Obscure gastrointestinal bleeding: single centre experience of capsule endoscopy

Systematic review and meta-analysis of the diagnostic and therapeutic yield of small bowel endoscopy in patients with overt small bowel bleeding

BACKGROUND

Small bowel endoscopy, including small bowel capsule endoscopy (SBCE) and balloon-assisted endoscopy (BAE), is useful for small bowel bleeding (SBB) assessment. However, the specific management strategy for overt SBB is not well established. This meta-analysis aimed to evaluate the pooled diagnostic yields (DYs) and therapeutic yields (TYs) of small bowel endoscopy in overt SBB and to determine the optimal endoscopy timing.

METHODS

A comprehensive literature search was performed of studies examining the DY and/or TY of small bowel endoscopy in overt SBB. Data on the DY, TY, and timing of small bowel endoscopy were extracted, pooled, and analyzed. The pooled DY and TY of small bowel endoscopy for patients with overt SBB were calculated. Meta-regression and subgroup analysis were performed.

RESULTS

Twenty-two studies were included. The pooled DY was 65.2% and 74.0% for SBCE and BAE, respectively. The pooled TY of SBCE and BAE was 55.9% and 35.8%, respectively. A meta-regression model showed that the timing of endoscopy was significantly associated with the DY of BAE and the TY of SBCE and BAE.

CONCLUSIONS

Small bowel capsule endoscopy and BAE would be useful diagnostic and therapeutic modalities in overt SBB. According to the subgroup analysis, in which the TY seemed to be higher within 2 days after bleeding for SBCE and BAE, the optimal timing of endoscopy would be within 2 days.

Positive Fecal Occult Blood Test is a Predictive Factor for Gastrointestinal Bleeding after Capsule Endoscopy in Patients with Unexplained Iron Deficiency Anemia: A Korean Multicenter CAPENTRY Study

BACKGROUND/AIMS

Capsule endoscopy (CE) is recommended as the primary method for the evaluation of unexplained anemia. This study aimed to assess the diagnostic yield of CE in patients with unexplained iron deficiency anemia (IDA) without overt bleeding, and to evaluate their long-term outcomes and related clinical factors.

METHODS

Data of patients who underwent CE for the evaluation of IDA were reviewed from a CE registry in Korea. Additional clinical data were collected by the involved investigators of each hospital through a review of medical records.

RESULTS

Among a total of 144 patients, the diagnostic yield of CE was 34%. Gastrointestinal (GI) bleeding was found in 6.3% (n=9) of the patients (occult bleeding in four patients and overt bleeding in five patients) during a mean follow-up of 17.8 months. Patients with a positive fecal occult blood test (FOBT) result at the initial diagnosis had a higher rate of GI bleeding after CE (p=0.004). In addition, a positive FOBT result was the only independent predictive factor for GI bleeding (hazard ratio, 5.30; 95% confidence interval, 1.41-19.85; p=0.013).

CONCLUSION

Positive FOBT is a predictive factor for GI bleeding during follow-up after CE in patients with unexplained IDA without overt bleeding. Thus, patients with positive FOBT need to be more closely followed up.

Bleeding detection in wireless capsule endoscopy videos - Color versus texture features

Wireless capsule endoscopy (WCE) is an effective technology that can be used to make a gastrointestinal (GI) tract diagnosis of various lesions and abnormalities. Due to a long time required to pass through the GI tract, the resulting WCE data stream contains a large number of frames which leads to a tedious job for clinical experts to perform a visual check of each and every frame of a complete patient’s video footage. In this paper, an automated technique for bleeding detection based on color and texture features is proposed. The approach combines the color information which is an essential feature for initial detection of frame with bleeding. Additionally, it uses the texture which plays an important role to extract more information from the lesion captured in the frames and allows the system to distinguish finely between borderline cases. The detection algorithm utilizes machine‐learning‐based classification methods, and it can efficiently distinguish between bleeding and nonbleeding frames and perform pixel‐level segmentation of bleeding areas in WCE frames. The performed experimental studies demonstrate the performance of the proposed bleeding detection method in terms of detection accuracy, where we are at least as good as the state‐of‐the‐art approaches. In this research, we have conducted a broad comparison of a number of different state‐of‐the‐art features and classification methods that allows building an efficient and flexible WCE video processing system.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

Retention associated with video capsule endoscopy: systematic review and meta-analysis

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) has become a major diagnostic tool for small-bowel evaluation. However, retention of the video capsule endoscope remains a major concern.

METHODS

We performed a systematic review of VCE retention rates by using Pubmed and SCOPUS (1995-2015). We included studies that enrolled at least 10 patients, included VCE retention rates, and separated retention rates by indication. We used Comprehensive Meta-Analysis (Version 3.0) to calculate pooled prevalence rates with 95% confidence intervals (CIs) and assessed heterogeneity by using the Cochran Q statistic.

RESULTS

We included 25 studies (N = 5876) for patients undergoing VCE for evaluation of potential small-bowel bleeding, 9 studies (N = 968) for patients with suspected inflammatory bowel disease (IBD), 11 studies (N = 558) for patients with established IBD, and 8 studies for patients (N = 111) undergoing VCE for evaluation of abdominal pain and/or diarrhea. We used a random effects model and found that the pooled retention rate was 2.1% for patients with suspected small-bowel bleeding (95% CI, 1.5%-2.8%). Retention rates were 3.6% (95% CI, 1.7%-8.6%) for suspected IBD, 8.2% (95% CI, 6.0%-11.0%) for established IBD, and 2.2% (95% CI, 0.9%-5.0%) for abdominal pain and/or diarrhea. Based on subgroup analysis, subsequent VCE completion rates after performance of a patency capsule or CT enterography in patients with IBD to exclude retentions due to strictures was 2.7% (95% CI, 1.1%-6.4%). Reasons for retention were provided in 60 (77%) studies. The most common reasons for retention were small-bowel strictures, although etiology was not provided in all studies.

CONCLUSION

VCE retention occurs in approximately 2% of patients undergoing evaluation for small-bowel bleeding and is most likely due to small-bowel strictures. Retention rates in patients with suspected or known IBD were approximately 4% and 8%, based on our meta-analysis. These rates decreased by half in those studies that used either a patency capsule or CT enterography to assess patency before performing VCE.

The Role of Capsule Endoscopy in Patients with Obscure Gastrointestinal Bleeding

Obscure gastrointestinal bleeding (OGIB) accounts for 5% of all gastrointestinal (GI) bleeding cases and is often caused by small bowel lesions. Capsule endoscopy (CE), which allows non-invasive visualization of the small bowel mucosa, has revolutionized the evaluation of OGIB. CE is preferred by both patients and physicians mainly because of its non-invasiveness, and is widely used as the first-line diagnostic modality for OGIB. The diagnostic yield of CE in OGIB has been reported to be in the range of 32% to 83%. Although no direct comparison has been made, a meta-analysis showed similar diagnostic yields between CE and double-balloon enteroscopy (DBE) for OGIB. However, CE could enhance the yield of subsequent DBE and serve as a guide for optimizing the insertion route for DBE. Even after negative CE, selected patients could benefit from second-look CE for OGIB. In terms of outcomes, a favorable clinical impact after CE has been reported in several studies. However, observations indicate that CE might not influence clinical outcomes directly, but rather play a role in selecting patients with OGIB who are likely to benefit from subsequent evaluation and intervention.

Sporadic small bowel tumors detected by capsule endoscopy in patients with occult gastrointestinal bleeding

Intestinal tumors represent less than 6% of digestive tumors, and, because of the limitations of intestinal investigations, these tumors are difficult to diagnose. In this context, capsule endoscopy has proven effective, especially in patients with obscure digestive bleeding. In a large series of patients undergoing capsule endoscopy, small bowel tumors are found in 2.4-8.9% of cases. The aim of this retrospective, single-center study, based on prospective database, is to evaluate the frequency of small bowel tumors detected by capsule endoscopy in patients with occult gastrointestinal bleeding. During 2004-2014, 849 consecutive patients underwent CE at our Department for occult gastrointestinal bleeding. Following capsule endoscopy, the medical records of the study population were reviewed. Results of double-balloon enteroscopy or surgery performed after capsule endoscopy were retrieved. Capsule endoscopy identified 55 small bowel tumors (6.5%), of which 28 malignancies (51%) and 27 benign neoplasms (49%) underwent surgery or endoscopic treatment. Malignancies included adenocarcinoma (18.7%), gastrointestinal stromal tumors (GIST) (12%) and lymphoma (6.7%). Benign neoplasms included dysplastic adenomatous polyps (36%) and hyperplastic polyps (25.3%). Non-neoplastic masses included one inflammatory polyp. Capsule retention occurred in four patients (5.3%) and the retained capsule was retrieved during surgery. In our experience neoplasms of small bowel are found in 6.5% of patients with occult gastrointestinal bleeding. Of these malignancies, small bowel neoplasms are found in 3.3% of cases. Capsule endoscopy is an effective and sensitive diagnostic tool, and plays an important role in the algorithm for the diagnostic workup of suspected small bowel tumors.

Comparison of the diagnostic yield and outcomes between standard 8 h capsule endoscopy and the new 12 h capsule endoscopy for investigating small bowel pathology

AIM: To evaluate the completion rate and diagnostic yield of the PillCam SB2-ex in comparison to the PillCam SB2.

METHODS: Two hundred cases using the 8-h PillCam SB2 were retrospectively compared to 200 cases using the 12 h PillCam SB2-ex at a tertiary academic center. Endoscopically placed capsules were excluded from the study. Demographic information, indications for capsule endoscopy, capsule type, study length, completion of exam, clinically significant findings, timestamp of most distant finding, and significant findings beyond 8 h were recorded.

RESULTS: The 8 and 12 h capsule groups were well matched respectively for both age (70.90 ± 14.19 vs 71.93 ± 13.80, P = 0.46) and gender (45.5% vs 48% male, P = 0.69). The most common indications for the procedure in both groups were anemia and obscure gastrointestinal bleeding. PillCam SB2-ex had a significantly higher completion rate than PillCam SB2 (88% vs 79.5%, P = 0.03). Overall, the diagnostic yield was greater for the 8 h capsule (48.5% for SB2 vs 35% for SB2-ex, P = 0.01). In 4/70 (5.7%) of abnormal SB2-ex exams the clinically significant finding was noted in the small bowel beyond the 8 h mark.

CONCLUSION: In our study, we found the PillCam SB2-ex to have a significantly increased completion rate, though without any improvement in diagnostic yield compared to the PillCam SB2.

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

OBJECTIVE

This study aimed to identify the risk factors associated with rebleeding and long-term outcomes after capsule endoscopy (CE) for obscure gastrointestinal bleeding (OGIB) in a follow-up study.

METHODS

Data of consecutive patients who underwent CE due to OGIB from June 2002 to January 2012 were retrospectively reviewed. The Cox proportional hazard model was used to evaluate the risk factors associated with rebleeding, while Kaplan-Meier survival curves and the log-rank test were used to analyze cumulative rebleeding rates.

RESULTS

The overall rebleeding rate after CE in patients with OGIB was 28.6% (97/339) during a median follow-up of 48 months (range 12-112 months). Multivariate analysis showed that age ≥60 years (hazard ratio [HR] 2.473, 95% confidence interval [CI] 1.576-3.881, P = 0.000), positive CE findings (HR 3.393, 95% CI 1.931-5.963, P = 0.000), hemoglobin ≤70 g/L before CE (HR 2.010, 95% CI 1.261-3.206, P = 0.003), nonspecific treatments (HR 2.500, 95% CI 1.625-3.848, P = 0.000) and the use of anticoagulants, antiplatelet or non-steroidal anti-inflammatory drugs after CE (HR 2.851, 95% CI 1.433-5.674, P = 0.003) were independent risk factors associated with rebleeding. Univariate analysis showed that chronic hepatitis was independently associated with rebleeding in CE-negative patients (P = 0.021).

CONCLUSIONS

CE has a significant impact on the long-term outcome of patients with OGIB. Further investigation and close follow-up in patients with OGIB and those with negative CE findings are necessary.

Is Occult Obscure Gastrointestinal Bleeding a Definite Indication for Capsule Endoscopy? A Retrospective Analysis of Diagnostic Yield in Patients with Occult versus Overt Bleeding

Background/Aim. Usefulness of capsule endoscopy (CE) for diagnosing small-bowel lesions in patients with obscure gastrointestinal bleeding (OGIB) has been reported. Most reports have addressed the clinical features of overt OGIB, with few addressing occult OGIB. We aimed to clarify whether occult OGIB is a definite indication for CE. Methods. We retrospectively compared the cases of 102 patients with occult OGIB and 325 patients with overt OGIB, all having undergone CE. The diagnostic yield of CE and identification of various lesion types were determined in cases of occult OGIB versus overt OGIB. Results. There was no significant difference in diagnostic yield between occult and overt OGIB. The small-bowel lesions in cases of occult OGIB were diagnosed as ulcer/erosive lesions (n = 18, 18%), vascular lesions (n = 11, 11%), and tumors (n = 4, 3%), and those in cases of overt OGIB were diagnosed as ulcer/erosive lesions (n = 51, 16%), vascular lesions (n = 31, 10%), and tumors (n = 20, 6%). Conclusion. CE detection rates and CE identification of various small-bowel diseases do not differ between patients with occult versus overt OGIB. CE should be actively performed for patients with either occult or overt OGIB.

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.