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Matsubara Y, Tsuboi A, Hirata I, Sumioka A, Takasago T, Tanaka H, Yamashita K, Hiyama Y, Takigawa H, Murakami E, Tsuge M, Urabe Y, Oka S. Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes. BMC Gastroenterol 2024; 24:287. [PMID: 39187770 PMCID: PMC11346274 DOI: 10.1186/s12876-024-03377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/14/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. METHODS This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. RESULTS Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037). CONCLUSIONS Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.
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Affiliation(s)
- Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
- Department of Gastroenterology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuichi Hiyama
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masataka Tsuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Martinov Nestorov J, Sokic-Milutinovic A, Pavlovic Markovic A, Krstic M. Could Capsule Endoscopy Be Useful in Detection of Suspected Small Bowel Bleeding and IBD-10 Years of Single Center Experience. Diagnostics (Basel) 2024; 14:862. [PMID: 38732278 PMCID: PMC11083052 DOI: 10.3390/diagnostics14090862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 05/13/2024] Open
Abstract
A retrospective study in patients who underwent video capsule endoscopy (VCE) between 2006 and 2016 was conducted in the Clinic for gastroenterology and Hepatology, University Clinical Center of Serbia. A total of 245 patients underwent VCE. In 198 patients the indication was obscure gastrointestinal bleeding (OGIB), with 92 patients having overt and the other 106 occult bleeding. The remaining 47 patients underwent VCE due to suspected small bowel (SB) disease (i.e., Von Hippel-Lindau syndrome, familial adenomatous polyposis, Peutz Jeghers syndrome, Crohn's disease, prolonged diarrhea, abdominal pain, congenital lymphangiectasia, protein-losing enteropathy, tumors, refractory celiac disease, etc.). VCE identified a source of bleeding in 38.9% of patients (in the obscure overt group in 48.9% of patients, and in the obscure occult group in 30.2% of patients). The most common findings were angiodysplasias, tumors, Meckel's diverticulum and Crohn's disease. In the smaller group of patients with an indication other than OGIB, 38.3% of patients had positive VCE findings. The most common indication is OGIB, and the best candidates are patients with overt bleeding; patients with IBD should be evaluated in this setting.
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Affiliation(s)
- Jelena Martinov Nestorov
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.S.-M.); (A.P.M.); (M.K.)
- Clinic for Gastroenterology and Hepatology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Aleksandra Sokic-Milutinovic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.S.-M.); (A.P.M.); (M.K.)
- Clinic for Gastroenterology and Hepatology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Aleksandra Pavlovic Markovic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.S.-M.); (A.P.M.); (M.K.)
- Clinic for Gastroenterology and Hepatology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Miodrag Krstic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.S.-M.); (A.P.M.); (M.K.)
- Clinic for Gastroenterology and Hepatology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Choi KS, Park D, Kim JS, Cheung DY, Lee BI, Cho YS, Kim JI, Lee S, Lee HH. Deep learning in negative small-bowel capsule endoscopy improves small-bowel lesion detection and diagnostic yield. Dig Endosc 2024; 36:437-445. [PMID: 37612137 DOI: 10.1111/den.14670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/20/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES Although several studies have shown the usefulness of artificial intelligence to identify abnormalities in small-bowel capsule endoscopy (SBCE) images, few studies have proven its actual clinical usefulness. Thus, the aim of this study was to examine whether meaningful findings could be obtained when negative SBCE videos were reanalyzed with a deep convolutional neural network (CNN) model. METHODS Clinical data of patients who received SBCE for suspected small-bowel bleeding at two academic hospitals between February 2018 and July 2020 were retrospectively collected. All SBCE videos read as negative were reanalyzed with the CNN algorithm developed in our previous study. Meaningful findings such as angioectasias and ulcers were finally decided after reviewing CNN-selected images by two gastroenterologists. RESULTS Among 202 SBCE videos, 103 (51.0%) were read as negative by humans. Meaningful findings were detected in 63 (61.2%) of these 103 videos after reanalyzing them with the CNN model. There were 79 red spots or angioectasias in 40 videos and 66 erosions or ulcers in 35 videos. After reanalysis, the diagnosis was changed for 10 (10.3%) patients who had initially negative SBCE results. During a mean follow-up of 16.5 months, rebleeding occurred in 19 (18.4%) patients. The rebleeding rate was 23.6% (13/55) for patients with meaningful findings and 16.1% (5/31) for patients without meaningful findings (P = 0.411). CONCLUSION Our CNN algorithm detected meaningful findings in negative SBCE videos that were missed by humans. The use of deep CNN for SBCE image reading is expected to compensate for human error.
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Affiliation(s)
- Kyung Seok Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - DoGyeom Park
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Young Cheung
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Seok Cho
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Il Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seungchul Lee
- Institute for Convergence Research and Education in Advanced Technology, Yonsei University, Seoul, Korea
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang, Korea
- Graduate School of Artificial Intelligence, Pohang University of Science and Technology, Pohang, Korea
| | - Han Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Sangnawakij P, Böhning D, Holling H, Jansen K. Nonparametric estimation of the random effects distribution for the risk or rate ratio in rare events meta-analysis with the arm-based and contrast-based approaches. Stat Med 2024; 43:706-730. [PMID: 38111986 DOI: 10.1002/sim.9981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/28/2023] [Accepted: 11/21/2023] [Indexed: 12/20/2023]
Abstract
Rare events are events which occur with low frequencies. These often arise in clinical trials or cohort studies where the data are arranged in binary contingency tables. In this article, we investigate the estimation of effect heterogeneity for the risk-ratio parameter in meta-analysis of rare events studies through two likelihood-based nonparametric mixture approaches: an arm-based and a contrast-based model. Maximum likelihood estimation is achieved using the EM algorithm. Special attention is given to the choice of initial values. Inspired by the classification likelihood, a strategy is implemented which repeatably uses random allocation of the studies to the mixture components as choice of initial values. The likelihoods under the contrast-based and arm-based approaches are compared and differences are highlighted. We use simulations to assess the performance of these two methods. Under the design of sampling studies with nested treatment groups, the results show that the nonparametric mixture model based on the contrast-based approach is more appropriate in terms of model selection criteria such as AIC and BIC. Under the arm-based design the results from the arm-based model performs well although in some cases it is also outperformed by the contrast-based model. Comparisons of the estimators are provided in terms of bias and mean squared error. Also included in the comparison is the mixed Poisson regression model as well as the classical DerSimonian-Laird model (using the Mantel-Haenszel estimator for the common effect). Using simulation, estimating effect heterogeneity in the case of the contrast-based method appears to behave better than the compared methods although differences become negligible for large within-study sample sizes. We illustrate the methodologies using several meta-analytic data sets in medicine.
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Affiliation(s)
- Patarawan Sangnawakij
- Department of Mathematics and Statistics, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Dankmar Böhning
- Mathematical Sciences and Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Heinz Holling
- Institute of Psychology, University of Münster, Münster, Germany
| | - Katrin Jansen
- Institute of Psychology, University of Münster, Münster, Germany
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Zullo A, De Francesco V, Gatta L, Scaccianoce G, Colombo M, Bringiotti R, Azzarone A, Rago A, Corti F, Repici A, Hassan C, Rossi RE. Small bowel lesions in patients with iron deficiency anaemia without overt bleeding: a multicentre study. Ann Hematol 2024; 103:1-4. [PMID: 37940717 DOI: 10.1007/s00277-023-05450-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/07/2023] [Indexed: 11/10/2023]
Abstract
The diagnostic work-up in iron deficiency anaemia (IDA) patients can be challenging when bleedings or malabsorption are not clinically manifest. Lesions on the small bowel mucosa may cause IDA. We evaluated the prevalence of lesions on the small bowel mucosa detected at Videocapsule Endoscopy (VCE) in IDA patients following negative upper and lower endoscopies. Clinical and endoscopic data collected in 5 centres were retrieved. Lesions with a high bleeding potential (P2) were computed, and predictive factors investigated at multivariate analysis. By considering data of 230 patients, the endoscopic examination detected a total of 96 (41.7%; 95% CI: 35.4-48.1) P2 lesions on the small bowel mucosa, including 4 (1.7%) cancers. The use of non-steroidal anti-inflammatory drugs was found to be the only associated factor at both univariate (OR: 5.7, 95% CI: 2.4-13.4; P <0.001) and multivariate (OR: 2.8; 95% CI: 1.7-3.9, P <0.01) analyses. Present study showed that evaluation of small bowel mucosa with VCE allows to disclose a potential cause of IDA in near half patients. The cooperation between haematologists and gastroenterologists in the diagnostic work-up may be useful.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology Unit, 'Nuovo Regina Margherita' Hospital, Rome, Italy.
| | | | - Luigi Gatta
- Gastroenterology Unit, 'Versilia Hospital', Lido di Camaiore, Italy
| | | | - Matteo Colombo
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | | | - Angela Rago
- Haematolgy Unit, 'Santo Spirito' Hospital, Rome, Italy
| | - Federico Corti
- Gastroenterology Unit, 'Versilia Hospital', Lido di Camaiore, Italy
| | - Alessandro Repici
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cesare Hassan
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Roberta Elisa Rossi
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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6
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Hirata I, Tsuboi A, Matsubara Y, Sumioka A, Takasago T, Tanaka H, Yamashita K, Takigawa H, Kotachi T, Yuge R, Urabe Y, Oka S. Long-term outcomes of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. J Gastroenterol Hepatol 2024; 39:165-171. [PMID: 37837361 DOI: 10.1111/jgh.16379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND AND AIM Although small-bowel capsule endoscopy (CE) is widely used for obscure gastrointestinal bleeding (OGIB), long-term outcomes for OGIB patients after negative CE remain unclear. Herein, we defined negative CE as P0 (no bleeding potential) or P1 (less likely to bleed), based on the P classification using CE. We aimed to clarify long-term outcomes of patients with OGIB after negative CE. METHODS This single-center observational study enrolled 461 consecutive patients with OGIB who underwent CE from March 2014 to October 2021 and were followed up for >1 year. We examined rebleeding rates and predictive factors. RESULTS Two hundred and twenty-four (49%) patients had P0, and 237 (51%) had P1 findings. Rebleeding occurred in 9% and 16% of patients in the P0 and P1 groups, respectively. Two patients in the P0 group and 15 in the P1 group showed rebleeding from the small bowel. The rate of small-bowel rebleeding was significantly lower in the P0 group than that in the P1 group (1% vs 6%, P = 0.002), as was the cumulative rebleeding rate (P = 0.004). In the multivariate analysis, history of endoscopic hemostasis (hazard ratio [HR] = 15.958, 95% confidence interval [CI]:4.950-51.447, P < 0.001) and P1 CE findings (HR = 9.989, 95% CI: 2.077-48.030, P = 0.004) were independently predicted small-bowel rebleeding. CONCLUSIONS OGIB with P0 CE findings rarely showed rebleeding from the small bowel. Rebleeding may occur in patients with OGIB. Patients with history of endoscopic hemostasis for small-bowel lesions or P1 CE findings should be followed up intensively.
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Affiliation(s)
- Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahiro Kotachi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ryo Yuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastrointestinal Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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7
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Ho AHY, Lui RN. The current and future clinical applications of capsule endoscopy. J Gastroenterol Hepatol 2024; 39:28-33. [PMID: 38238541 DOI: 10.1111/jgh.16490] [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: 01/04/2024] [Accepted: 01/04/2024] [Indexed: 01/31/2024]
Affiliation(s)
- Agnes H Y Ho
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rashid N Lui
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Kim JH, Nam SJ. Prediction models for recurrence in patients with small bowel bleeding. World J Clin Cases 2023; 11:3949-3957. [PMID: 37388787 PMCID: PMC10303624 DOI: 10.12998/wjcc.v11.i17.3949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/10/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
Obscure gastrointestinal bleeding (OGIB) has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy. OGIB can present as overt bleeding or occult bleeding, and small bowel lesions are the most common causes. The small bowel can be evaluated using capsule endoscopy, device-assisted enteroscopy, computed tomography enterography, or magnetic resonance enterography. Once the cause of small-bowel bleeding is identified and targeted therapeutic intervention is completed, the patient can be managed with routine visits. However, diagnostic tests may produce negative results, and some patients with small bowel bleeding, regardless of diagnostic findings, may experience rebleeding. Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans. Several studies have identified different factors associated with rebleeding, and a limited number of studies have attempted to create prediction models for recurrence. This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding. These models may aid clinicians in forming tailored patient management and surveillance.
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Affiliation(s)
- Ji Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
| | - Seung-Joo Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
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Pennazio M, Cortegoso Valdivia P, Triantafyllou K, Gralnek IM. Diagnosis and management of small-bowel bleeding. Best Pract Res Clin Gastroenterol 2023; 64-65:101844. [PMID: 37652647 DOI: 10.1016/j.bpg.2023.101844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/02/2023] [Indexed: 09/02/2023]
Abstract
Small-bowel (SB) bleeding is a challenging problem for the clinician, presenting many pitfalls in both diagnosis and subsequent treatment. Videocapsule endoscopy (VCE) and device-assisted enteroscopy (DAE) have revolutionized the approach to the patient with SB bleeding, allowing for the endoscopic diagnosis and management of what was previously only a surgical matter. The patients' assessment in SB bleeding is of foremost importance, as treatment success relies on a detailed evaluation of clinical history, suspicion for underlying lesions, and a careful selection and timing of diagnostic and therapeutic tools. This review will summarize current state-of-the-art evidence and practice points, to provide the clinician with a comprehensive guide towards the management of SB bleeding.
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Affiliation(s)
- Marco Pennazio
- University Division of Gastroenterology, City of Health and Science University Hospital, University of Turin, Turin, Italy.
| | - Pablo Cortegoso Valdivia
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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10
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Oka P, Ray M, Sidhu R. Small Bowel Bleeding: Clinical Diagnosis and Management in the Elderly. Expert Rev Gastroenterol Hepatol 2023:1-8. [PMID: 37184832 DOI: 10.1080/17474124.2023.2214726] [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: 05/16/2023]
Abstract
INTRODUCTION With the global increase in life expectancy, there is an increase in gastrointestinal presentations in the elderly. Small bowel bleeding (SBB) is a cause of significant morbidity in the elderly requiring multiple hospital visits, investigations and potentially expensive therapy. AREAS COVERED In this review we will outline the different modalities which are used for the diagnosis and management of SBB. We will also discuss the common causes of SBB in the elderly. EXPERT OPINION SBB in elderly has a significant impact on the quality of life of the elderly. Larger randomized studies in the elderly are urgently required to help guide clinicians on the best and most cost-effective treatment algorithm in this challenging cohort.
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Affiliation(s)
- Priya Oka
- Department of Gastroenterology, University of Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Royal Hallamshire Hospital, Sheffield, UK
| | - Meghna Ray
- Department of Gastroenterology, University of Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Royal Hallamshire Hospital, Sheffield, UK
| | - Reena Sidhu
- Department of Gastroenterology, University of Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Royal Hallamshire Hospital, Sheffield, UK
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11
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Pennazio M, Rondonotti E, Despott EJ, Dray X, Keuchel M, Moreels T, Sanders DS, Spada C, Carretero C, Cortegoso Valdivia P, Elli L, Fuccio L, Gonzalez Suarez B, Koulaouzidis A, Kunovsky L, McNamara D, Neumann H, Perez-Cuadrado-Martinez E, Perez-Cuadrado-Robles E, Piccirelli S, Rosa B, Saurin JC, Sidhu R, Tacheci I, Vlachou E, Triantafyllou K. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2023; 55:58-95. [PMID: 36423618 DOI: 10.1055/a-1973-3796] [Citation(s) in RCA: 86] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.
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Affiliation(s)
- Marco Pennazio
- University Division of Gastroenterology, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | | | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, London, UK
| | - Xavier Dray
- Sorbonne University, Endoscopy Unit, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Martin Keuchel
- Clinic for Internal Medicine, Agaplesion Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Tom Moreels
- Division of Gastroenterology and Hepatology, University Hospital Saint-Luc, Brussels, Belgium
| | - David S Sanders
- Sheffield Teaching Hospitals NHS Foundation Trust, Gastroenterology Sheffield, Sheffield, UK
| | - Cristiano Spada
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cristina Carretero
- Department of Gastroenterology. University of Navarre Clinic, Healthcare Research Institute of Navarre, Pamplona, Spain
| | - Pablo Cortegoso Valdivia
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Fuccio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Begona Gonzalez Suarez
- Gastroenterology Department - ICMDiM, Hospital Clínic of Barcelona, DIBAPS, CiBERHED, Barcelona, Spain
| | - Anastasios Koulaouzidis
- Centre for Clinical Implementation of Capsule Endoscopy, Store Adenomer Tidlige Cancere Center, Svendborg, University of Southern Denmark, Denmark
| | - Lumir Kunovsky
- 2nd Department of Internal Medicine - Gastroenterology and Geriatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Deirdre McNamara
- TAGG Research Centre, Department of Clinical Medicine, Trinity Centre, Tallaght Hospital, Dublin, Ireland
| | - Helmut Neumann
- Department of Medicine I, University Medical Center Mainz, Mainz, Germany
| | | | | | - Stefania Piccirelli
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
| | - Bruno Rosa
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga/Guimarães, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jean-Christophe Saurin
- Gastroenterology and Endoscopy Unit, Hospices Civils de Lyon, Hôpital E. Herriot, Lyon, France
| | - Reena Sidhu
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, Sheffield, United Kingdom.,Department of Infection, Immunity and Cardiovascular Diseases, University of Sheffield, United Kingdom
| | - Ilja Tacheci
- 2nd Department of Internal Medicine - Gastroenterology, University Hospital Hradec Králové, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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12
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Otani K, Shimada S, Watanabe T, Nadatani Y, Higashimori A, Ominami M, Fukunaga S, Hosomi S, Kamata N, Tanaka F, Nagami Y, Taira K, Fujiwara Y. Long-term rebleeding rate and predictive factors of rebleeding after capsule endoscopy in patients with obscure GI bleeding. Gastrointest Endosc 2022; 96:956-969.e3. [PMID: 35850171 DOI: 10.1016/j.gie.2022.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/04/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The incidence of rebleeding in obscure GI bleeding (OGIB) remains unclear. This study used capsule endoscopy (CE) to determine the long-term rebleeding rate and predictive factors for rebleeding in patients with OGIB. METHODS This single-center, observational study enrolled consecutive patients with OGIB who underwent CE as the first small intestinal examination between March 2004 and December 2015 and were followed up through medical records or letters. RESULTS Three hundred eighty-nine patients were included in the analysis. Survival curve analysis showed that the overall cumulative rebleeding rate in OGIB during the 5 years was 41.7%. Multivariate analysis using the Cox proportional hazards model revealed that overt OGIB (hazard ratio [HR], 2.017; 95% confidence interval [CI], 1.299-3.131; P = .002), anticoagulants (HR, 1.930; 95% CI, 1.093-3.410; P = .023), positive balloon-assisted enteroscopy findings after CE (HR, 2.927; 95% CI, 1.791-4.783; P < .001), and iron supplements without therapeutic intervention (HR, 2.202; 95% CI, 1.386-3.498; P = .001) were associated with rebleeding, whereas a higher minimum hemoglobin level (HR, .902; 95% CI, .834-.975; P = .009) and therapeutic intervention (HR, .288; 95% CI, .145-.570; P < .001) significantly reduced the risk of rebleeding. Among the Charlson Comorbidity Index components, liver cirrhosis was an independent predictor associated with rebleeding in patients with OGIB (HR, 4.362; 95% CI, 2.622-7.259; P < .001) and in patients with negative CE findings (HR, 8.961; 95% CI, 4.424-18.150; P < .001). CONCLUSIONS Rebleeding is common during the long-term follow-up of patients with OGIB. Careful follow-up is required for patients with liver cirrhosis or previous massive bleeding.
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Affiliation(s)
- Koji Otani
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Sunao Shimada
- Department of Gastroenterology, Osaka City Juso Hospital, Osaka, Japan
| | - Toshio Watanabe
- Department of Premier Preventive Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yuji Nadatani
- Department of Premier Preventive Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Akira Higashimori
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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13
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Mohan N, Jarrett S, Pop A, Rodriguez D, Dudnick R. Effect of small bowel transit time on accuracy of video capsule endoscopy in evaluating suspected small bowel bleeding. World J Gastrointest Pharmacol Ther 2022; 13:88-95. [PMID: 36405301 PMCID: PMC9669782 DOI: 10.4292/wjgpt.v13.i6.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/02/2022] [Accepted: 09/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Obscure small bowel bleeding is defined as gastrointestinal bleeding (GIB) that is unidentifiable with esophagogastroduodenoscopy and a colonoscopy with video capsule endoscopy (VCE) being the next gold standard step for evaluation. Small bowel transit time (SBTT) is a metric of a VCE study that is defined as the time the capsule takes to travel through the small intestine.
AIM To determine if SBTT within the VCE study, correlates to overall detection of obscure small bowel bleeds. Furthermore, we attempted to identify any existing correlation between SBTT and re-bleeding after a negative VCE study.
METHODS This is a single center retrospective analysis of VCE studies performed for overt and occult GIB at Einstein Medical Center, Philadelphia, between 2015 and 2019. Inclusion criteria primarily consisted of patients 18 years or older who had a VCE study done as part of the workup for a GIB. Patients with incomplete VCEs, poor preparation, or with less than 6 mo of follow up were excluded. A re-bleeding event was defined either as overt or occult within a 6-mo timeframe. Overt re-bleeding was defined as Visible melena or hematochezia with > 2 gm/dL drop in hemoglobin defined an overt re-bleeding event; whereas an unexplained > 2 gm/dL drop in hemoglobin with no visible bleeding defined an occult re-bleed.
RESULTS Results indicated that there was a significant and positive point biserial correlation between SBTT of 220 min and detection of a bleeding focus with a statistically significant p value of 0.008. However, the area under the curve was negligible when trying to identify a threshold time for SBTT to discriminate between risk of re-bleeding events after a negative VCE.
CONCLUSION In terms of SBTT and association with accuracy of VCE finding a bleeding focus, 220 min was found to be adequate transit time to accurately find a bleeding focus, when present. It was found that no threshold SBTT could be identified to help predict re-bleeding after a negative VCE.
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Affiliation(s)
- Nandakumar Mohan
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA 19141, United States
| | - Simone Jarrett
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA 19141, United States
| | - Alexander Pop
- Division of Gastrointestinal Diseases and Hepatology, Einstein Medical Center Philadelphia, Philadelphia, PA 19141, United States
| | - Daniel Rodriguez
- Department of Urban Health and Nutrition, Lasalle University, Philadelphia, PA 19141, United States
| | - Robert Dudnick
- Division of Gastrointestinal Diseases and Hepatology, Einstein Medical Center Philadelphia, Philadelphia, PA 19141, United States
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14
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Thurm T, Gluck N, Barak O, Deutsch L. Octa-nonagenarians can perform video capsule endoscopy safely and with a higher diagnostic yield than 65-79-year-old patients. J Am Geriatr Soc 2022; 70:2958-2966. [PMID: 35788980 PMCID: PMC9796662 DOI: 10.1111/jgs.17953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Video capsule endoscopy (VCE) is an effective, noninvasive modality for small bowel (SB) investigation. Its usage in the older adults is rising. However, data in octa-nonagenarians regarding diagnostic yield and motility are lacking. Our aim was to evaluate and compare safety and efficacy of VCE between age subgroups of older adult patients. METHODS This was a retrospective study of prospectively documented data. All consecutive VCEs of patients ≥65 years (01/2010-12/2017) were included. Patients unable to swallow the capsule or videos with significant recording technical malfunction were excluded. The cohort was divided into the younger group aged 65-79 years old and octa-nonagenarians aged ≥80 years old. Indications for referral, diagnostic yield and transit times were compared between groups. RESULTS A total of 535 VCEs were performed in 499 older adult patients (51.2% males); 82.8% were 65-79 years old and 17.2% were ≥80 years old. The ≥80-year-old group had higher rates of clinically significant findings (52.7% vs. 40.0%, p = 0.025), active bleeding (12.5% vs. 6.5%, p = 0.053) and angioectasia (36.0% vs. 23.4%, p = 0.014). Crohn's disease was newly diagnosed in approximately 8% of the entire cohort and 12% of the ≥80 years old. Anemia was the most common indication in both groups, followed by overt bleeding in the ≥80-year-old group (25% vs. 9.9% in 65-79-year-old group, p < 0.001) and Crohn's disease in the 65-79 years old (17.2% vs. 5.4% in ≥80 years old, p = 0.004). Groups were comparable in transit time and cecal documentation rates. CONCLUSIONS In octa-nonagenarians, VCE is as safe as in younger older-adults with a higher diagnostic yield of significant and treatable conditions.
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Affiliation(s)
- Tamar Thurm
- Department of Gastroenterology and Liver DiseasesTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael,Sackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Nathan Gluck
- Department of Gastroenterology and Liver DiseasesTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael,Sackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Orly Barak
- Sackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael,Geriatric DivisionTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael
| | - Liat Deutsch
- Department of Gastroenterology and Liver DiseasesTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael,Sackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael
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15
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Xu H, Chen Y, Wang M, Zhu S. Clinical features of capsule endoscopy in young adults: A single‐center retrospective study. JGH Open 2022; 6:637-642. [PMID: 36091324 PMCID: PMC9446405 DOI: 10.1002/jgh3.12801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/04/2022] [Accepted: 07/17/2022] [Indexed: 11/09/2022]
Abstract
Background and Aim Capsule endoscopy (CE) has been used in clinical examination among people of various ages, while few studies exclusively focused on the young. We aimed to explore its clinical features in young adults and those with obscure gastrointestinal bleeding (OGIB). Methods A total of 479 young adults aged 18–44 years were analyzed, with median age of 33 years. Primary positive findings of patients were classified into four kinds of lesions, and potential risk of bleeding among patients with OGIB was assessed based on Saurin classification (P0‐2 lesions). Results The overall completion rate and diagnostic yield of CE among young adults were 89.77 and 77.04%, respectively. Significant differences were found among overall completion rate/diagnostic yield and inpatient status/CE brand. Positive diagnostic yield among 157 patients with OGIB was 51.59% (P1‐2 lesions), and the significant risk of bleeding was 37.04% (P2 lesions). Among patients with OGIB in which 134 patients with a total of 216 lesions, ulceration was the commonest P2 lesions, followed by angioectasia and telangiectasia. Inpatient rate, completion rate, and diagnostic yield were higher among patients with overt OGIB, and disease categories of overt OGIB were different compared with occult OGIB. Conclusion CE is an optimal tool for discovering lesions in young adults and could play a role in evaluating the bleeding risk of young adults with OGIB.
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Affiliation(s)
- Hui‐Wen Xu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
| | - Yi‐Ru Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
| | - Mei‐Qian Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
| | - Sen‐Lin Zhu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
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16
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de Sousa Magalhães R, Sousa-Pinto B, Boal Carvalho P, Rosa B, Moreira MJ, Cotter J. RHEMITT score: Predicting the risk of mid gastrointestinal rebleeding after small bowel capsule endoscopy: A prospective validation. J Gastroenterol Hepatol 2022; 37:310-318. [PMID: 34555864 DOI: 10.1111/jgh.15695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/02/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM The RHEMITT score (Renal disease; Heart failure; Endoscopic findings; Major bleeding; Incomplete SBCE; Tobacco; Treatment by enteroscopy) was the first score to accurately predict the individual risk of small bowel rebleeding after capsule endoscopy (SBCE). The aim of the study is on the prospective validation of the RHEMITT score. METHODS Cohort of consecutive patients with mid-gastrointestinal bleeding (MGIB) submitted to SBCE and followed prospectively, during at least 12 months, since 2017 until 2020. Rebleeding was defined as an overt bleeding event (melena or hematochezia) or a hemoglobin decrease of at least 2 g/dL. The RHEMITT score was calculated for each patient and the rebleeding rates compared. The performance of the score was tested by calculating the area under curve of the receiver operator characteristic curve. A rebleeding-free survival was assessed, corresponding to the period between the date of SBCE and the date of the first post-SBCE rebleeding event. RESULTS We included 162 patients, 102 (62.9%) were female, with a mean age of 64 years old. The sensitivities and specificities of the score grades for predicting rebleeding were as following: for low-risk patients, 0% (0-10%) and 28.8% (21.1-36.5%); for intermediate-risk patients, 23.3% (8.2-38.4%) and 72% (64.3-79.7%); for high-risk patients, 76.7% (61.6-91.8%) and 99.2% (97.7-100%), corresponding to an area under curve of the receiver operator characteristic of 0.988 (P < 0.001). Kaplan-Meyer plots were statistically different according to the attributed risk (log-rank P value <0.001; Breslow-Wilcoxon P value <0.001). CONCLUSION The RHEMITT score performed with excellent discriminative power in predicting rebleeding risk, and we herewith propose a surveillance of MGIB patients guided by the RHEMITT score.
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Affiliation(s)
- Rui de Sousa Magalhães
- Gastroenterology Department, Hospital Senhora da Oliveira-Guimarães, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães, Portugal
| | - Bernardo Sousa-Pinto
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Pedro Boal Carvalho
- Gastroenterology Department, Hospital Senhora da Oliveira-Guimarães, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães, Portugal
| | - Bruno Rosa
- Gastroenterology Department, Hospital Senhora da Oliveira-Guimarães, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães, Portugal
| | - Maria João Moreira
- Gastroenterology Department, Hospital Senhora da Oliveira-Guimarães, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital Senhora da Oliveira-Guimarães, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães, Portugal
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17
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Snook J, Bhala N, Beales ILP, Cannings D, Kightley C, Logan RP, Pritchard DM, Sidhu R, Surgenor S, Thomas W, Verma AM, Goddard AF. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut 2021; 70:2030-2051. [PMID: 34497146 PMCID: PMC8515119 DOI: 10.1136/gutjnl-2021-325210] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA-for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease- with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.
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Affiliation(s)
- Jonathon Snook
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Neeraj Bhala
- Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust and Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ian L P Beales
- Gastroenterology, University of East Anglia, Norwich, UK
| | - David Cannings
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Chris Kightley
- Digestive Diseases, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | | | - D Mark Pritchard
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool and Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Reena Sidhu
- Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Sue Surgenor
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Wayne Thomas
- Haematology, Plymouth Hospitals NHS Foundation Trust, Plymouth, Plymouth, UK
| | - Ajay M Verma
- Digestive Diseases, Kettering General Hospital NHS Foundation Trust, Kettering, UK
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18
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Zhao R, Nakamura M, Wu S, Uchida G, Yamamura T, Gao YJ, Goto H, Fujishiro M, Ge ZZ. The role of early video capsule endoscopy in the diagnosis and prognosis of obscure gastrointestinal bleeding: A multi-center propensity score matching study. J Gastroenterol Hepatol 2021; 36:2540-2548. [PMID: 33724526 DOI: 10.1111/jgh.15491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/17/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Video capsule endoscopy (VCE) is a first-line procedure for the diagnosis of obscure gastrointestinal bleeding (OGIB). The opinions on the timing for such diagnostic evaluation remain unclear. We aimed to explore the role of early VCE in OGIB patients. METHODS A total of 997 patients that underwent VCE at Renji Hospital and Nagoya University from May 15, 2002, to December 28, 2016, were included in this study. We matched patients that underwent early VCE within 14 days of bleeding (early group, n = 678) to patients that did not (late group, n = 319) via 1:1 propensity score matching (PSM). We then compared VCE diagnostic rates and the prevalence of post-VCE rebleeding in patients with initial negative VCE findings within 1 year between these groups before and after PSM. RESULTS Following PSM, early VCE was associated with a significantly higher rate of OGIB diagnosis (56.4% vs 45.5%, P = 0.001) and with a significantly lower incidence of rebleeding within 1 year following treatment (24.7% vs 36.7%, P = 0.041). In univariate and multivariate analyses, VCE timing (odds ratio 0.648; 95% confidence interval 0.496-0.847, P = 0.001 and odds ratio 0.666; 95% confidence interval 0.496-0.894, P = 0.007, respectively) was found to be linked with a higher rate of positive findings. CONCLUSION Early VCE can improve the reliability of OGIB diagnosis while also reducing rates of post-VCE rebleeding. This suggests that timely and accurate diagnosis can help to improve OGIB patient treatment and prognosis.
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Affiliation(s)
- Ran Zhao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Shan Wu
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Genta Uchida
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Yun-Jie Gao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Zhi-Zheng Ge
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
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19
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Westrich D, Hachem C, Boumitri C. Iron Deficiency and the Small bowel. Curr Gastroenterol Rep 2021; 23:12. [PMID: 34236539 DOI: 10.1007/s11894-021-00812-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options. RECENT FINDINGS Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.
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Affiliation(s)
- David Westrich
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, 63104, USA
| | - Christine Hachem
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, 63104, USA
| | - Christine Boumitri
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, 63104, USA.
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20
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Pérez-Cuadrado Robles E, Perrod G, Moreels TG, Zamora Nava LE, Blanco Velasco G, Esteban Delgado P, Samaha E, Hernández-Mondragón ÓV, Rahmi G, Cellier C. A comprehensive systematic review and meta-analysis of risk factors for rebleeding following device-assisted enteroscopy therapy of small-bowel vascular lesions. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 112:249-257. [PMID: 32193939 DOI: 10.17235/reed.2020.6802/2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION the aim of this study was to determine the risk factors for rebleeding following device-assisted enteroscopy therapy of small bowel vascular lesions. METHODS this is a systematic review and meta-analysis. A literature search was performed from January 2003 to October 2019. All studies reporting on at least one risk factor for bleeding recurrence after endoscopic therapy of small bowel vascular lesions were included. A meta-analysis of those risk factors reported in at least three studies was performed to assess their association with rebleeding. The OR and 95 % CI were used for binary outcome data. Heterogeneity analysis was performed using the Tau and I2 index. If I2 > 20 %, potential sources of heterogeneity were identified by sensitivity analyses and a random-effect model was used. RESULTS the search identified a total of 572 articles and 35 full-text records were assessed for eligibility after screening. Finally, eight studies that included 548 patients were selected. The overall median rebleeding rate was 38.5 % (range: 10.9-53.3 %) with a median follow-up of 24.5 months. Female sex (OR: 1.96, 95 % CI: 1.14-3.37, p = 0.01, I2 = 0 %), Osler-Weber syndrome (OR: 4.35, 95 % CI: 1.22-15.45, p = 0.02, I2 = 0 %) and cardiac disease (OR: 1.89, 95 % CI: 1.12-2.97, p = 0.005, I2: 0 %) were associated with rebleeding. According to the sensitivity analysis, overt bleeding (OR: 2.13, 95 % CI: 1.22-3.70, p = 0.007, I2 = 0 %), multiple lesions (OR: 4.57, 95 % CI: 2.04-10.22, p < 0.001, I2 = 0 %) and liver cirrhosis (OR: 2.61, 95 % CI: 1.11-6.13, p = 0.03, I2 = 0 %) were also predictors for rebleeding. CONCLUSIONS patient characteristics and comorbidities should be considered for follow-up patient management after effective device-assisted endoscopic therapy, as they can predict rebleeding.
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Affiliation(s)
| | | | - Tom G Moreels
- Gastroenterology, Cliniques universitaires Saint-Luc, Belgium
| | | | | | | | - Elia Samaha
- Gastroenterology, Hotel Dieu de France, Lebanon
| | | | - Gabriel Rahmi
- Gastroenterology, Georges-Pompidou European Hospital, Francia
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21
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Rosa B, Margalit-Yehuda R, Gatt K, Sciberras M, Girelli C, Saurin JC, Cortegoso Valdivia P, Cotter J, Eliakim R, Caprioli F, Baatrup G, Keuchel M, Ellul P, Toth E, Koulaouzidis A. Scoring systems in clinical small-bowel capsule endoscopy: all you need to know! Endosc Int Open 2021; 9:E802-E823. [PMID: 34079861 PMCID: PMC8159625 DOI: 10.1055/a-1372-4051] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/26/2020] [Indexed: 02/08/2023] Open
Abstract
AbstractCapsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2
3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4
5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8
9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.
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Affiliation(s)
- Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Reuma Margalit-Yehuda
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Kelly Gatt
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Carlo Girelli
- Department of Internal Medicine, Gastroenterology & Digestive Endoscopy, Hospital of Busto Arsizio, Italy
| | - Jean-Christophe Saurin
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastro-Entérologie et d'Endoscopie Digestive, Lyon, France
| | - Pablo Cortegoso Valdivia
- Gastroenterology & Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Jose Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Flavio Caprioli
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Cà Granda, Ospedale Policlinico di Milano, Milan, Italy
| | - Gunnar Baatrup
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Pierre Ellul
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Ervin Toth
- Skåne University Hospital, Lund University, Malmö, Sweden
| | - Anastasios Koulaouzidis
- Endoscopy Unit, The Royal Infirmary of Edinburgh, Scotland, UK
- Department of Social Medicine & Public Health, Pomeranian Medical University, Szczecin, Poland
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Negative Video Capsule Endoscopy Had a High Negative Predictive Value for Small Bowel Lesions, but Diagnostic Capability May Be Lower in Young Patients with Overt Bleeding. Can J Gastroenterol Hepatol 2021; 2021:8825123. [PMID: 34036087 PMCID: PMC8123999 DOI: 10.1155/2021/8825123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/18/2021] [Accepted: 04/28/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Patients with potential small bowel bleeding (PSBB) who have negative results of video capsule endoscopy (VCE), clinical course, rate of rebleeding, and missed lesions with their predictors are essential for further management decision. METHODS This retrospective study included patients presenting with PSBB who had negative VCE findings between January 2008 and December 2016. All patients had to have at least two years of follow-up data to be included. Patients with <2 years of follow-up in their medical record were interviewed by telephone to determine if any unrecorded rebleeding episodes occurred. RESULTS One hundred forty-two patients were included. The mean age was 60.9 years, and 52.8% were male. Eighty-one patients presented with overt bleeding. The median duration of follow-up was 5.08 years. During the follow-up period, 30 patients experienced rebleeding. The cumulative rate of rebleeding at 1, 2, and 5 years was 10.0%, 14.3%, and 22.4%, respectively. Multivariate analysis showed nonsteroidal anti-inflammatory drugs (NSAIDs) and presentation of overt bleeding to be independent predictors of rebleeding. There were only nine small bowel lesions (6.3%) missed by VCE. These nine patients, compared with others, were significantly younger and tended to present with overt bleeding. CONCLUSION Rebleeding was not uncommon in PSBB after negative VCE; however, the rate of missing small bowel lesions was low. Nonetheless, further investigations may be considered in young patients who present with overt bleeding.
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23
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Cho YK, Park H, Moon JR, Jeon SR, Kim HG, Lee TH, Park J, Kim JO, Lee JS, Goong HJ, Ko BM, Park S. Clinical Outcomes between P1 and P0 Lesions for Obscure Gastrointestinal Bleeding with Negative Computed Tomography and Capsule Endoscopy. Diagnostics (Basel) 2021; 11:diagnostics11040657. [PMID: 33917389 PMCID: PMC8067371 DOI: 10.3390/diagnostics11040657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A simple classification for the relevance of lesions (P0, P1, and P2; no bleeding potential, less likely to bleed, and more likely to bleed, respectively) based on capsule endoscopy (CE) findings has been used. This study aimed at investigating rebleeding rates and predictive factors of P0 and P1 lesions after obtaining negative findings in both, CE and computed tomography (CT), for patients with obscure gastrointestinal bleeding (OGIB). METHODS Among 193 patients resulted in negative CE findings defined as P0 or P1 lesions, 84 patients with negative results on CT images were enrolled in this study. The rebleeding rates and predictive factors were assessed in the P0 and P1 groups. RESULTS Overall rebleeding rate in patients with negative CT and CE was 17.9%; 18.4% in the P0 group; 17.4% in the P1 group within a median follow-up duration of 18.5 months. In the P0 and P1 groups, the cumulative rebleeding rates were 9.2%, 25.4%, and 25.4%, and 6.9%, 11.8%, and 18.6% at 12, 24, and 60 months, respectively (p = 0.97). There were no independent rebleeding associated factors in the P0 group, whereas Charlson comorbidity index (CCI) (hazard ratio (HR) = 2.019, 95% confidence interval (CI): 1.158-3.519, p = 0.013), and initial low hemoglobin (Hb) level (<8 g/dL) (HR = 15.085, 95% CI: 1.182-192.514, p = 0.037) were independent predictive factors responsible for rebleeding in the P1 group. CONCLUSIONS Despite having negative findings on CT and CE, patients with OGIB have a significant potential rebleeding risk. Although there was no significant difference in rebleeding rates between the P0 and P1 groups on CE, the P1 group, with CCI or low initial Hb level, should be cautiously observed after the first bleeding episode.
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Affiliation(s)
- Young Kyu Cho
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Heesu Park
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Jung Rock Moon
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Seong Ran Jeon
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
- Correspondence: ; Tel.: +82-2-709-9202; Fax: +82-2-709-9581
| | - Hyun Gun Kim
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Tae Hee Lee
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Junseok Park
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Jin-Oh Kim
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Joon Seong Lee
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Hyeon Jeong Goong
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Bong Min Ko
- Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea; (Y.K.C.); (H.P.); (J.R.M.); (H.G.K.); (T.H.L.); (J.P.); (J.-O.K.); (J.S.L.); (H.J.G.); (B.M.K.)
| | - Suyeon Park
- Department of biostatistics, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea;
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Abstract
Video capsule endoscopy and device-assisted enteroscopy are complementary technologies. Capsule endoscopy is a highly acceptable technology with high diagnostic yield that can guide a subsequent enteroscopy approach. This article aims to focus on the role of video capsule endoscopy as a prelude to deep enteroscopy with a focus on the strengths and limitations of either approach.
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25
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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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26
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Melson J, Trikudanathan G, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Jirapinyo P, Krishnan K, Kumta NA, Pannala R, Parsi MA, Sethi A, Trindade AJ, Watson RR, Maple JT, Lichtenstein DR. Video capsule endoscopy. Gastrointest Endosc 2021; 93:784-796. [PMID: 33642034 DOI: 10.1016/j.gie.2020.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pichamol Jirapinyo
- Department of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Amrita Sethi
- Department of Digestive and Liver Diseases, Columbia University Medical Center/New York-Presbyterian, New York, New York, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Pennazio M, Rondonotti E, Pellicano R, Cortegoso Valdivia P. Small bowel capsule endoscopy: where do we stand after 20 years of clinical use? Minerva Gastroenterol (Torino) 2020; 67:101-108. [PMID: 32677419 DOI: 10.23736/s2724-5985.20.02745-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Small bowel capsule endoscopy (SBCE) was introduced into clinical practice almost 20 years ago and, nowadays, it is an essential tool for the study of the small bowel. SBCE allows a radiation-free examination of the entire mucosal surface of the small bowel with high-quality images, limited invasivity and a good safety profile. Nevertheless, the main limitation of SBCE is the lack of any possible direct therapeutic intervention. Indications for SBCE have evolved throughout the years, from "old" ones such as suspected small bowel bleeding (still the main indication for SBCE) to newer ones such as refractory celiac disease, hereditary polyposis syndromes and Crohn's disease. Thus, nowadays SBCE has a key role in the diagnostic algorithms in many conditions. Furthermore, the introduction in the SBCE field of cutting-edge technologies, as artificial intelligence systems, is likely to shorten the reading time making SBCE even more effective and easy to perform. Preliminary data are extremely promising and solid evidence is being gathered by current studies.
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Affiliation(s)
- Marco Pennazio
- University Division of Gastroenterology, Città della Salute e della Scienza, University of Turin, Turin, Italy -
| | | | - Rinaldo Pellicano
- University Division of Gastroenterology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Pablo Cortegoso Valdivia
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
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28
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Takada K, Yabuuchi Y, Kakushima N. Evaluation of current status and near future perspectives of capsule endoscopy: Summary of Japan Digestive Disease Week 2019. Dig Endosc 2020; 32:529-531. [PMID: 32124490 DOI: 10.1111/den.13659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Kazunori Takada
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Wetwittayakhlang P, Wonglhow J, Netinatsunton N, Chamroonkul N, Piratvisuth T. Re-bleeding and its predictors after capsule endoscopy in patients with obscure gastrointestinal bleeding in long-term follow-up. BMC Gastroenterol 2019; 19:216. [PMID: 31842770 PMCID: PMC6916023 DOI: 10.1186/s12876-019-1137-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022] Open
Abstract
Background Capsule endoscopy (CE) is the preferred diagnostic test of choice in the investigation of obscure gastrointestinal bleeding (OGIB). Although, a conservative strategy is recommended in the short-term, for cases with a negative result from CE, the impact of CE on long-term re-bleeding still remains unclear. Hence, the aim of this study was to determine the long-term re-bleeding rate along with predictors after CE in patients with OGIB. Methods We retrospectively reviewed 216 patients with OGIB, whom had received a CE examination, so as to investigate the cause of obscure GI bleeding; between July 2008 and March 2018. The patient’s characteristics, medication use, CE finding, treatments strategy, re-bleeding episodes and follow-up information were collected from the institutional electronic medical chart and CE database. Re-bleeding free survival was evaluated using Kaplan-Meier curves with log rank test, whilst predictors associated with the re-bleeding episodes were analyzed via the use of Cox proportional hazard model. Results One hundred and thirty-three patients with OGIB, having received CE were enrolled in the analysis. The pool rate of re-bleeding was 26.3% (35/133) during a follow-up duration of 26 months after CE. Patients with positive CE study, without specific treatment, had higher rates of re-bleeding (47.6%) than those with positive study whom received specific treatment (25.7%), and negative study (20.8%) (p = 0.042). Although, the re-bleeding free survival was not significantly different among the groups (log rank test; P = 0.10). Re-bleeding events occurring within 6, 12, and 24 months after CE were 36, 64 and 92%, respectively. The high-frequency re-bleeding etiologies were the small bowel angiodysplasias and abnormal vascular lesions. Furthermore, independent predictors for re-bleeding after CE were patients with cirrhosis (hazard ratio, HR 4.06), incomplete CE visualization (HR 2.97), and a history of previous GI bleeding (HR 2.80). Conclusions The likelihood of re-bleeding after CE was higher in patients with positive CE study than those with negative study. Specific treatments, or therapeutic interventions for patients with detectable lesions reduced the probability of re-bleeding episodes in long-term follow-up. Close follow-up for recurrent bleeding is recommeded for at least 2 years after CE.
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Affiliation(s)
- Panu Wetwittayakhlang
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.
| | - Jirapat Wonglhow
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Nisa Netinatsunton
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Naichaya Chamroonkul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Teerha Piratvisuth
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
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Clinical Utility of Emergency Capsule Endoscopy for Diagnosing the Source and Nature of Ongoing Overt Obscure Gastrointestinal Bleeding. Gastroenterol Res Pract 2019; 2019:5496242. [PMID: 31885542 PMCID: PMC6914955 DOI: 10.1155/2019/5496242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/26/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background and Aims In patients with ongoing overt obscure gastrointestinal bleeding (OGIB), prompt detection of the bleeding source is crucial to treatment success. However, there is no consensus on the optimal timing of diagnostic capsule endoscopy (CE). We investigated the clinical utility of emergency CE for detecting the source of ongoing overt OGIB. Methods We retrospectively evaluated 146 consecutive patients who, between February 2009 and July 2018, underwent emergency CE at Hiroshima University Hospital to detect the source of ongoing overt OGIB. Patients with a bleeding source located outside the small bowel were excluded. The remaining 127 patients were stratified according to the timing of CE relative to the onset of bleeding: patients in group A (n = 15, 12 men; mean age: 75 years; age range: 62–83 years) underwent CE within 48 hours of bleeding onset, whereas patients in group B (n = 112, 73 men; mean age: 65 years; age range: 17–88 years) underwent CE at >48 hours after bleeding onset. All patients underwent double-balloon endoscopy, and the final diagnosis was compared against the CE findings. Results The CE lesion detection rate was significantly higher in group A (12/15 patients, 80%) than in group B (53/112 patients, 47%) (p = 0.0174). There was no significant difference between the two groups regarding the patients' background characteristics. Vascular lesions were the most frequent finding in both groups. The diagnostic concordance rate between emergency CE and double-balloon endoscopy was 100% in group A and 92.9% in group B. Rebleeding after endoscopic treatment was confirmed in only one patient in group B. Conclusions Emergency CE represents a useful diagnostic modality in patients with ongoing overt OGIB, potentially improving detection rates and reducing rebleeding risk.
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31
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The future of capsule endoscopy in clinical practice: from diagnostic to therapeutic experimental prototype capsules. GASTROENTEROLOGY REVIEW 2019; 15:179-193. [PMID: 33005262 PMCID: PMC7509905 DOI: 10.5114/pg.2019.87528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 02/08/2023]
Abstract
Capsule endoscopy (CE) is indicated as a first-line clinical examination for the detection of small-bowel pathology, and there is an ever-growing drive for it to become a method for the screening of the entire gastrointestinal tract (GI). Although CE's main function is diagnosis, the research for therapeutic capabilities has intensified to make therapeutic capsule endoscopy (TCE) a target within reach. This manuscript presents the research evolution of CE and TCE through the last 5 years and describes notable problems, as well as clinical and technological challenges to overcome. This review also reports the state-of-the-art of capsule devices with a focus on CE research prototypes promising an enhanced diagnostic yield (DY) and treatment. Lastly, this article provides an overview of the research progress made in software for enhancing DY by increasing the accuracy of abnormality detection and lesion localisation.
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Leung KK, Khan U, Zhang M, McCurdy JD, James PD. History of malignancy and relevant symptoms may predict a positive computed tomography enterography in obscure gastrointestinal bleeds. J Gastroenterol Hepatol 2019; 34:1511-1516. [PMID: 30965387 DOI: 10.1111/jgh.14682] [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] [Received: 06/16/2018] [Revised: 03/24/2019] [Accepted: 04/03/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM This study aimed to assess the clinical utility of computed tomography enterography (CTE) and identify factors associated with a diagnostic CTE for patients with obscure gastrointestinal bleeding (OGIB). METHODS A retrospective observational study was performed at a Canadian tertiary care center from 2005 to 2015. A total of 138 patients underwent a CTE for OGIB. Univariate and multivariate logistic regressions were performed to determine factors associated with a diagnostic CTE. A highly sensitive clinical rule was then developed to help identify OGIB patients for whom a CTE may be beneficial in their clinical work-up. RESULTS A possible bleeding source was identified in 30 (22%) cases. The presence of abdominal or constitutional symptoms as well as history of colorectal cancer was significantly associated with a positive CTE in univariate and multivariate analyses (P < 0.05). A positive CTE could be predicted based on the presence of abdominal or constitutional symptoms and history of colorectal cancer with 90% sensitivity (95% CI 74-98%) in our population. CONCLUSION CTE identified a possible source of OGIB in one in five cases. In patients with the presence of abdominal or constitutional symptoms and a personal history of colorectal cancer, CTE may contribute to their diagnostic work-up.
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Affiliation(s)
- Kristel K Leung
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Usman Khan
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Mei Zhang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey D McCurdy
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul D James
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Sakai E, Ohata K, Nakajima A, Matsuhashi N. Diagnosis and therapeutic strategies for small bowel vascular lesions. World J Gastroenterol 2019; 25:2720-2733. [PMID: 31235995 PMCID: PMC6580356 DOI: 10.3748/wjg.v25.i22.2720] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.
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Affiliation(s)
- Eiji Sakai
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
| | - Atsushi Nakajima
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Nobuyuki Matsuhashi
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
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Robertson AR, Yung DE, Douglas S, Plevris JN, Koulaouzidis A. Repeat capsule endoscopy in suspected gastrointestinal bleeding. Scand J Gastroenterol 2019; 54:656-661. [PMID: 31017489 DOI: 10.1080/00365521.2019.1606932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: This study aims to review the utility of repeat capsule endoscopy (CE) with on-going concern of small bowel (SB) bleeding following initial SB investigation with CE. Materials and methods: A specifically designed database of CE examinations performed over 13 years, with hospital records, was retrospectively interrogated for patients undergoing multiple CEs to investigate iron deficiency anaemia (IDA) or suspected SB bleeding. Results: 1335/2276 (58.7%) of CEs were performed to investigate IDA or SB bleeding; 92 were repeat CEs carried out for ongoing clinical concern. The median time interval between initial and repeat CE procedures was 466.5 (range 1-3066) days. Twenty-four patients had initially normal CE; on repeat examination, abnormalities were detected in 11/24 (45.8%). 3/21 (14.2%) of patients with angioectasia on first CE had alternative causes for IDA or GI bleeding detected on repeat CE. Six patients with active bleeding, without an identifiable source on initial CE, undergoing repeat CE had a cause isolated in 5/6 (83.3%). Changing CE device did not affect diagnostic yield (DY) compared to repeat CE using the same device (27.5% to 26.8%). Conclusions: It is known that CE can miss clinically relevant and serious lesions. Our results suggest that patients with an initially negative or inconclusive CE frequently have a cause of SB bleeding detected on repeat CE. The DY of repeat CE is highest in those with bleeding on their initial CE (83.3%) and lower in those with initially normal examinations (45.8%) or when an alternative cause, such as angioectasia is seen (14.2%).
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Affiliation(s)
- A R Robertson
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - D E Yung
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - S Douglas
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - J N Plevris
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - A Koulaouzidis
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
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Chetcuti Zammit S, Sanders DS, McAlindon ME, Sidhu R. Optimising the use of small bowel endoscopy: a practical guide. Frontline Gastroenterol 2019; 10:171-176. [PMID: 31205659 PMCID: PMC6540267 DOI: 10.1136/flgastro-2018-101077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 02/04/2023] Open
Abstract
The wireless nature of capsule endoscopy offers patients the least invasive option for small bowel investigation. It is now the first-line test for suspected small bowel bleeding. Furthermore meta-analyses suggest that capsule endoscopy outperforms small bowel imaging for small bowel tumours and is equivalent to CT enterography and magnetic resonance enterography for small bowel Crohn's disease. A positive capsule endoscopy lends a higher diagnostic yield with device-assisted enteroscopy. Device-assisted enteroscopy allows for the application of therapeutics to bleeding points, obtain histology of lesions seen, tattoo lesions for surgical resection or undertake polypectomy. It is however mainly reserved for therapeutics due to its invasive nature. Device-assisted enteroscopy has largely replaced intraoperative enteroscopy. The use of both modalities is discussed in detail for each indication. Current available guidelines are compared to provide a concise review.
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Affiliation(s)
- Stefania Chetcuti Zammit
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Mark E McAlindon
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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Alsahafi M, Cramer P, Chatur N, Donnellan F. The impact of inpatient capsule endoscopy on the need for therapeutic interventions in patients with obscure gastrointestinal bleeding. Saudi J Gastroenterol 2019; 26:53-60. [PMID: 31997779 PMCID: PMC7045773 DOI: 10.4103/sjg.sjg_415_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/AIM There are limited data evaluating the impact of inpatient video capsule endoscopy (VCE) on the need for therapeutic interventions in hospitalized patients with obscure gastrointestinal bleeding (OGIB). The objective of this study was to determine the impact of inpatient VCE on the need for therapeutic interventions and rehospitalization for recurrent bleeding. PATIENTS AND METHODS Hospitalized patients who underwent VCE for OGIB indication were retrospectively included. Clinical data were collected including therapeutic interventions performed after VCE. Specific therapeutic interventions were defined as the medical, endoscopic, or surgical treatment directly targeting the cause of OGIB. Patients were followed up to determine the rate of rehospitalization. RESULTS A total of 48 inpatient VCE were identified, of which 43 VCE were performed for OGIB indication and were included for analysis. The completion rate and the diagnostic yield were 78.5% and 55.8%, respectively. Subsequent specific therapeutic interventions were performed in 65.2% and 5.8% of patients with positive and negative VCE, respectively (P < 0.001). After a median follow up of 30 months (minimum 12, maximum 58), rehospitalization for recurrent bleeding occurred in 30.4% and 17% of patients with positive and negative VCE, respectively. Patients with angiodysplasia on VCE were significantly more likely to be readmitted (P = 0.02). Throughout the course of the follow-up, only 2 (11.7%) patients with negative VCE underwent specific therapeutic interventions. CONCLUSION Inpatient VCE is an effective tool to identify patients who need specific therapeutic interventions. Patients with negative VCE are unlikely to be readmitted or require specific therapeutic interventions in the index admission.
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Affiliation(s)
- Majid Alsahafi
- Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,Address for correspondence: Dr. Majid Alsahafi, Department of Medicine, King Abdulaziz University, Building 10, second Floor, P.O. Box 80215, Jeddah - 21589, Saudi Arabia. E-mail:
| | - Paula Cramer
- Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nazira Chatur
- Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fergal Donnellan
- Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Mosquera-Klinger GA, Camargo Trillos J, Gómez Ramirez LA, Bustamante Duque M, Carvajal Gutierrez JJ. Experiencia con videocápsula endoscópica en el estudio y diagnóstico de enfermedades del intestino delgado en un hospital de alta complejidad en Medellín, Colombia. ACTA ACUST UNITED AC 2018. [DOI: 10.22516/25007440.223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introducción: el intestino delgado (ID) es un órgano difícil de estudiar debido a su gran tamaño y ubicación anatómica; los estudios endoscópicos convencionales (esofagogastroduodenoscopia y colonoscopia) no logran evaluarlo en su totalidad y la enteroscopia con balón es más invasiva, con mayores efectos adversos y tasas de complicaciones. La videocápsula endoscópica (VCE) es una tecnología mínimamente invasiva que permite visualizar de forma dinámica y completa la mucosa del ID; es el método directo más seguro y con menos tasas de complicaciones.Metodología: se realizó un estudio descriptivo de corte transversal, para describir la experiencia clínica en la utilización de la VCE en un hospital de alta complejidad en Medellín, Colombia; asimismo, determinar las indicaciones, síntomas más comunes y hallazgos anormales.Resultados: se realizaron 374 VCE en el período de estudio: 282 ambulatorias (75,4 %) y 92 hospitalizados (24,6 %). En ambos grupos la indicación más frecuente fue sangrado digestivo oscuro (38,65 % y 53,26 %, respectivamente), seguidos por anemia crónica en el 27,65 % de ambulatorios y por enfermedad inflamatoria intestinal (EII) en 21,74 % de los hospitalizados. Los hallazgos anormales fueron más frecuentes en el yeyuno y las lesiones más comunes fueron angiodisplasias y lesiones inflamatorias.Conclusiones: en las indicaciones más frecuentes (sangrado digestivo oscuro y anemia) se documentaron potenciales fuentes de sangrado en más del 70 % de los casos; siendo las lesiones vasculares e inflamatorias los hallazgos más comunes. En seguimiento o evaluación de EII se documentaron en más del 50 % lesiones inflamatorias. La VCE es muy segura, no se presentó ninguna complicación relacionada con la VCE.
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Negative video capsule enteroscopy – what's the next step? GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:663-669. [DOI: 10.1016/j.gastrohep.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 02/08/2023]
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Yung DE, Koulaouzidis A, Douglas S, Plevris JN. Earlier use of capsule endoscopy in inpatients with melena or severe iron deficiency anemia reduces need for colonoscopy and shortens hospital stay. Endosc Int Open 2018; 6:E1075-E1084. [PMID: 30211295 PMCID: PMC6133651 DOI: 10.1055/a-0640-2956] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 03/07/2018] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Capsule endoscopy(CE) is a well-established investigation for iron deficiency anemia (IDA) and melena, usually following negative upper and lower endoscopy. We aimed to study the effect of earlier CE in the investigative pathway for inpatients with IDA or melena at a large tertiary referral centre. Patients and methods We analyzed inpatients undergoing CE for IDA or melena from 2005 to 2017, without signs/symptoms suggesting lower gastrointestinal tract pathology. Patients underwent CE following negative upper and lower gastrointestinal endoscopy (Group 1), or negative upper gastrointestinal endoscopy (UGIE) only (Group 2). Results One hundred and seventy inpatients underwent CE for IDA (n = 44) and melena (n = 126). In Group 1, 46/95 (48.4%) patients had small bowel (SB) findings. CE found 16/95 (16.8 %) gastric and 12/95 (12.6 %) colon findings. Three of 12 patients with colon findings required repeat colonoscopy. One hundred and three colon investigations were carried out for 95 admissions. In Group 2, 33/75 (44.0%) patients had SB findings. There were 12/75 (16.0 %) gastric and 11/75 (14.7 %) colon findings. In patients with positive CE, significant colonic findings led to colonoscopy in 10 of 39 patients (diagnostic yield 6/10). Thirty-six patients had negative CE; 15 underwent colonoscopy (diagnostic yield 9/15). The remaining 21 of 36 patients with no further colonoscopy did not develop adverse outcomes related to colonic pathology. Twenty-six colon investigations were carried out in 75 admissions. Patients in Group 2 had shorter mean times from admission to CE (5.08 ± 3.80 vs. 6.38 ± 3.80 days; P = 0.02) and hospital stays (10.5 ± 9.58 vs. 12.5 ± 11.4 days; P = 0.04) compared to Group 1. Conclusion Earlier use of CE in inpatients with melena or IDA, no signs of lower gastrointestinal pathology and negative UGIE resulted in shortened hospital stays, significant DY from both small bowel and upper gastrointestinal tract, and two-thirds less unnecessary colon investigations without affecting clinical outcomes.
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Affiliation(s)
- Diana E. Yung
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom,Corresponding author Diana E. Yung, MBChB Endoscopy UnitThe Royal Infirmary of Edinburgh51 Little France CrescentEH16 4SA+07789588408
| | - Anastasios Koulaouzidis
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Sarah Douglas
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - John N. Plevris
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Niikura R, Yamada A, Hirata Y, Hayakawa Y, Suzuki H, Yamamoto S, Fujishiro M, Koike K. Role of warfarin as a predictor of recurrent bleeding after negative small-bowel capsule endoscopy. Gastrointest Endosc 2018; 88:574-574.e2. [PMID: 30115312 DOI: 10.1016/j.gie.2018.04.2344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/14/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Hirata
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoku Hayakawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirobumi Suzuki
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Shinzo Yamamoto
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Kunihara S, Oka S, Tanaka S, Tsuboi A, Otani I, Chayama K. Management of occult obscure gastrointestinal bleeding patients based on long-term outcomes. Therap Adv Gastroenterol 2018; 11:1756284818787408. [PMID: 30034534 PMCID: PMC6048613 DOI: 10.1177/1756284818787408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/15/2018] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Sayoko Kunihara
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
| | | | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University
Hospital, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
| | - Ichiro Otani
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
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Abstract
PURPOSE OF REVIEW The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias. SUMMARY SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.
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Uchida G, Hirooka Y, Nakamura M, Watanabe O, Yamamura T, Matsushita M, Suhara H, Ishikawa T, Furukawa K, Funasaka K, Ohno E, Kawashima H, Miyahara R, Goto H. Nomogram-based prediction of rebleeding in small bowel bleeding patients: the 'PRSBB' score. Sci Rep 2018; 8:6378. [PMID: 29686230 PMCID: PMC5913298 DOI: 10.1038/s41598-018-24868-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/22/2018] [Indexed: 02/08/2023] Open
Abstract
Small bowel capsule endoscopy (SBCE) and balloon-assisted endoscopy (BAE) have revolutionized the diagnosis and treatment of small bowel bleeding (SBB), allowing access to the small bowel and identification of specific bleeding lesions. However, some patients experience rebleeding after small bowel investigation, and there are no definitive algorithms for determining the most appropriate follow-up strategy in SBB patients. We developed and validated a nomogram that can predict rebleeding risk and be used to develop a risk-stratified follow-up strategy in SBB patients. A retrospective study was performed using data from 401 SBB patients who underwent SBCE at Nagoya University Hospital. We developed and internally validated a predictive model for rebleeding in the form of a nomogram using Cox regression models and a bootstrap resampling procedure. Optimal risk factors were selected according to the least absolute shrinkage and selection operator (LASSO). The LASSO method identified 8 independent predictors of rebleeding that could be assessed to obtain a ‘predicting rebleeding in SBB’, or ‘PRSBB’ score: age, sex, SBB type, transfusion requirement, cardiovascular disease, liver cirrhosis, SBCE findings, and treatment. The c-statistic for the predictive model was 0.681. In conclusion, our PRSBB score can help clinicians devise appropriate follow-up plans.
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Affiliation(s)
- Genta Uchida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Osamu Watanabe
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Masanobu Matsushita
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Suhara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Tziatzios G, Gkolfakis P, Hassan C, Toth E, Zullo A, Koulaouzidis A, Dimitriadis GD, Triantafyllou K. Meta-analysis shows similar re-bleeding rates among Western and Eastern populations after index video capsule endoscopy. Dig Liver Dis 2018; 50:226-239. [PMID: 29396130 DOI: 10.1016/j.dld.2017.12.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/27/2017] [Accepted: 12/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Video capsule endoscopy (VCE) is the first-line diagnostic procedure for investigating obscure gastrointestinal bleeding (OGIB). Different re-bleeding rates following index VCE have been reported among Western and Eastern studies. METHODS We conducted a comprehensive literature search to identify studies examining re-bleeding rates after VCE for OGIB. Meta-analysis assessed the pooled proportion of re-bleeding events after VCE for OGIB according to study's origin (Western vs. Eastern) and according to the length of follow-up (≥24 months vs. <24 months). We also calculated the re-bleeding odds ratios (OR; 95% CI) after positive vs. negative index VCE, overt vs. occult initial presentation of bleeding and after interventional treatment for positive index cases, according to the study's origin. RESULTS We included 46 (30 Western and 16 Eastern) studies with 5796 patients. Significant heterogeneity was detected among meta-analyzed studies. Overall, the pooled re-bleeding rate was similar between Western (29%; 95% CI: 23-34) and Eastern (21%; 95% CI: 15-27) populations, irrespective of the length of follow-up. The odds of re-bleeding was significantly higher after positive as compared to negative index VCE in Eastern studies (OR: 1.77; 95% CI: 1.07-2.94). Application of specific treatment after positive index VCE was associated with lower re-bleeding odds in both Western (OR: 0.37; 95% CI: 0.16-0.87) and Eastern (OR: 0.39; 95% CI: 0.21-0.72) populations. CONCLUSIONS Patients undergoing VCE for OGIB have similar re-bleeding rates in the East and the West, regardless of the length of follow-up. However, increased re-bleeding odds after positive index VCE is observed in Eastern studies.
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Affiliation(s)
- Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Cesare Hassan
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Anastasios Koulaouzidis
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - George D Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece.
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Kono Y, Kawano S, Okamoto Y, Obayashi Y, Baba Y, Sakae H, Abe M, Gotoda T, Inokuchi T, Kanzaki H, Iwamuro M, Kawahara Y, Okada H. Clinical outcome of patients with obscure gastrointestinal bleeding during antithrombotic drug therapy. Therap Adv Gastroenterol 2018; 11:1756283X17746930. [PMID: 29399040 PMCID: PMC5788140 DOI: 10.1177/1756283x17746930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/16/2017] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuki Okamoto
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuka Obayashi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuki Baba
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Sakae
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Makoto Abe
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tatsuhiro Gotoda
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshihiro Inokuchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromitsu Kanzaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshiro Kawahara
- Department of Endoscopy, Okayama University Hospital, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Development and validation of a new scoring system to determine the necessity of small-bowel endoscopy in obscure gastrointestinal bleeding. Dig Liver Dis 2017; 49:1218-1224. [PMID: 28958410 DOI: 10.1016/j.dld.2017.08.036] [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: 01/10/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Small bowel capsule endoscopy (SBCE) is the recommended first-line procedure for obscure gastrointestinal bleeding (OGIB). However, a method for predicting the necessity of subsequent double-balloon endoscopy (DBE) has not been established. AIMS We aimed to develop a new scoring system that predicts the necessity of DBE in OGIB. METHODS A retrospective study was performed in 330 patients who underwent SBCE for OGIB at Nagoya University Hospital. The enrolled patients were randomly assigned to either a development or a validation dataset. The former was used to construct a prediction scoring system to assess the necessity of DBE using independent predictors selected by logistic regression. The diagnostic yield of the prediction model was assessed using the validation dataset. RESULTS Multivariate logistic regression analysis of the development dataset identified OGIB type, blood transfusion, and SBCE findings as independent predictors of the necessity of DBE. A prediction score gave an area under the receiver operating characteristics curve of 0.77. The sensitivity, specificity, positive predictive value, and negative predictive value at a cutoff ≥2.5 points were 72.5%, 74.6%, 72.6%, and 74.5%, respectively. CONCLUSION Our scoring system may aid clinicians in deciding when to recommend DBE for patients with OGIB.
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47
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Yung DE, Koulaouzidis A, Plevris JN. Response. Gastrointest Endosc 2017; 86:575. [PMID: 28826556 DOI: 10.1016/j.gie.2017.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Diana E Yung
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Anastasios Koulaouzidis
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - John N Plevris
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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48
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Capsule endoscopy in obscure GI bleeding: better to be negative, but let us not be too positive. Gastrointest Endosc 2017; 86:574-575. [PMID: 28826553 DOI: 10.1016/j.gie.2017.04.012] [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: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/11/2022]
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49
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Johnston CA, Yung DE, Joshi A, Plevris JN, Koulaouzidis A. Small bowel malignancy in patients undergoing capsule endoscopy at a tertiary care academic center: Case series and review of the literature. Endosc Int Open 2017; 5:E463-E470. [PMID: 28573179 PMCID: PMC5451279 DOI: 10.1055/s-0043-106186] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/02/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Small bowel cancer is rare, accounting for < 5 % of all gastrointestinal neoplasms. Capsule endoscopy has become the procedure of choice for non-invasive diagnosis of small bowel diseases. Data on capsule endoscopy diagnosis of small bowel cancer are limited. The objective of the study was to determine the frequency, indications and diagnostic work-up of patients with small bowel malignancy found by capsule endoscopy at a Scottish tertiary center. PATIENTS AND METHODS In this retrospective study, records all patients who underwent small bowel capsule endoscopy at our center over a 10-year period were reviewed for possible malignancy. Further data were gathered on preceding and subsequent investigations, management and outcome of these patients. RESULTS From 1949 studies, small bowel malignancies were diagnosed in only 7 patients (0.36 %; 2F/5M; median age 50, range 34 - 67). The main indication was iron-deficiency anemia (n = 5). Prior to capsule endoscopy, 6 of 7 patients had bidirectional endoscopies and one had gastroscopy. All prior investigations were normal or nondiagnostic. Two of 7 experienced capsule retention. Five of 7 underwent surgery. Four patients died, giving a 5-year survival rate of 42.9 %. CONCLUSION Small bowel malignancies diagnosed by capsule endoscopy are rare, and the median age of 50 indicates they are more common in relatively younger patients. Capsule endoscopy is effective at diagnosing a rare malignancy when other imaging modalities have failed.
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Affiliation(s)
- Connor A Johnston
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Diana E Yung
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alka Joshi
- Ninewells Hospital and Medical School, Dundee, UK
| | - John N Plevris
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
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50
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Liu JH, Liu DY, Wang L, Han LP, Qi ZY, Ren HJ, Feng Y, Luan FM, Mi LT, Shan SM. Animal experimental studies using small intestine endoscope. World J Gastroenterol 2017; 23:3684-3689. [PMID: 28611521 PMCID: PMC5449425 DOI: 10.3748/wjg.v23.i20.3684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/28/2017] [Accepted: 03/21/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the feasibility and safety of a novel enteroscope, negative-pressure suction endoscope in examining the small intestine of a porcine model.
METHODS In vitro experiments in small intestinal loops from 20 pigs and in vivo experiments in 20 living pigs were conducted.
RESULTS In in vitro experiments, a negative pressure of > 0.06 MPa was necessary for optimal visualization of the intestine, and this pressure did not cause gross or histological damage to the mucosa. For satisfactory examination of the small intestine in vivo, higher negative pressure (> 1.00 MPa) was required. Despite this higher pressure, the small intestine did not show any gross or microscopic damage in the suctioned areas. The average time of examination in the living animals was 60 ± 7.67 min. The animals did not experience any apparent ill effects from the procedure.
CONCLUSION Small intestine endoscope was safely performed within a reasonable time period and enabled complete visualization of the intestine in most cases.
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