AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding

Capsule endoscopy for obscure gastrointestinal bleed in the tropics: A single-center experience on 350 patients

BACKGROUND

Obscure gastrointestinal bleed (OGIB), now called small bowel bleed (SBB), comprises 5% to 10% of all gastrointestinal (GI) bleed episodes and capsule endoscopy (CE) is a tool for its evaluation. Studies on CE in a large sample of SBB patients from the tropics are limited.

METHODS

We did a retrospective analysis of a prospectively maintained database of patients with SBB undergoing CE using PillCam or MiroCam CE.

RESULTS

Of 350 patients (age 52.4 ± 17.4 years; 248 [70.9%] male) undergoing CE, 243 (69.4%) and 107 (30.6%) had overt and occult SBB, respectively. CE detected lesions in 244 (69.7%) patients (single lesion in 172 [49.1%]; multiple in 72 [20.6%]). The single lesions included vascular malformations (52, 14.9%), ulcer/erosion (47, 13.4%), tumor (24, 6.9%), hookworm (19, 5.4%), stricture (15, 4.3%), hemobilia (1, 0.3%) and blood without identifiable lesion (9, 2.6%). Of 72 with multiple lesions, ulcer with stricture was the commonest finding (n = 43, 12.3%). No abnormality was detected in 106 (30.3%) patients. The frequency of lesion detection was comparable among patients with overt and occult SBB (173/243, 71.2% vs. 71/107, 66.3%, respectively; p = 0.4). Younger patients (0 to 39 years) more often had multiple lesions on CE than the older (≥ 40 years) ones (26/76, 34.2% vs. 46/228, 20.2%, respectively; p = 0.001).

CONCLUSION

CE has a high diagnostic yield in SBB in the tropics, regardless of the type of bleed or of CE brand and the duration of recording. Multiple lesions associated with SBB are commoner among younger (< 40 years) patients.

Engineered Bacteria for Visualization and Localization of Gastrointestinal Bleeding: A Promising Application

Gastrointestinal bleeding, especially obscure gastrointestinal bleeding (OGIB), is a common and serious clinical emergency with a notable incidence rate. However, the current diagnostic method, gastroscopy, is invasive and often struggles to efficiently detect microhemorrhagic lesions, leading to diagnostic challenges and potential misdiagnoses. Here, we developed an intelligently engineered bacterium utilizing synthetic biology techniques for in vivo localization detection of gastrointestinal bleeding. By constructing three gene circuit modules within E. coli Nissle 1917 for heme recognition, response, and output generation, we have successfully enabled specific heme sensing and real-time optical signal production in vivo. This innovative strategy overcomes the limitations of the existing diagnostic methods, offering a noninvasive and precise means of detecting gastrointestinal bleeding. These advancements hold promise for enhancing diagnostic accuracy and treatment efficacy in future clinical settings within the realm of gastroenterology.

Obscure Bleeding from a Metastatic Small Bowel Tumor Diagnosed Using Motorized Spiral Enteroscopy: A Case Study and a Literature Review

Small bowel tumors are relatively rare, representing only around 5% of all gastrointestinal neoplasms, with a progressively increasing incidence. Currently, there are no established guidelines for diagnostic approaches, screening procedures, or management strategies for small bowel tumors. We present here the case of a patient with a rare type of metastatic tumor of the small bowel originating from primary lung adenocarcinoma who presented with abdominal pain, severe iron-deficiency anemia, and melena. The initial investigations, gastroscopy and colonoscopy, failed to identify the bleeding source. The obscure bleeding source and diagnosis were achieved through power motorized spiral enteroscopy (MSE), which allowed the visualization and biopsy of the tumor. Histopathological examination established the presence of a poorly differentiated non-mucinous adenocarcinoma originating from the lung. This case is reported to provide evidence of the efficiency of MSE in the diagnosis of small bowel tumors, with the method providing higher insertion depth in a reduced amount of time.

Could Capsule Endoscopy Be Useful in Detection of Suspected Small Bowel Bleeding and IBD-10 Years of Single Center Experience

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.

Diagnosis of Occult and Obscure Gastrointestinal Bleeding

Occult and obscure bleeding are challenging conditions to manage; however, recent advances in gastroenterology and endoscopy have improved our diagnostic and therapeutic capabilities. Obscure gastrointestinal (GI) bleeding is an umbrella category of bleeding of unknown origin that persists or recurs after endoscopic evaluation of the entire bowel fails to reveal a bleeding source. This review details the evaluation of patients with occult and obscure GI bleeding and offers diagnostic algorithms. The treatment of GI bleeding depends on the type and location of the bleeding lesion and an overview of how to manage these conditions is presented.

Endoscopic Treatment of Small Bowel Bleeding

Approximately 5% of all gastrointestinal (GI) bleeding originates from the small bowel. Endoscopic therapy of small bowel bleeding should only be undertaken after consideration of the different options, and the risks, benefits, and alternatives of each option. Endoscopic therapy options for small bowel bleeding are like those treatments used for other forms of bleeding in the upper and lower GI tract. Available endoscopic treatment options include thermal therapy (eg, argon plasma coagulation and bipolar cautery), mechanical therapy (eg, hemoclips), and medical therapy (eg, diluted epinephrine injection). Patients with complicated comorbidities would benefit from evaluation and planning of available treatment options, including conservative and/or medical treatments, beyond endoscopic therapy.

Computer-Aided Bleeding Detection Algorithms for Capsule Endoscopy: A Systematic Review

Capsule endoscopy (CE) is a widely used medical imaging tool for the diagnosis of gastrointestinal tract abnormalities like bleeding. However, CE captures a huge number of image frames, constituting a time-consuming and tedious task for medical experts to manually inspect. To address this issue, researchers have focused on computer-aided bleeding detection systems to automatically identify bleeding in real time. This paper presents a systematic review of the available state-of-the-art computer-aided bleeding detection algorithms for capsule endoscopy. The review was carried out by searching five different repositories (Scopus, PubMed, IEEE Xplore, ACM Digital Library, and ScienceDirect) for all original publications on computer-aided bleeding detection published between 2001 and 2023. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) methodology was used to perform the review, and 147 full texts of scientific papers were reviewed. The contributions of this paper are: (I) a taxonomy for computer-aided bleeding detection algorithms for capsule endoscopy is identified; (II) the available state-of-the-art computer-aided bleeding detection algorithms, including various color spaces (RGB, HSV, etc.), feature extraction techniques, and classifiers, are discussed; and (III) the most effective algorithms for practical use are identified. Finally, the paper is concluded by providing future direction for computer-aided bleeding detection research.

[Radiologic Diagnosis of Gastrointestinal Bleeding]

Gastrointestinal (GI) bleeding is not a single disease but a symptom and clinical manifestation of a broad spectrum of conditions in the GI tract. According to its clinical presentation, GI bleeding can be classified into overt, occult, and obscure types. Additionally, it can be divided into upper and lower GI bleeding based on the Treitz ligament. Variable disease entities, including vascular lesions, polyps, neoplasms, inflammation such as Crohn's disease, and heterotopic pancreatic or gastric tissue, can cause GI bleeding. CT and conventional angiographies and nuclear scintigraphy are all radiologic imaging modalities that can be used to evaluate overt bleeding. For the work-up of occult GI bleeding, CT enterography (CTE) can be the first imaging modality. For CTE, an adequate bowel distention is critical for obtaining acceptable diagnostic performance as well as minimizing false positives and negatives. Meckel's scintigraphy can be complementarily useful in cases where the diagnosis of CTE is suboptimal. For the evaluation of obscured GI bleeding, various imaging modalities can be used based on clinical status and providers' preferences.

Identification, characterization of Apyrase (APY) gene family in rice (Oryza sativa) and analysis of the expression pattern under various stress conditions

Apyrase (APY) is a nucleoside triphosphate (NTP) diphosphohydrolase (NTPDase) which is a member of the superfamily of guanosine diphosphatase 1 (GDA1)-cluster of differentiation 39 (CD39) nucleoside phosphatase. Under various circumstances like stress, cell growth, the extracellular adenosine triphosphate (eATP) level increases, causing a detrimental influence on cells such as cell growth retardation, ROS production, NO burst, and apoptosis. Apyrase hydrolyses eATP accumulated in the extracellular membrane during stress, wounds, into adenosine diphosphate (ADP) and adenosine monophosphate (AMP) and regulates the stress-responsive pathway in plants. This study was designed for the identification, characterization, and for analysis of APY gene expression in Oryza sativa. This investigation discovered nine APYs in rice, including both endo- and ecto-apyrase. According to duplication event analysis, in the evolution of OsAPYs, a significant role is performed by segmental duplication. Their role in stress control, hormonal responsiveness, and the development of cells is supported by the corresponding cis-elements present in their promoter regions. According to expression profiling by RNA-seq data, the genes were expressed in various tissues. Upon exposure to a variety of biotic as well as abiotic stimuli, including anoxia, drought, submergence, alkali, heat, dehydration, salt, and cold, they showed a differential expression pattern. The expression analysis from the RT-qPCR data also showed expression under various abiotic stress conditions, comprising cold, salinity, cadmium, drought, submergence, and especially heat stress. This finding will pave the way for future in-vivo analysis, unveil the molecular mechanisms of APY genes in stress response, and contribute to the development of stress-tolerant rice varieties.

Effect of Different Modalities of Purgative Preparation on the Diagnostic Yield of Small Bowel Capsule for the Exploration of Suspected Small Bowel Bleeding: A Multicenter Randomized Controlled Trial

INTRODUCTION

The aim of our study was to compare clear liquid diet with 2 different polyethylene glycol (PEG)-based bowel preparation methods regarding diagnostic yield of small bowel capsule endoscopy (SBCE) in patients with suspected small bowel bleeding (SBB).

METHODS

In this prospective multicenter randomized controlled trial, consecutive patients undergoing SBCE for suspected SBB between September 2010 and February 2016 were considered. Patients were randomly assigned to standard regimen, that is, clear fluids only (prep 1), standard regimen plus 500 mL PEG after SBCE ingestion (prep 2), or standard regimen plus 2 L PEG plus 500 mL PEG after SBCE ingestion (prep 3). The primary outcome was the detection of at least one clinically significant lesion in the small bowel. The quality of small bowel cleansing was assessed. A questionnaire on the clinical tolerance was filled by the patients.

RESULTS

We analyzed 834 patients. No significant difference was observed for detection of P1 or P2 small bowel lesions between prep1 group (40.5%), prep 2 group (40.2%), and prep 3 group (38.5%). Small bowel cleansing was improved in prep 2 and 3 groups compared with that in prep 1 group. Compliance to the preparation and tolerance was better in prep 2 group than in prep 3 group.

DISCUSSION

Small bowel purgative before SBCE allowed better quality of cleansing. However, it did not improve diagnostic yield of SBCE for suspected SBB.

A Practical Guide to the Evaluation of Small Bowel Bleeding

Gastrointestinal bleeding is a common clinical problem encountered in both the inpatient and outpatient settings. Although the evaluation of upper and lower gastrointestinal bleeding is often straightforward, bleeding from the small bowel may pose a clinical challenge. In this article, we review the indications, modalities, and differential diagnoses of small bowel bleeding. On completion of the article, clinicians should be able to identify common causes of small bowel bleeding, understand the advantages and disadvantages of the modalities used to evaluate small bowel bleeding, and enact a stepwise management approach to the patient with presumed small bowel bleeding.

Anemia as a Problem: GEH Approach

BACKGROUND

Anemia is present in almost 5% of adults worldwide and accompanies clinical findings in many diseases. Diseases of the gastrointestinal (GI) tract and liver are a common cause of anemia, so patients with anemia are often referred to a gastroenterologist.

SUMMARY

Anemia could be caused by various factors such as chronic bleeding, malabsorption, or chronic inflammation. In clinical practice, iron deficiency anemia and the combined forms of anemia due to different pathophysiological mechanisms are most common. Esophagogastroduodenoscopy, colonoscopy, and the small intestine examinations in specific situations play a crucial role in diagnosing anemia. In anemic, GI asymptomatic patients, there are recommendations for bidirectional endoscopy. Although GI malignancies are the most common cause of chronic bleeding, all conditions leading to blood loss, malabsorption, and chronic inflammation should be considered. From a gastroenterologist's perspective, the clinical spectrum of anemia is vast because many different digestive tract diseases lead to bleeding. Key Messages: The gastroenterological approach in solving anemia's problem requires an optimal strategy, consideration of the accompanying clinical signs, and the fastest possible diagnosis. Although patients with symptoms of anemia are often referred to gastroenterologists, the diagnostic approach requires further improvement in everyday clinical practice.

Risk factors for rebleeding in patients with obscure gastrointestinal bleeding from southern China

Background

To identify the risk factors associated with rebleeding in obscure gastrointestinal bleeding (OGIB) patients from southern China.

Methods

This retrospective study involved 229 patients who underwent small bowel endoscopy in our hospital between 1 January 2018 and 1 December 2020. The clinical characteristics and risk factors related to rebleeding were retrospectively evaluated.

Results

Rebleeding patients were significantly older than non-rebleeding patients (53.0 ± 15.9 vs. 46.2 ± 17.8 years), had lower hemoglobin concentrations (89.2 ± 28.1 vs. 126.2 ± 25.1 g/L), and higher blood urea nitrogen concentrations (5.4 ± 2.6 vs. 4.5 ± 2.2 µmol/L), respectively. A higher percentage of rebleeding patients had diabetes mellitus (13.9% vs. 2.9%) and overt bleeding (70.4% vs. 38.6%), and required blood transfusions (43.1% vs. 8.0%), compared with non-rebleeding patients, respectively. Multivariate logistic analysis indicated that drinking alcohol (odds ratio (OR): 9.27; 95% confidence interval (CI) = 1.35–63.78), anemia (OR: 17.38; 95% CI = 5.48–55.10), and blood transfusion (OR: 3.76; 95% CI = 1.04–13.56) increased the risk of rebleeding in OGIB patients.

Conclusion

Our data suggested that OGIB patients who drink alcohol, have anemia, and require blood transfusion have an increased risk of rebleeding.

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn's disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Acquired Refractory Iron Deficiency Anemia

Anemia is a global health problem affecting one-third of the world population, and half of the cases are due to iron deficiency (ID). Iron deficiency anemia (IDA) is the leading cause of disability in several countries. Although multiple mechanisms may coexist, ID and IDA causes can be classified as i) insufficient iron intake for the body requirement, ii) reduced absorption, and iii) blood losses. Oral iron represents the mainstay of IDA treatment. IDA is defined as "refractory" when the hematologic response after 4 to 6 weeks of treatment with oral iron (an increase of >=1 g/dL of Hb) is absent. The cause of iron-refractory anemia is usually acquired and frequently related to gastrointestinal pathologies, although a rare genetic form called iron-refractory iron deficiency anemia (IRIDA) exists. In some pathological circumstances, either genetic or acquired, hepcidin increases, limiting the absorption in the gut, remobilization, and recycling of iron, thereby reducing iron plasma levels. Indeed, conditions with high hepcidin levels are often under-recognized as iron refractory, leading to inappropriate and unsuccessful treatments. This review provides an overview of the iron refractory anemia underlying conditions, from gastrointestinal pathologies to hepcidin dysregulation and iatrogenic or provoked conditions, and the specific diagnostic and treatment approach.

The Optimal Timing for Using Capsule Endoscopy for Patients with Gastrointestinal Bleeding

Objectives

Capsule endoscopy (CE) is a useful diagnostic modality for patients with occult gastrointestinal (GI) bleeding. However, most previous studies utilizing CE have focused on techniques, patient characteristics, safety and feasibility, and case analyses. Studies evaluating the optimal timing for utilizing CE, which is an essential factor for obtaining a better diagnostic yield, remain scarce in the literature. Considering that a CE examination is expensive, we, therefore, undertook this study to evaluate, analyze, and determine the optimal time for performing CE in patients with occult GI bleeding.

Methods

Seventy-five patients were initially recruited, but finally, sixty patients with significant GI bleeding with an unknown etiology after traditional endoscopic examinations were included in the study. All data were collected from a local hospital in Taiwan, encompassing the period from 2010 to 2018. The relationship between the timing of CE examination and the diagnostic correction rate (DCR) was then analyzed statistically.

Results

More female (58.3%) and older adult (68.3%) patients were in our study. Based on the four analytical models used in the study, the results showed that the most optimal time to perform CE is within three days after GI bleeding occurs.

Deep transfer learning approaches for bleeding detection in endoscopy images

Wireless capsule endoscopy is a non-invasive, wireless imaging tool that has developed rapidly over the last several years. One of the main limiting factors using this technology is that it produces a huge number of images, whose analysis, to be done by a doctor, is an extremely time-consuming process. In this research area, the management of this problem has been addressed with the development of Computer-aided Diagnosis systems thanks to which the automatic inspection and analysis of images acquired by the capsule has clearly improved. Recently, a big advance in classification of endoscopic images is achieved with the emergence of deep learning methods. The proposed expert system employs three pre-trained deep convolutional neural networks for feature extraction. In order to construct efficient feature sets, the features from VGG19, InceptionV3 and ResNet50 models are then selected and fused using the minimum Redundancy Maximum Relevance method and different fusion rules. Finally, supervised machine learning algorithms are employed to classify the images using the extracted features into two categories: bleeding and nonbleeding images. For performance evaluation a series of experiments are performed on two standard benchmark datasets. It has been observed that the proposed architecture outclass the single deep learning architectures, with an average accuracy in detection bleeding regions of 97.65 % and 95.70 % on well-known state-of-the-art datasets considering three different fusion rules, with the best combination in terms of accuracy and training time obtained using mean value pooling as fusion rule and Support Vector Machine as classifier.

Overt gastrointestinal bleeding following haploidentical haematopoietic stem cell transplantation: incidence, outcomes and predictive models

Gastrointestinal bleeding (GIB) accounts for a significant proportion of life-threatening bleeding cases occurring after allogeneic haematopoietic stem cell transplantation (allo-HSCT). However, data on GIB after haploidentical HSCT (haplo-HSCT) are not available. A total of 3180 patients received haplo-HSCT at Peking University People's Hospital from January 2015 to November 2019, and GIB occurred in 188 of these patients (incidence of 5.9%). Platelet counts <30 × 10⁹/L, viral hepatitis, acute kidney injury (AKI), gastrointestinal disease or bleeding before HSCT and sinusoidal obstruction syndrome (SOS) were determined to be significant risk factors for the occurrence of GIB after haplo-HSCT. Grade III-IV acute graft-versus-host disease (aGVHD), AKI, thrombotic microangiopathy (TMA), disseminated intravascular coagulation (DIC) and gastrointestinal disease or bleeding before HSCT were significantly related to mortality in patients with GIB after haplo-HSCT. The predictive models developed for the occurrence and mortality of GIB performed well in terms of discrimination, and they might assist clinicians with personalised strategies for GIB prevention and treatment in patients after haplo-HSCT.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of Gastrointestinal Endoscopy in 398 Patients With Iron Deficiency Anemia Who Lack Gastrointestinal Symptoms: Basrah Experience

Introduction

The diagnosis of iron deficiency anemia (IDA) relies heavily on symptom presentation, and patients lacking typical gastrointestinal (GI) symptoms represent a diagnostic challenge. IDA may be the initial manifestation of underlying pathology. This study sought to evaluate the effectiveness of different GI endoscopic studies in patients with IDA who lack GI symptoms.

Methods

We conducted an observational, multicenter retrospective analysis of 398 asymptomatic IDA patients admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We analyzed demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings.

Results

The mean age of the study population was 52±9 years (range, 23 to 85 years), and 53% were men. Most patients were older than 45 years (n=353, 89%) with mild to moderate IDA. Patients underwent esophagogastroduodenoscopy (EGD, n=102), colonoscopy (n=271), or bidirectional endoscopy (n=25). The mean hospital stay was 2.72±1.66 days. The most common EGD results were atrophic gastritis (n=31), peptic ulcer (n=25), and negative findings (n=25). The most common colonoscopic results were negative findings (n=118), nonspecific colonic inflammatory changes (n=117), and non-bleeding hemorrhoids (n=29). We found no significant association between any endoscopic findings and age, gender, the severity of anemia, and length of hospitalization.

Conclusions

The presence of symptoms is of limited value in guiding diagnostic procedures concerning GI etiologies. Asymptomatic patients with IDA patients should receive an endoscopic examination irrespective of iron parameters, age, or gender for potentially treatable pathologies, especially for patients with suspected malignancies.

Evaluation of Low-Dose Multidetector Computed Tomography Whole Gastroenterography With Oral Administration of Contrast Agents

PURPOSE

To evaluate the degree of gastric, enteric, colonic, and rectal filling in multidetector computed tomography (MDCT) whole gastroenterography.

METHODS

In this prospective study involving 124 patients, 78 and 46 patients underwent MDCT whole gastroenterography using positive and neutral oral contrast agents, respectively. The degree of filling of the stomach, small and large bowel, was qualitatively analyzed by experienced radiologists using a 3-point scoring system.

RESULTS

The majority of patients received a score of ≥2 for small intestine filling using both positive and neutral contrast agents (90.5% and 78.2%, respectively), and <9% of the patients had a score of 0. The highest score for the degree of filling in the small intestine was observed in the ileum, followed by the duodenum and jejunum. There was a significant difference in the degree of filling achieved with positive and neutral contrast agents in the duodenum (P = .013) and jejunum (P = .047). More than 74% of cases had an optimal filling of the stomach, whereas >80% of the cases had an optimal filling of the colorectal segments. Only ≤5.1% had a score of 0 for the analyzed segments of the colorectum. Positive and neutral contrast agents were associated with similar degree of filling in the stomach and colon segments without a significant difference in the extent of contrast agent filling (P > .05).

CONCLUSIONS

Multidetector computed tomography whole gastroenterography was found to be a simple, safe, noninvasive, painless, and effective modality for the diagnosis of stomach and bowel complications in clinical settings.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.

Capsule endoscopy: Is the software TOP 100 a reliable tool in suspected small bowel bleeding?

BACKGROUND

Small bowel capsule endoscopy (SBCE) is the reference standard tool for diagnosing small bowel bleeding (SBB). The "TOP 100", which performs an automatic selection of the 100 images that mostly likely contain abnormalities, emerged as a new functionality of the RAPID Reader® software in 2017.

AIM

To compare the concordance of findings between the standard reading (SR) and the use of TOP 100 in suspected SBB.

METHODS

Retrospective study, including consecutive patients submitted to SBCE for suspected SBB. Two experienced readers performed SR and reported the most important findings. Another experienced reader, who was blinded to the SR results, reviewed all the SBCE videos using TOP 100 and reported the most important findings. The relevant findings were defined as the presence of high bleeding potential lesions (P2).

RESULTS

97 patients were included. The TOP 100 detected 81/97(83.5%) of the P2 lesions, in particular 64/67(95.5%) of the angioectasias and 17/30(56.7%) of the ulcers. The TOP 100 identified all sites of active bleeding (n = 9).

CONCLUSION

The TOP 100 identified all sites of active bleeding, as well as the vast majority of significant lesions (83.5%); in particular, it detected over 95% of the angioectasias. Although SR remains the reference standard in the SBCE review, these findings demonstrate that TOP 100 allows for a quick preview reading constituting an important asset in the identification of lesions that may require priority full review and intervention planning.

Isolated Gastric Varices due to Essential Thrombocytosis Related to Splenic Vein Thrombosis: A Challenge to Uncover the Concealed Diagnosis

Essential thrombocytosis is associated with gastrointestinal (GI) vascular thrombosis. Sinistral portal hypertension (left-sided portal hypertension) due to splenic vein thrombosis can lead to isolated gastric varices and should be suspected in a patient with obscure GI bleeding with normal liver function. This case reviews the challenges presented in diagnosing isolated gastric varices due to splenic vein thrombosis through radiologic or endoscopic studies. Unrevealing radiologic or endoscopic studies does not rule out splenic vein thrombosis, which should be suspected in a patient with essential thrombocytosis and obscure GI bleeding.

Manejo endovascular de la hemorragia digestiva, experiencia del Hospital Universitario Clínica San Rafael

Introducción. La hemorragia digestiva ocasiona el 2 % de las hospitalizaciones; se clasifica en alta o baja, la primera se presenta en el 80 % de casos. Después de la estabilización hemodinámica, se determinan la causa y el tratamiento mediante la endoscopia; no obstante, esta falla en 10 a 20 % de los casos, y del 15 al 20 % requieren cirugía mayor, con una mortalidad de más del 40 %. El tratamiento para la hemorragia digestiva mediante la formación de émbolos de los vasos mesentéricos, es una conducta bien establecida, produce buenos resultados, evita la cirugía y disminuye la morbimortalidad. Objetivos. Determinar la indicación y el éxito del tratamiento endovascular para la hemorragia digestiva en nuestra institución. Materiales y métodos. estudio retrospectivo y descriptivo, se incluyeron 10 pacientes que requirieron la urgente formación de émbolos por falla o imposibilidad del manejo endoscópico, y que presentaban gran riesgo quirúrgico y anestésico con la técnica abierta. Se evaluaron la causa de la hemorragia, la arteria comprometida, los hallazgos angiográficos, la hemoglobina antes y después de la formación de los émbolos, la reincidencia de la hemorragia, las complicaciones, la necesidad de intervención quirúrgica, la eficacia del procedimiento y la mortalidad a 30 días. Resultados. Todos los pacientes se intervinieron por vía endovascular, para la oclusión selectiva de las arterias comprometidas. La hemorragia se controló en todos ellos. Se presentaron dos muertes tempranas (<30 días) no asociadas con el procedimiento. No hubo complicaciones secundarias a la formación de los émbolos o al acceso percutáneo y, tampoco, necesidad de cirugías mayores posteriores para controlar la hemorragia. Conclusión. Los métodos endovasculares para controlar la hemorragia digestiva son eficaces, no se acompañan de complicaciones, y disminuyen la morbimortalidad y la necesidad de cirugías mayores. Se requieren estudios con mayor número de pacientes para lograr un mayor grado de certeza.

Use of a Transparent Cap Increases the Diagnostic Yield in Antegrade Single-Balloon Enteroscopy for Obscure GI Bleed

BACKGROUND AND AIMS

Single-balloon enteroscopy (SBE) is utilized in the evaluation of obscure gastrointestinal bleeding, but 40-50% of these patients experience continued GI blood loss, in part due to missed lesions. The utilization of a transparent cap attached to the end of the endoscope can improve mucosal visualization in other endoscopic applications, but has not yet been evaluated in SBE. The aim of this study was to evaluate the impact of a cap on the diagnostic yield of SBE.

METHODS

Consecutive adult patients scheduled for anterograde SBE for the evaluation of obscure GI bleeding were screened for inclusion from 2014 to 2017. Patients were randomized to SBE with or without a transparent cap. The primary outcome was the proportion of enteroscopies in which a P2 lesion (high potential for bleeding) was identified.

RESULTS

A total of 90 patients (65.7 ± 12.7 years old, 47.7% female) were analyzed. There were significantly more P2 arteriovenous malformations identified in the cap group (14.8% vs. 0%, p = 0.02). Additionally, the use of a cap was associated with a significantly greater depth of small bowel insertion (191.9 cm vs. 156.2 cm, p = 0.01). There was one perforation in the group without a cap, successfully treated with clip placement, and no adverse events in the cap group.

CONCLUSIONS

The use of a transparent cap during SBE performed for the evaluation of obscure gastrointestinal bleeding may be an important, safe augmentation to standard SBE techniques.

Paraesophageal hernia repair: a curative consideration for chronic anemia?

INTRODUCTION

Chronic anemia is a common, coinciding or presenting diagnosis in patients with paraesophageal hernia (PEH). Presence of endoscopically identified ulcerations frequently prompts surgical consultation in the otherwise asymptomatic patient with anemia. Rates of anemia resolution following paraesophageal hernia repair (PEHR) often exceed the prevalence of such lesions in the study population. A defined algorithm remains elusive. This study aims to characterize resolution of anemia after PEHR with respect to endoscopic diagnosis.

MATERIALS AND METHODS

Retrospective review of a prospectively maintained database of patients with PEH and anemia undergoing PEHR from 2007 to 2018 was performed. Anemia was determined by preoperative labs: Hgb < 12 mg/dl in females, Hgb < 13 mg/dl in males, or patients with ongoing iron supplementation. Improvement of post-operative anemia was assessed by post-operative hemoglobin values and continued necessity of iron supplementation.

RESULTS

Among 56 identified patients, 45 were female (80.4%). Forty patients (71.4%) were anemic by hemoglobin value, 16 patients (28.6%) required iron supplementation. Mean age was 65.1 years, with mean BMI of 27.7 kg/m². One case was a Type IV PEH and the rest Type III. 32 (64.0%) had potential source of anemia: 16 (32.0%) Cameron lesions, 6 (12.0%) gastric ulcers, 12 (24.0%) gastritis. 10 (20.0%) had esophagitis and 4 (8%) Barrett's esophagus. 18 (36%) PEH patients had normal preoperative EGD. Median follow-up was 160 days. Anemia resolution occurred in 46.4% of patients. Of the 16 patients with pre-procedure Cameron lesions, 10 (63%) had resolution of anemia. Patients with esophagitis did not achieve resolution. 72.2% (13/18) of patients with no lesions on EGD had anemia resolution (p = 0.03).

CONCLUSION

Patients with PEH and identifiable ulcerations showed 50% resolution of anemia after hernia repair. Patients without identifiable lesions on endoscopy demonstrated statistically significant resolution of anemia in 72.2% of cases. Anemia associated with PEH adds an indication for surgical repair with curative intent.

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

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

Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review

Background: Small bowel bleeding accounts for 5-10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.

Development of a Comorbidity Index to Identify Patients With Small Bowel Bleeding at Risk for Rebleeding and Small Bowel Vascular Diseases

BACKGROUND & AIMS

We aimed to establish a comorbidity index for small bowel vascular diseases (SBVD) associated with small bowel bleeding (SBB) and recurrent bleeding.

METHODS

We performed a retrospective analysis of 404 patients diagnosed with SBB via double-balloon enteroscopy, at 2 hospitals in Japan from June 2003 through July 2016. We collected data on comorbidities, computed Charlson Comorbidity Index and anticoagulation and risk factors in atrial fibrillation (ATRIA) scores, and analyzed associations with SBVD, rebleeding, and overall survival associated with bleeding and/or comorbidities. We used these data to develop a comorbidity index to identify patients at risk for SBVD, rebleeding, and reduced survival time. We validated our findings in a separate, prospective cohort of 88 patients with SBB.

RESULTS

We developed a weighted index (the Ohmiya index) that identified patients who developed SBVD with an area under the receiver operating characteristic (AUROC) curve of 0.7758; this value was higher than that of the Charlson index score (0.6828; P < .0001) or ATRIA score (0.6728; P < .0001) alone. Among the 51 patients taking oral anticoagulants, there was no significant difference in AUROCs for the Ohmiya score (0.5254) vs the outcomes registry for better informed treatment score (0.5857; P = .4300). In the retrospective cohort, the Ohmiya index identified patients with SBVD with 68% sensitivity (93/137), 84% specificity (223/267), and 78% accuracy (316/404); in the validation cohort, these values were 63% (22/35), 85% (45/53), and 76% (67/88), respectively. Onset age <50 years and index score <2 identified patients with Meckel's diverticulum and Crohn's disease with 53% accuracy. Onset age ≥50 years and index score <2 identified patients with inflammatory diseases, drug-induced injuries, or tumors with 72% accuracy. An index score ≥2 identified patients with SBVD with 68% accuracy, regardless of age. Among patients with Ohmiya index scores ≥2, 33% had rebleeding; among patients with scores <2, 15% had rebleeding (hazard ratio for score ≥2, 1.729; 95% CI, 1.038-2.882; P = .0355).

CONCLUSION

We developed an index, based on comorbidities and age of onset of SBB, that identified patients at risk for rebleeding and vascular disease (for example, enteroscopic hemostasis for SBVD, medication for inflammatory diseases, surgery with enteroscopic tattooing for tumors and diverticula). UMIN: 000025693.

Diagnosis of chronic anaemia in gastrointestinal disorders: A guideline by the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP)

Anaemia is a common pathologic condition, present in almost 5% of the adult population. Iron deficiency is the most common cause; other mechanisms can be involved, making anaemia a multi-factorial disorder in most cases. Anaemia being a frequent manifestation in the diseases of the gastrointestinal tract, patients are often referred to gastroenterologists. Furthermore, upper and lower endoscopy and enteroscopy are pivotal to the diagnostic roadmap of anaemia. In spite of its relevance in the daily clinical practice, there is a limited number of gastroenterological guidelines dedicated to the diagnosis of anaemia. For this reason, the Italian Association of Hospital Gastroenterologists and Endoscopists and the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition commissioned a panel of experts to prepare a specific guideline on anaemia and its diagnostic roadmap in the gastroenterological scenario. The panel also discussed about the potential involvement of gastroenterologists and endoscopists in the management of patients with anaemia, with particular attention to the correct use of investigations. The panel paid particular attention to practical issues with the aim to support gastroenterologists in their clinical practice when dealing with patients with anaemia.

CapsoCam SV-1 Versus PillCam SB 3 in the Detection of Obscure Gastrointestinal Bleeding: Results of a Prospective Randomized Comparative Multicenter Study

BACKGROUND AND STUDY AIM

Newer capsule with a panoramic viewing mode is available and might increase the detection rate of bleeding lesions in patients with obscure gastrointestinal bleeding (OGIB). Furthermore, an improved patient acceptance rate is expected.

MATERIALS AND METHODS

In a randomized prospective comparative multicenter study, patients with OGIB were included and examined either with CapsoCam SV-1 or with PillCam SB 3. Detection of bleeding lesions, transit, and evaluation time and adverse events were evaluated. Physicians were interviewed about their experience with both capsules and the evaluation software. A detailed subject questionnaire analyzed acceptance of each capsule. Follow-up was 3 months.

RESULTS

In total, 181 patients with OGIB were recruited into the study. After exclusion of 28 patients 153 patients were randomized and CapsoCam SV-1 (n=78) or PillCam SB 3 (n=75) was administered. CapsoCam SV-1 detected more cases of bleeding (31/79, diagnostic yield 39.7%) compared with PillCam SB 3 (26/75, diagnostic yield 34.6%, NS). Transit time of both capsules was not different. Evaluation time with PillCam SB 3 was superior to CapsoCam SV-1 (27 vs. 40 min, P=0.01). In total, 95% of the physicians were satisfied with each capsule system and evaluation software. The acceptance rate of the patients to retrieve the CapsoCam SV-1 was high. Adverse events/serious adverse events were 17.9%/1.3% with CapsoCam SV-1 and 16%/0% with PillCam SB 3. Rebleeding rate was 28.75% within 3 months.

CONCLUSIONS

CapsoCam SV-1 detected more lesions; however, relevant bleeding sources were visualized by both capsules. Physician's satisfaction was high with both capsule systems and evaluation software. Patient's acceptance with CapsoCam SV-1 was unexpectedly high. Serious adverse events were 0% with PillCam SB 3 and 1.3% with CapsoCam SV-1.

Is a bleeding scan prior to single-balloon enteroscopy necessary in patients with obscure gastrointestinal bleeding?

BACKGROUND/PURPOSE

To evaluate the efficacy and accuracy of bleeder localization in a pre-enteroscopic bleeding scan in patients with obscure gastrointestinal bleeding (OGIB).

METHODS

From January 2009 to December 2014, 98 patients with OGIB undergoing single-balloon enteroscopy (SBE) were enrolled. These patients were classified based on their history of a previous bleeding scan; 56 patients had undergone a previous bleeding scan, whereas 42 had not. The clinical characteristics, endoscopic findings, and rebleeding rate were compared between these two groups. The ability of the bleeding scan to localize the bleeding site was analyzed.

RESULTS

The mean age of patients was 56 ± 22 years; final diagnostic yield, 65.3%; and the most common etiology of OGIB, angiodysplasia (29.6%). There was no significant difference in demographic characteristics, OGIB etiologies, and final diagnostic yields (67.9% vs. 61.2%, bleeding scan vs. control group) between groups. In the bleeding scan group, the rate of positive detection was approximately 80.4%. However, only 26.7% patients with a positive bleeding scan showed correct localization of bleeding. Moreover, the bleeding scan delayed SBE (8.9 days vs. 3.0 days, p < 0.001). During the 24 months of follow-up, 15 patients (15.3%) exhibited rebleeding and needed to be hospitalized, but there was no significant difference between the groups.

CONCLUSION

In our study, bleeding scans in patients with OGIB revealed poor localization of the bleeder and delay in performing SBE. Thus, a bleeding scan prior to SBE showed a limited role for patients with OGIB.

Radiologic Assessment of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding represents a broad differential of disease throughout the GI tract. The proper diagnostic evaluation of patients presenting with symptoms of GI bleeding depends on the overall clinical acuity and suspected source locations. The radiologic assessment of these patients is centered around computed tomography (CT) angiography, CT enterography, conventional angiography, and nuclear scintigraphy.

Imaging Workup of Acute and Occult Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding is defined as occurring distal to the ligament of Treitz and presents as hematochezia, melena, or with anemia and positive fecal occult blood test. Imaging plays a pivotal role in the localization and treatment of lower gastrointestinal bleeds. Imaging tests in the workup of acute lower gastrointestinal bleeding include computed tomography (CT) angiography, nuclear medicine scintigraphy, and conventional catheter angiography. Catheter angiography can also be used to deliver treatment. Imaging tests in the workup of occult lower gastrointestinal bleeding include CT enterography and nuclear medicine Meckel scan.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Case of Bleeding Ileal Varices after a Colectomy Diagnosed by Capsule Endoscopy

We report a case of bleeding ileal varices associated with intra-abdominal adhesions after colectomy which was successfully diagnosed using capsule endoscopy. A 77-year-old woman visited the emergency department for several episodes of melena. She had a medical history of neoadjuvant chemo-radiation therapy and subsequent surgery for rectal cancer 6 years previously. Conventional diagnostic examinations including upper endoscopy, colonoscopy, and abdominal computed tomography could not detect any bleeding focus, however, following capsule endoscopy revealed venous dilatations with some fresh blood in the distal ileum, indicating bleeding ileal varices. The patient underwent exploratory laparotomy and the affected ileum was successfully resected. No further gastrointestinal bleeding occurred during the 6 months follow-up. Small intestinal varices are important differential for obscure gastrointestinal bleeding especially in patients with a history of abdominal surgery in the absence of liver cirrhosis, and capsule endoscopy can be a good option for diagnosing small intestinal varices.

Practical gastrointestinal investigation of iron deficiency anaemia

About 10% of oesophagogastroduodenoscopies (OGDs) and colonoscopies are done for investigation of iron deficiency anemia (IDA) . Much of the existing guidance on investigation of IDA predates CRC screening, which has driven significant improvements in colonoscopy quality and completion rates, as well as a reduction in Helicobacter pylori prevalence and increase in PPI usage, and therefore probably needs re-consideration. New investigations, e.g. CT colonography, enteroscopy and capsule endoscopy have also been introduced. Areas covered: This review updates the approach to practical investigation of IDA. Medline was searched using the terms iron deficiency AND anemia AND/OR gastroscopy, colonoscopy, capsule and enteroscopy, together with review of recent relevant published abstracts on the topic. Expert commentary: Gastrointestinal pathology is now a more common cause of IDA than upper GI causes, reflecting better colonoscopy accuracy and completion rates as well as changing disease patterns, and carcinomas are more likely cause IDA than benign adenomas. Increasing use of antiplatelet and anticoagulants is driving greater presentation of IDA. Capsule endoscopy, enteroscopy and CT colonography are increasingly used. Fecal occult blood testing may be a useful simple screening method in the frail, as a negative test can avoid the need for invasive tests.

Meta-analysis shows similar re-bleeding rates among Western and Eastern populations after index video capsule endoscopy

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.

Unexplained iron deficiency anemia: does Helicobacter pylori have a role to play?

Background and aim

Testing for Helicobacter pylori (Hp) infection is recommended for work-up of unexplained iron deficiency anemia (IDA), although the evidence supporting this recommendation is scant. The aim of this study was to investigate the association between Hp infection and unexplained iron deficiency (ID) or IDA in the older adult population without significant upper gastrointestinal source of blood loss.

Methods

Retrospective single-center cohort study; 523 out of 1253 consecutive patients who underwent esophagogastroduodenoscopy with no significant upper and/or lower gastrointestinal source for blood loss or risk factors for IDA. Comparisons were made between the Hp-positive and Hp-negative groups using Fisher exact test, chi-square test and Student’s t-test. Univariate and multiple logistic regression analyses were used to identify significant risk factors associated with ID and IDA.

Results

One hundred and three subjects (19.7%) had Hp infection and 420 (80.3%) were negative for Hp. Sixty-eight (22.1%) out of 307 subjects with available serum iron profile had unexplained ID and 28 (5.4%) out of 510 subjects with available hemoglobin profile had unexplained IDA. No association was found between ID/IDA and Hp infection in univariate and multiple logistic regression analyses.

Conclusion

We found no association between unexplained ID or IDA and Hp infection in older adult population without peptic ulcer disease or significant upper gastrointestinal source of blood loss.

Tumor vs Non-Tumor Origin of Occult and Obscure Gastrointestinal Bleeding Requiring Hospitalization

Aims and Background

Occult/obscure gastrointestinal bleeding is often problematic to diagnose. It often leads to delayed treatment, a particularly dangerous circumstance when tumor origins are involved. This study reports the six-year experience of an Italian Surgery Center in the identification of the nature (tumor versus non tumor) and site of origin (upper, middle, lower gastrointestinal tract) of occult/obscure bleeding requiring hospitalization, as well as in its treatment.

Methods

Diagnostic instrumental examinations employed were: esophagogastroduodenoscopy, rectocolonoscopy, computerized tomography small bowel follow-through examination, capsule endoscopy, biopsy, angiography, abdominal computerized tomography scans and ultrasound. Therapies included: interventional radiology and surgery.

Results

Thirty-five cases of obscure and 27 cases of occult bleeding were examined; all received a definite diagnosis during hospitalization. In the cases with obscure bleeding the diagnosis was inflammatory bowel disease (n = 7), angiodysplasia (5 gastric, 2 duodenal, 2 jejunal, 3 ileal, 4 right colon), small bowel tumors (4 non-Hodgkin lymphomas, 1 leiomyoma, 6 adenocarcinomas), and gastric metaplasia of Meckel's diverticulum (n = 1). There were significantly more nontumor lesions than tumors (P <0.005), and a middle tract source was significantly more frequent than upper/lower tract sources (P <0.0001). Intestinal resections were performed for all small bowel tumors (8 laparotomic, 3 laparoscopic), 5 angiodysplasias, all cases of inflammatory bowel disease and gastric metaplasia of Meckel's diverticulum; arterial embolization was performed for 11 angiodysplasias. In the cases with occult bleeding the diagnosis was sigmoid colon polyps in 6 (treatment, endoscopic polypectomy) and right colon cancer in 21 (treatment, right hemicolectomy). There were significantly more tumors than nontumor lesions (P <0.0001); all derived from the lower gastrointestinal tract. In all cases, the interventions resolved the bleeding completely.

Conclusions

The results show that more than 50% of cases with obscure/occult bleeding requiring hospitalization are motivated by malignant gastrointestinal tumors, 34% of which are located in the small bowel, usually a difficult tract to explore. Thanks to modern technology, however, their diagnosis and treatment can nowadays be promptly and successfully achieved.

Challenging Diagnosis of Ileal Gastrointestinal Stromal Tumor Presenting with Obscure Digestive Bleeding

We report a case of a patient observed in emergency condition for recurrent episodes of massive obscure gastrointestinal bleeding that required surgical control. At laparotomy we found an ileal mass with the characteristics of a gastrointestinal stromal tumor (GIST) at histopathological analysis. GISTs should always be considered as a possible cause of obscure gastrointestinal bleeding, although they are often difficult to diagnose preoperatively. Laparotomy is sometimes the only way to obtain a diagnosis. Starting from this case, we reviewed the literature about GISTs, focusing our attention on their diagnosis and the possible surgical and nonsurgical therapies.

Double-balloon enteroscopy (DBE) in patients presenting with obscure gastrointestinal bleeding (OGIB)

BACKGROUND AND STUDY AIMS

Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of unknown origin that persists or recurs after an initial negative investigation. Identifying the source of OGIB represents a diagnostic challenge that is frequently focused on visualizing the small intestine. Conventional diagnostic methods, such as push enteroscopy, small-bowel follow-through, radionuclide scanning, and angiography, each exhibit inherent limitations. Double balloon enteroscopy (DBE) was designed specifically to evaluate the entire small bowel. DBE allows for better visualization, biopsy of the identified lesions and application of therapeutic techniques. This study sought to assess the role of DBE in the diagnosis and management of patients with OGIB.

PATIENTS AND METHODS

This prospective study was conducted to analyse data from 31 patients presenting with OGIB referred for DBE in the Endoscopy Unit at the Internal Medicine Department of the Faculty of Medicine, Cairo University.

RESULTS

Five patients had lesions in locations other than the small intestine that accounted for GI bleeding. Thus, the potential source of OGIB was defined as the small intestine in 18 of 26 patients (69.2%), and negative DBE findings were noted in eight patients (30.8%). Major findings included small intestinal tumours in eight patients, vascular bleeding lesions in 8 patients and ulcerations in 2 patients. Endoscopic haemostasis was performed in eight patients with vascular lesions. The three patients with Petuz-Jegher syndrome underwent polypectomy of their major polyps. Patients with gastrointestinal tumours were referred for surgery.

CONCLUSION

DBE is an excellent endoscopic procedure that has a relatively high diagnostic and therapeutic yield. The procedure is feasible and exhibits a high safety profile with a low complication rate when performed by an experienced endoscopist.

Clinical factors associated with positive capsule endoscopy findings in patients with obscure gastrointestinal bleeding: a single-center study

BACKGROUND

Capsule endoscopy (CE) is a useful tool for patients with obscure gastrointestinal bleeding (OGIB), but positive finding rate differs among trials, which may be attributable to the difference in patients' background.

OBJECTIVES

To evaluate the predictive factors associated with positive findings on CE.

METHODS

Consecutive patients with OGIB who underwent CE between March 2004 and May 2015 at a single university hospital were enrolled. Patients' clinical factors and CE data were reviewed retrospectively, and we evaluated the relationship between clinical factors and positive findings by univariate and multivariate logistic regression analyses.

RESULTS

Five hundred and seventy-eight patients were included in the analysis. Positive CE findings were obtained in 284 patients (49.1%). In multivariate analysis, low hemoglobin level (odds ratio (OR), 1.142 per 1 g/dL decrease; p < .001), Charlson comorbidity index (CCI) score (OR, 1.170 per 1 point increase; p = .002), and non-steroidal anti-inflammatory drug (NSAID) use (OR, 1.640; p = .044) were associated with an increased prevalence of positive findings. As for components of CCI, malignant tumor (OR, 1.839; p = .017) was associated with the positive findings.

CONCLUSIONS

OGIB patient with a low-hemoglobin level, complex and severe comorbidities, and NSAID use should receive CE.