, Smith JP, Pines JM, Fleischer DE. Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med 2013; 61:438-443.e1. [PMID: 23398660 DOI: 10.1016/j.annemergmed.2012.11.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/05/2012] [Accepted: 11/13/2012] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE Video capsule endoscopy has been used to diagnose gastrointestinal hemorrhage and other small bowel diseases but has not been tested in an emergency department (ED) setting. The objectives in this pilot study are to demonstrate the ability of emergency physicians to detect blood in the upper gastrointestinal tract with capsule endoscopy after a short training period, measure ED patient acceptance of capsule endoscopy, and estimate the test characteristics of capsule endoscopy to detect acute upper gastrointestinal hemorrhage. METHODS During a 6-month period at a single academic hospital, eligible patients underwent video capsule endoscopy (Pillcam Eso2; Given Imaging) in the ED. Video images were reviewed by 4 blinded physicians (2 emergency physicians with brief training in capsule endoscopy interpretation and 2 gastroenterologists with capsule endoscopy experience). RESULTS A total of 25 subjects with acute upper gastrointestinal hemorrhage were enrolled. There was excellent agreement between gastroenterologists and emergency physicians for the presence of fresh or coffee-ground blood (0.96 overall agreement; κ=0.90). Capsule endoscopy was well tolerated by 96% of patients and showed an 88% sensitivity (95% confidence interval 65% to 100%) and 64% specificity (95% confidence interval 35% to 92%) for the detection of fresh blood. Capsule endoscopy missed 1 bleeding lesion located in the postpyloric region, which was not imaged because of expired battery life. CONCLUSION Video capsule endoscopy is a sensitive way to identify upper gastrointestinal hemorrhage in the ED. It is well tolerated and there is excellent agreement in interpretation between gastroenterologists and emergency physicians.
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25
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Chandran S, Testro A. Response. Gastrointest Endosc 2013; 78:672-3. [PMID: 24054749 DOI: 10.1016/j.gie.2013.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 06/19/2013] [Indexed: 12/11/2022]
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26
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Khamaysi I, Gralnek IM. Acute upper gastrointestinal bleeding (UGIB) - initial evaluation and management. Best Pract Res Clin Gastroenterol 2013; 27:633-8. [PMID: 24160923 DOI: 10.1016/j.bpg.2013.09.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 09/15/2013] [Accepted: 09/17/2013] [Indexed: 02/07/2023]
Abstract
Acute upper gastrointestinal bleeding (UGIB) is the most common reason that the 'on-call' gastroenterologist is consulted. Despite the diagnostic and therapeutic capabilities of upper endoscopy, there is still significant associated morbidity and mortality in patients experiencing acute UGIB, thus this is a true GI emergency. Acute UGIB is divided into non-variceal and variceal causes. The most common type of acute UGIB is 'non-variceal' and includes diagnoses such as peptic ulcer (gastric and duodenal), gastroduodenal erosions, Mallory-Weiss tears, erosive oesophagitis, arterio-venous malformations, Dieulafoy's lesion, and upper GI tract tumours and malignancies. This article focuses exclusively on initial management strategies for acute upper GI bleeding. We discuss up to date and evidence-based strategies for patient risk stratification, initial patient management prior to endoscopy, potential causes of UGIB, role of proton pump inhibitors, prokinetic agents, prophylactic antibiotics, vasoactive pharmacotherapies, and timing of endoscopy.
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Affiliation(s)
- Iyad Khamaysi
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; The Endoscopy Unit of the Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
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27
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Meltzer AC, Pinchbeck C, Burnett S, Buhumaid R, Shah P, Ding R, Fleischer DE, Gralnek IM. Emergency physicians accurately interpret video capsule endoscopy findings in suspected upper gastrointestinal hemorrhage: a video survey. Acad Emerg Med 2013; 20:711-5. [PMID: 23859585 DOI: 10.1111/acem.12165] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/19/2013] [Accepted: 02/20/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND Acute upper gastrointestinal (GI) hemorrhage is a common emergency department (ED) presentation whose severity ranges from benign to life-threatening and the best tool to risk stratify the disease is an upper endoscopy, either by scope or by capsule, a procedure performed almost exclusively by gastroenterologists. Unfortunately, on-call gastroenterology specialists are often unavailable, and emergency physicians (EPs) currently lack an alternative method to endoscopically visualize a suspected acute upper GI hemorrhage. Recent reports have shown that video capsule endoscopy is well tolerated by ED patients and has similar sensitivity and specificity to endoscopy for upper GI hemorrhage. OBJECTIVES The study objective was to determine if EPs can detect upper GI bleeding on capsule endoscopy after a brief training session. METHODS A survey study was designed to demonstrate video examples of capsule endoscopy to EPs and determine if they could detect upper GI bleeding after a brief training session. All videos were generated from a prior ED-based study on patients with suspected acute upper GI hemorrhage. The training session consisted of less than 10 minutes of background information and capsule endoscopy video examples. EPs were recruited at the American College of Emergency Physicians Scientific Assembly in Denver, Colorado, from October 8, 2012, to October 10, 2012. Inclusion criteria included being an ED resident or attending physician and the exclusion criteria included any formal endoscopy training. The authors analyzed the agreement between the EPs and expert adjudicated capsule endoscopy readings for each capsule endoscopy video. For the outcome categories of blood (fresh or coffee grounds type) or no blood detected, the sensitivity and specificity were calculated. RESULTS A total of 126 EPs were enrolled. Compared to expert gastroenterology-adjudicated interpretation, the sensitivity to detect blood was 0.94 (95% confidence interval [CI] = 0.91 to 0.96) and specificity was 0.87 (95% CI = 0.80 to 0.92). CONCLUSIONS After brief training, EPs can accurately interpret video capsule endoscopy findings of presence of gross blood or no blood with high sensitivity and specificity.
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Affiliation(s)
| | | | - Sarah Burnett
- George Washington University School of Medicine; Washington; DC
| | - Rasha Buhumaid
- Emergency Medicine; George Washington University; Washington; DC
| | - Payal Shah
- Emergency Medicine; George Washington University; Washington; DC
| | - Ru Ding
- Emergency Medicine; George Washington University; Washington; DC
| | | | - Ian M. Gralnek
- Rappaport Faculty of Medicine; Technion-Israel Institute of Technology and the GI Outcomes Unit; Department of Gastroenterology; Rambam Health Care Campus; Haifa; Israel
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28
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Chandran S, Testro A, Urquhart P, La Nauze R, Ong S, Shelton E, Philpott H, Sood S, Vaughan R, Kemp W, Brown G, Froomes P. Risk stratification of upper GI bleeding with an esophageal capsule. Gastrointest Endosc 2013; 77:891-8. [PMID: 23453185 DOI: 10.1016/j.gie.2013.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 01/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Analysis of upper GI bleeding (UGIB) presentations to our institutions suggests that many patients admitted for endoscopic investigation could be managed safely as outpatients. OBJECTIVE To learn whether an esophageal capsule could identify a low-risk group of patients with UGIB who could safely wait for elective EGD. DESIGN Diagnostic, nonrandomized, single-blind (investigator) study. SETTING Three tertiary-care referral centers. PATIENTS Eighty-three consecutive adult patients referred for management of UGIB. INTERVENTION A capsule endoscopy (CE) was performed before EGD for the investigation and management of UGIB. MAIN OUTCOME MEASUREMENTS Detection rates of UGIB source and identification of a low-risk group of patients who would have been suitable for outpatient EGD based on CE findings. RESULTS In total, 62 of 83 patients (75%) had a cause for bleeding identified. Findings were concordant across both modalities in 34 patients (55%). Twenty-one patients (38%) with positive EGD results had negative CE results, 7 of whom were due to lack of duodenal visualization alone. However, 7 of 28 patients (25%) with normal EGD results had positive CE results. The subgroup of patients with duodenal visualization on CE, 23 of 25 (92%), were concordant with EGD for low-risk lesions that would have been suitable for outpatient management. LIMITATIONS Low duodenal visualization rates with CE and low concordance between EGD and CE. CONCLUSION Although CE is not currently ready to be used as a triage tool, when duodenal visualization was achieved CE correlated well with EGD findings and identified 92% of patients who may have been managed as outpatients.
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Affiliation(s)
- Sujievvan Chandran
- Department of Gastroenterology, Austin Health, Heidelberg, Victoria, Australia
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29
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Gutkin E, Shalomov A, Hussain SA, Kim SH, Cortes R, Gray S, Judeh H, Pollack S, Rubin M. Pillcam ESO(®) is more accurate than clinical scoring systems in risk stratifying emergency room patients with acute upper gastrointestinal bleeding. Therap Adv Gastroenterol 2013; 6:193-8. [PMID: 23634183 PMCID: PMC3625024 DOI: 10.1177/1756283x13481020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) accounts for 400,000 hospital admissions in the US each year. Despite advances, mortality rates remain high and are estimated to be 5-10%. Early therapeutic endoscopy is widely recommended as a means of reducing morbidity and mortality. The Rockall and Blatchford scores are clinical scoring systems devised to assist in risk stratifying patients with UGIB. In a prior study we found that rapid live bedside video capsule endoscopy (VCE) utilizing Pillcam ESO(®) correctly identified patients with high-risk stigmata of bleeding seen on upper endoscopy. In this study, we compare the accuracy of the Rockall and Blatchford scores with Pillcam ESO(®) in predicting high-risk endoscopic stigmata. METHODS Pre-endoscopy Blatchford and Rockall scores were calculated for 25 patients (14 males, 11 females) presenting to the emergency room with acute UGIB. The average patient was 66 years of age. A total of 24 out of 25 patients underwent upper endoscopy within 24 hours. One patient did not undergo endoscopy due to clinical instability. The timing of endoscopy was based on clinical parameters in 12 patients, and on live view VCE with Pillcam ESO(®) in the other 13 patients. Positive VCE was defined as red blood, clot or coffee grounds. Mean Rockall and Blatchford scores for all 24 patients were compared to determine potential differences between high- and low-risk patients. Rockall and Blatchford scores were also compared with VCE findings. RESULTS Of 24 patients, 13 had high-risk stigmata on upper endoscopy. The mean Rockall and Blatchford scores were 3 and 13, respectively. In the 11 patients without stigmata, the mean Rockall and Blatchford scores were 2 and 11, respectively. There was no statistically significant difference between the Blatchford scores of the two groups (95% confidence interval [CI] -5.1 to 1.3; p = 0.22). There was no statistically significant difference between the Rockall scores of the two groups (95% CI -2.3 to 0.3; p = 0.11). In the subgroup of 12 patients who underwent VCE prior to endoscopy, 8/12 had positive findings, which were all confirmed at endoscopy. All 4 patients with negative VCE had no high-risk stigmata at endoscopy. CONCLUSION In emergency room patients with acute UGIB, neither the Rockall nor the Blatchford scores were able to differentiate high- and low-risk patients identified at endoscopy. Live view VCE, however, was accurate in predicting high-risk endoscopic stigmata, and may be better suited as a risk stratification tool. Additional studies with a larger cohort will be required to validate these findings.
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Affiliation(s)
- Ellen Gutkin
- Division of Gastroenterology, New York Hospital Queens Weill Cornell Medical College, 56-45 Main Street, Flushing, NY 11355, USA
| | - Albert Shalomov
- New York Hospital Queens Weill Cornell Medical College, Flushing, NY, USA
| | - Syed A. Hussain
- New York Hospital Queens Weill Cornell Medical College, Flushing, NY, USA
| | - Sang H. Kim
- New York Hospital Queens Weill Cornell Medical College, Flushing, NY, USA
| | | | - Sondra Gray
- New York Hospital Queens Weill Cornell Medical College, Flushing, NY, USA
| | - Hani Judeh
- New York Hospital Queens Weill Cornell Medical College, Flushing, NY, USA
| | | | - Moshe Rubin
- New York Hospital Queens Weill Cornell Medical College, Flushing, NY, USA
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30
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Abstract
Now, more than 10 years after the approval of video capsule endoscopy (VCE), the technology has become an essential component in the management of several clinical conditions. Currently, two capsules are approved in the USA for visualizing the small bowel mucosa, one capsule is authorized for oesophageal assessment and several others are in use or under evaluation worldwide. New investigations have focused on optical improvements, advances in intestinal cleansing and risk reduction strategies to optimize VCE methodologies in clinical care. Established indications diagnosed using VCE include unexplained gastrointestinal bleeding, small bowel Crohn's disease (in adults and children >10 years old), localization of small bowel tumours and a broad range of miscellaneous abnormalities. Investigations are ongoing to determine the utility of VCE in colon cancer screening, assessment of oesophageal disorders and diagnosis of coeliac disease. Active research is in progress into ways to improve the efficacy of VCE recording interpretation, prolong imaging time and further enhance optics and imaging methods. To expand the potential utility of VCE, novel devices that can manoeuvre within or insufflate the gut lumen, tag or biopsy suspect lesions, or target drug delivery to specific sites are in development. To facilitate these advances, consortia have been organized to promote innovative VCE technologies.
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31
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Tsoi KKF, Chiu PWY, Chan FKL, Ching JYL, Lau JYW, Sung JJY. The risk of peptic ulcer bleeding mortality in relation to hospital admission on holidays: a cohort study on 8,222 cases of peptic ulcer bleeding. Am J Gastroenterol 2012; 107:405-10. [PMID: 22108453 DOI: 10.1038/ajg.2011.409] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Urgent endoscopic intervention is important in the management of patients with peptic ulcer bleeding (PUB). Hospital admission on Sundays or on public holidays may be associated with an increased mortality. This study sets to investigate whether mortality among patients with PUB differs between holiday and weekday admissions, and also to investigate the association between mortality and the waiting time for endoscopy. METHODS Patients with PUB admitted to the Prince of Wales Hospital from 1993 to 2005 were prospectively recruited in the data set. Mortality and cause of death were documented. Predicting variables included patient characteristics, waiting time for endoscopy, and holiday or weekday admissions. Bivariate analyses and multivariate logistic regression models were used to evaluate risk factors on 30-day mortality after endoscopy. RESULTS A total of 8,222 patients with PUB were enrolled among which 1,573 (19.1%) were admitted on holidays. A total of 334 (4.1%) patients died within 30 days after hospital admission. There was no significant difference in mortality rate between holiday and weekday admissions (4.1 vs. 4.0%, P=0.876). Using logistic regression adjusted for age, hemodynamic shock, ulcer history, and severe comorbid illness, the waiting time for endoscopy was correlated with the risk of 30-day mortality (odds ratio (OR), 95% confidence interval (95% CI)=1.10, 1.06-1.14). Holiday admission has not increased the mortality risk (OR, 95% CI=1.07, 0.80-1.43). CONCLUSIONS When therapeutic endoscopy can be offered within 1 day after admission for PUB, holiday admission will not adversely affect bleeding mortality.
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Affiliation(s)
- Kelvin K F Tsoi
- Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, NT, Hong Kong
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