Length of endoscopic workup in gastrointestinal bleeding

The future of capsule endoscopy in clinical practice: from diagnostic to therapeutic experimental prototype capsules

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.

Earlier use of capsule endoscopy in inpatients with melena or severe iron deficiency anemia reduces need for colonoscopy and shortens hospital stay

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.

When to abandon the search for an elusive gastrointestinal bleeding source

BACKGROUND AND STUDY AIMS

 In some patients with gastrointestinal bleeding, even multiple consecutive endoscopic procedures fail to achieve lasting hemostasis. The current decision analysis was designed to answer the question of when to continue or abandon a sequence of endoscopic attempts of endoscopic hemostasis.

MATERIALS AND METHODS

 A decision tree with a threshold analysis was used to model the decision between continued endoscopy or expectant management. A low threshold probability was indicative of a preferred management option.

RESULTS

For continued endoscopy to be the favored decision, its probability of success in achieving hemostasis needed to exceed the success probability of expectant management by a greater amount than its costs exceeded those of expectant management. Endoscopic attempts at hemostasis should be discontinued if the costs of endoscopy are high compared with those of expectant management. The endoscopic attempt should be continued, if its probability for achieving lasting hemostasis is high.

CONCLUSIONS

Such principles are applicable as rule of thumb in managing patients with ongoing chronic gastrointestinal bleeding.