Comparison of Risk Factors Between Small Intestinal Ulcerative and Vascular Lesions in Occult Versus Overt Obscure Gastrointestinal Bleeding

"MURAL" model to predict bleeding from mural-based lesions in potential small bowel bleeding may improve diagnostic capability and decrease cost

In potential small bowel bleeding, video capsule endoscopy (VCE) is excellent to detect mucosal lesions, while mural-based lesions are better detected by computed tomography enterography (CTE). A predictive tool to identify mural-based lesions should guide selecting investigations. In this retrospective study, we developed and validated the "MURAL" model based on logistic regression to predicts bleeding from mural-based lesions. Cost-effectiveness analysis comparing diagnostic strategy among VCE, CTE, and MURAL model was performed. Of 296 patients, 196 and 100 patients were randomly included in the derivative and validation cohorts, respectively. The MURAL model comprises 5 parameters: age, presence of atherosclerosis, chronic kidney disease, antiplatelet use, and serum albumin level. The area under the receiver operating characteristic curve was 0.778 and 0.821 for the derivative and validation cohorts, respectively. At a cutoff value of 24.2%, the model identified mural-based lesions with 70% sensitivity and 83% specificity in the validation cohort. Cost-effectiveness analysis revealed that application of the MURAL model demonstrated a comparable missed lesion rate but had a lower missed tumor rate, and lower cost compared to VCE strategy. The model for predicting mural-based lesions provide some guidance in investigative decision-making, which may improve diagnostic efficiency and reduce costs.

Clinical Utility of Capsule Endoscopy and Double-Balloon Enteroscopy in the Management of Obscure Gastrointestinal Bleeding

BACKGROUND

Obscure gastrointestinal bleeding (OGIB) is a common but embarrassing problem for gastroenterologists. Most bleeding lesions associated with OGIB are present in the small intestine and sometimes cannot be identified due to the difficulty associated with physical accessibility. Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) have enabled in the process of diagnosing and have evolved to become approaches to treating OGIB.

SUMMARY

CE is a minimally invasive procedure and has a high diagnostic yield in patients with OGIB. DBE offers additional advantage of biopsy collection for pathological diagnosis and therapeutic intervention, but it should be noted that it sometimes causes severe adverse events such as acute pancreatitis, intestinal bleeding, and intestinal perforation. CE should be performed early in the workup course of OGIB. Positive CE findings enhance the diagnostic yield of subsequent DBE, and the effective therapeutic intervention improves the clinical outcomes of OGIB patients. On the contrary, there are no clear guidelines for further investigation of patients with negative CE findings at the present. Although patients in stable general condition may only require follow-up, repeated CE is useful to detect positive findings in patients with evidence of sustained bleeding and progressing anemia. We have revealed that repeated CE has higher positive finding rate than DBE in OGIB patients with negative CE findings in a preliminary study. Key Messages: CE and DBE have complementary roles in the management of OGIB, and the precise timing and proper sequence may be important for the approach to treating OGIB.

Usefulness of small bowel reexamination in obscure gastrointestinal bleeding patients with negative capsule endoscopy findings: Comparison of repeat capsule endoscopy and double-balloon enteroscopy

Background

Although capsule endoscopy (CE) is a noninvasive diagnostic tool for patients with obscure gastrointestinal bleeding (OGIB), bleeding lesions are often not detected. No strategies have been established to determine whether CE or double-balloon enteroscopy (DBE) should be performed after negative CE.

Methods

Among 652 patients who underwent CE for OGIB, a total of 359 patients had negative findings. Of these, 41 and 48 patients underwent repeat CE and DBE for small bowel reexamination, respectively. We compared the rate of positive findings between the two groups. The findings were considered positive if mucosal break, vascular lesion, tumor, or active bleeding was observed.

Results

The rate of positive findings in the repeat CE group was significantly higher than that in the DBE group (73.2% vs. 39.6%; p = 0.001). Logistic regression analysis showed that the repeat CE group was significantly associated with positive findings (odds ratio (OR), 4.2; 95% confidence interval (CI), 1.7-10.2; p = 0.002). Inverse probability of treatment-weighted analysis revealed that repeat CE was significantly associated with positive findings (OR, 4.4; 95% CI, 1.6-12.2; p = 0.004).

Conclusions

Reexamination via CE appears to have more diagnostic value than DBE for OGIB patients with negative CE findings.

Management of occult obscure gastrointestinal bleeding patients based on long-term outcomes

BACKGROUND

There is no consensus regarding the management of occult obscure gastrointestinal bleeding (OGIB) patients without a confirmed bleeding source. This study aimed to consider the management of occult OGIB patients based on their long-term outcomes.

METHODS

We retrospectively enrolled 357 consecutive occult OGIB patients (203 men; mean age: 59.7 years) who underwent capsule endoscopy (CE) at Hiroshima University Hospital, Japan and were followed up for more than 12 months (mean follow-up period; 50.2 months). Patients were divided into three groups as follows: Group A consisted of 98 of 157 patients who had positive findings and indication for treatment, Group B consisted of 59 of 157 patients who had positive findings but no indication for treatment, and Group C consisted of 200 patients who had negative small-bowel findings. We examined the rate of positive CE findings, detection rate and details of bleeding sources, overt bleeding rate, the rate of anemia exacerbation, 5-year anemia exacerbation rate, and overall survival rate.

RESULTS

The positive CE findings rate was 44% (157/357) and detection rate of bleeding source was 27% (98/357). The details of Group A were as follows: angioectasia (n = 61), nonspecific ulceration (n = 10), nonsteroidal anti-inflammatory drug-induced ulcer (n = 8), and others (n = 19). The details of Group B were as follows: erythema (n = 31), angioectasia (n = 25), and others (n = 3). There were no patients with overt bleeding in Group B. Although six patients had anemia exacerbation in Group B, they had angioectasia without a bleeding source.

CONCLUSION

The long-term outcomes of occult OGIB patients were good. Occult OGIB patients without bleeding source lesions may not require follow-up CE.

Arteriosclerosis Is a Major Predictor of Small Bowel Vascular Lesions

BACKGROUND

Most studies have focused on evaluating the association between the presence of small bowel vascular lesions (SBVLs) and patients' comorbidities.

AIMS

We sought to uncover a more fundamental indicator that may predict the presence of SBVLs by considering atherosclerosis qualitatively and quantitatively.

METHODS

We enrolled 79 consecutive patients with obscure gastrointestinal bleeding who had undergone computed tomography (CT) and capsule endoscopy or double-balloon endoscopy from January 2015 to June 2017. The SBVL frequency, type, and location, and the relationship between the presence of SBVLs and the patients' clinical characteristics were evaluated. Arterial wall calcification was assessed on unenhanced CT images, and a modified Agatston scoring system was used to determine the abdominal aorta calcium scores.

RESULTS

Of the 27 (34%) patients with SBVLs, 15 (19%) had type 1a, 12 (15%) had type 1b, and 2 (3%) had type 2a SBVLs. Most of the lesions were located in the jejunum. Cardiovascular disease (P = .017), chronic kidney disease (P = .025), and arteriosclerosis (P = .0036) were associated with the presence of SBVLs. Subsequent multivariate analysis revealed that arteriosclerosis (odds ratio [OR] 7.29; 95% confidence interval [CI] 1.13-143.9) and superior mesenteric artery calcification (OR 16.3; 95% CI 3.64-118.6) were independent predictors of the presence of SBVLs. The modified Agatston score was significantly higher in SBVL cases than in non-SBVL cases (6384 vs. 2666, P = .0023).

CONCLUSIONS

Arteriosclerosis, especially increased superior mesenteric artery calcification, is associated with an increased likelihood of SBVLs.

Clinical outcome of patients with obscure gastrointestinal bleeding during antithrombotic drug therapy

BACKGROUND

The clinical outcome of patients with obscure gastrointestinal bleeding (OGIB) during antithrombotic drug therapy has not been fully investigated.

METHODS

Patients who underwent video capsule endoscopy (VCE) for the investigation of OGIB at Okayama University Hospital from January 2009 to March 2016 were enrolled. We evaluated the VCE findings, the patterns of OGIB, and the rate of rebleeding within 1 year in antithrombotic drug users and antithrombotic drug nonusers.

RESULTS

A total of 181 patients were enrolled. Among the antithrombotic drug users, the rate of VCE positivity in the patients with overt OGIB was significantly higher in comparison with patients with occult OGIB (45% versus 16%, p = 0.014), whereas there was no significant difference among the antithrombotic drug nonusers (27% versus 26%, p = 1.0). Among the antithrombotic drug users, the rate of rebleeding among the VCE-positive patients was significantly higher in comparison with the VCE-negative patients (50% versus 5.9%, p = 0.011). Moreover, among antithrombotic drug users who did not receive therapeutic intervention, the rate of rebleeding among the VCE-positive patients was significantly higher in comparison with the VCE-negative patients (75% versus 6.3%, p = 0.001). However, among the antithrombotic drug nonusers who did not receive therapeutic intervention, the rebleeding rate of the VCE-positive patients was not significantly different from that of the VCE-negative patients (20% versus 9.4%, p = 0.43).

CONCLUSION

Therapeutic intervention should be considered for patients with overt OGIB who are VCE positive and who use antithrombotic drugs due to the high risk of rebleeding.