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DeLoughery TG, Jackson CS, Ko CW, Rockey DC. AGA Clinical Practice Update on Management of Iron Deficiency Anemia: Expert Review. Clin Gastroenterol Hepatol 2024; 22:1575-1583. [PMID: 38864796 DOI: 10.1016/j.cgh.2024.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 06/13/2024]
Abstract
DESCRIPTION In this Clinical Practice Update (CPU), we will Best Practice Advice (BPA) guidance on the appropriate management of iron deficiency anemia. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: No single formulation of oral iron has any advantages over any other. Ferrous sulfate is preferred as the least expensive iron formulation. BEST PRACTICE ADVICE 2: Give oral iron once a day at most. Every-other-day iron dosing may be better tolerated for some patients with similar or equal rates of iron absorption as daily dosing. BEST PRACTICE ADVICE 3: Add vitamin C to oral iron supplementation to improve absorption. BEST PRACTICE ADVICE 4: Intravenous iron should be used if the patient does not tolerate oral iron, ferritin levels do not improve with a trial of oral iron, or the patient has a condition in which oral iron is not likely to be absorbed. BEST PRACTICE ADVICE 5: Intravenous iron formulations that can replace iron deficits with 1 or 2 infusions are preferred over those that require more than 2 infusions. BEST PRACTICE ADVICE 6: All intravenous iron formulations have similar risks; true anaphylaxis is very rare. The vast majority of reactions to intravenous iron are complement activation-related pseudo-allergy (infusion reactions) and should be treated as such. BEST PRACTICE ADVICE 7: Intravenous iron therapy should be used in individuals who have undergone bariatric procedures, particularly those that are likely to disrupt normal duodenal iron absorption, and have iron-deficiency anemia with no identifiable source of chronic gastrointestinal blood loss. BEST PRACTICE ADVICE 8: In individuals with inflammatory bowel disease and iron-deficiency anemia, clinicians first should determine whether iron-deficiency anemia is owing to inadequate intake or absorption, or loss of iron, typically from gastrointestinal bleeding. Active inflammation should be treated effectively to enhance iron absorption or reduce iron depletion. BEST PRACTICE ADVICE 9: Intravenous iron therapy should be given in individuals with inflammatory bowel disease, iron-deficiency anemia, and active inflammation with compromised absorption. BEST PRACTICE ADVICE 10: In individuals with portal hypertensive gastropathy and iron-deficiency anemia, oral iron supplements initially should be used to replenish iron stores. Intravenous iron therapy should be used in patients with ongoing bleeding who do not respond to oral iron therapy. BEST PRACTICE ADVICE 11: In individuals with portal hypertensive gastropathy and iron-deficiency anemia without another identified source of chronic blood loss, treatment of portal hypertension with nonselective β-blockers can be considered. BEST PRACTICE ADVICE 12: In individuals with iron-deficiency anemia secondary to gastric antral vascular ectasia who have an inadequate response to iron replacement, consider endoscopic therapy with endoscopic band ligation or thermal methods such as argon plasma coagulation. BEST PRACTICE ADVICE 13: In patients with iron-deficiency anemia and celiac disease, ensure adherence to a gluten-free diet to improve iron absorption. Consider oral iron supplementation based on the severity of iron deficiency and patient tolerance, followed by intravenous iron therapy if iron stores do not improve. BEST PRACTICE ADVICE 14: Deep enteroscopy performed in patients with iron-deficiency anemia suspected to have small-bowel bleeding angioectasias should be performed with a distal attachment to improve detection and facilitate treatment. Small-bowel angioectasias may be treated with ablative thermal therapies such as argon plasma coagulation or with mechanical methods such as hemostatic clips. BEST PRACTICE ADVICE 15: Endoscopic treatment of angioectasias should be accompanied with iron replacement. Medical therapy for small-bowel angioectasias should be reserved for compassionate treatment in refractory cases when iron replacement and endoscopic therapy are ineffective.
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Affiliation(s)
- Thomas G DeLoughery
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Christian S Jackson
- Department of Gastroenterology, VA Loma Linda Veterans Health Care System, Loma Linda, California; Department of Medicine, Loma Linda University, Loma Linda, California
| | - Cynthia W Ko
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina
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Rossi RE, Zullo A, Ferretti S, Migliorisi G, Gatta L, De Francesco V, Del Forno A, Marcozzi G, Masoni B, Franchellucci G, Hassan C, Repici A. Diagnostic Yield of Small Bowel Videocapsule Endoscopy in Patients with Iron Deficiency Anemia. A Systematic Review and meta-analysis. J Clin Gastroenterol 2024:00004836-990000000-00256. [PMID: 38227849 DOI: 10.1097/mcg.0000000000001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND AIM Gastrointestinal (GI) bleeding or malabsorption represents the most frequent aetiologies of iron deficiency anemia (IDA). The cause of IDA remains undetermined in ~10% to 20% of patients undergoing upper and lower GI endoscopies. In this scenario, a small bowel examination with videocapsule endoscopy (VCE) is recommended. We performed a systematic review with meta-analysis to evaluate the diagnostic yield of VCE in patients with IDA without overt bleeding, assessing the prevalence of either any lesion or lesions at high potential of bleeding. MATERIALS AND METHODS A computerized literature search was performed using relevant keywords to identify all the pertinent articles published until March 2023. RESULTS Twelve studies with a total of 1703 IDA patients (Males: 47%; age range: 19-92 y) were included in this systematic review. The diagnostic yield of VCE for overall lesions in the small bowel was 61% (95% CI=44-77; 95 CI=97.2-98.1; I2=97.7%). When analyzing only small bowel lesions likely responsible of IDA, the diagnostic yield was 40% (95% CI=27-53; 95% CI=95.3-97; I2=96.3%). CONCLUSION VCE plays a relevant role in the diagnostic work-up of patients with IDA without overt bleeding with a satisfactory diagnostic yield.
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Affiliation(s)
- Roberta Elisa Rossi
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
| | - Angelo Zullo
- Gastroenterology Unit, 'Nuovo Regina Margherita' Hospital, Rome
| | - Silvia Ferretti
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
- Department of Biomedical Sciences, Humanitas University, Milan
| | - Giulia Migliorisi
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
- Department of Biomedical Sciences, Humanitas University, Milan
| | - Luigi Gatta
- Gastroenteorology Unit, 'Versilia' Hospital, Lido di Camaiore
| | | | | | - Giacomo Marcozzi
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
- Department of Biomedical Sciences, Humanitas University, Milan
| | - Benedetta Masoni
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
- Department of Biomedical Sciences, Humanitas University, Milan
| | - Gianluca Franchellucci
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
- Department of Biomedical Sciences, Humanitas University, Milan
| | - Cesare Hassan
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
- Department of Biomedical Sciences, Humanitas University, Milan
| | - Alessandro Repici
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Milan
- Department of Biomedical Sciences, Humanitas University, Milan
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Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia. Diagnostics (Basel) 2021; 12:diagnostics12010091. [PMID: 35054257 PMCID: PMC8774472 DOI: 10.3390/diagnostics12010091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/14/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022] Open
Abstract
Small bowel malignancies are rare and usually asymptomatic or symptoms are nonspecific. Therefore, small bowel tumors are difficult to diagnose. In patients with iron deficiency anemia (IDA) who have negative bidirectional endoscopy results, the small bowel may be considered the source of bleeding. However, in asymptomatic IDA patients with negative bidirectional endoscopy results, evidence supporting the routine use of capsule endoscopy (CE) is insufficient. CE can be considered in selected patients with recurrent or persistent IDA. The frequency of small bowel malignancies is low in patients undergoing CE for IDA, but the usefulness of CE for the diagnosis of small bowel malignancies in younger age groups with IDA has been reported. For patients with risk factors for small bowel malignancy, investigation of the small bowel should be considered. Efforts should be made to prevent adverse events, such as capsule retention or capsule aspiration, through meticulous history taking and endoscopic capsule delivery as necessary.
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Chang JY, Moon CM, Shim KN, Cheung DY, Lee HS, Lim YJ, Jeon SR, Park SJ, Kim KO, Song HJ, Jang HJ, Kim JH. 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. Clin Endosc 2020; 53:719-726. [PMID: 33153246 PMCID: PMC7719424 DOI: 10.5946/ce.2019.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 06/07/2020] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Ji Young Chang
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Dae Young Cheung
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyun Seok Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Yun Jeong Lim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Hyun Joo Song
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Hyun Joo Jang
- Department of Internal Medicine, Hallym University College of Medicine, Hwasung, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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Rockey DC, Altayar O, Falck-Ytter Y, Kalmaz D. AGA Technical Review on Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology 2020; 159:1097-1119. [PMID: 32828801 PMCID: PMC10824166 DOI: 10.1053/j.gastro.2020.06.045] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina
| | - Osama Altayar
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Yngve Falck-Ytter
- Department of Medicine and Gastroenterology, Case Western Reserve; University; Veterans Affairs Northeast Ohio Health System, Cleveland, Ohio
| | - Denise Kalmaz
- Division of Gastroenterology, University of California, San Diego, California
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Spada C, McNamara D, Despott EJ, Adler S, Cash BD, Fernández-Urién I, Ivekovic H, Keuchel M, McAlindon M, Saurin JC, Panter S, Bellisario C, Minozzi S, Senore C, Bennett C, Bretthauer M, Dinis-Ribeiro M, Domagk D, Hassan C, Kaminski MF, Rees CJ, Valori R, Bisschops R, Rutter MD. Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. United European Gastroenterol J 2019; 7:614-641. [PMID: 31210941 DOI: 10.1177/2050640619850365] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/24/2019] [Indexed: 12/17/2022] Open
Abstract
The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.
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Affiliation(s)
- Cristiano Spada
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy.,Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Deirdre McNamara
- TAGG Research Centre, Department of Clinical Medicine, Tallaght Hospital, Trinity College Dublin, Ireland
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, London, UK
| | - Samuel Adler
- Division of Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Brooks D Cash
- Department of Gastroenterology, Hepatology, and Nutrition, UT Health Science Center at Houston/Memorial Hermann, Houston, TX, USA.,McGovern Medical School, Department of Internal Medicine, Houston, TX, USA
| | | | - Hrvoje Ivekovic
- Department of Gastroenterology and Hepatology, University Hospital Centre, Zagreb, Croatia
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Mark McAlindon
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Jean-Christophe Saurin
- Gastroenterology and Endoscopy Unit, Hospices Civils de Lyon, Hôpital E. Herriot, Lyon, France
| | - Simon Panter
- Department of Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, UK
| | | | - Silvia Minozzi
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Carlo Senore
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Cathy Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn, Dublin, Ireland
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Mario Dinis-Ribeiro
- Servicio de Gastroenterologia, Instituto Portugues de Oncologia Francisco Gentil, Porto, Portugal
| | - Dirk Domagk
- Department of Medicine I, Josephs-Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Gastroenterological Oncology and Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Colin J Rees
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | - Roland Valori
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology. University Hospital Leuven, Leuven, Belgium
| | - Matthew D Rutter
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK.,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
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Contaldo A, Losurdo G, Albano F, Iannone A, Barone M, Ierardi E, Di Leo A, Principi M. The Spectrum of Small Intestinal Lesions in Patients with Unexplained Iron Deficiency Anemia Detected by Video Capsule Endoscopy. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:medicina55030059. [PMID: 30818850 PMCID: PMC6473446 DOI: 10.3390/medicina55030059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/16/2019] [Accepted: 02/21/2019] [Indexed: 02/07/2023]
Abstract
Background and objectives: Video-capsule endoscopy (VCE) has shown a large range (38⁻83%) of diagnostic yield in unexplained iron deficiency anemia (IDA) and obscure-occult bleeding. Therefore, we retrospectively investigated the VCE-detected spectrum and the prevalence of small bowel injuries and associated risk factors in inpatients with both of the above reported conditions. Methods: We selected inpatients with IDA (hemoglobin <12 g/dL in women, <13 g/dL in men) and obscure-occult bleeding. We excluded VCE indications other than IDA. Complete medical histories and laboratory tests were collected. All subjects underwent PillCam SB2/SB3. The VCE feature Lewis score was calculated when appropriate. We used the t-test and Fisher's exact test for continuous and categorical variables, respectively, in univariate analysis. For multivariate analysis, we used binomial logistic regression. Results: We retrieved 109 patients (female:male ratio of 53:56; age 63.4 ± 18.9 years). Eighty patients (73.4%) showed ≥1 small bowel lesions. The Lewis score was calculated in 41 patients: 13 (31.7%) showed a mild (<135) and 28 (68.3%) a moderate-severe (135⁻790 and >790, respectively) score. In univariate analysis, the small bowel transit time (6.2 ± 2.9 versus 5.2 ± 2.1 h; p = 0.049) and non-steroidal anti-inflammatory drug use for at least two weeks (17.5% versus 0%; p = 0.01) were significantly higher in subjects with injuries. These associations were not confirmed at multivariate analysis. The severity of a lesion directly correlated with proton pump inhibitor (PPI) use and duration (not confirmed in multivariate analysis). VCE can reveal the source of obscure-occult bleeding in a high percentage of unexplained IDAs. A wide spectrum of endoscopic pictures may be found. Known as well as supposed risk factors for small bowel lesions may be detected.
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Affiliation(s)
- Antonella Contaldo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Francesca Albano
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
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Olano C, Pazos X, Avendaño K, Calleri A, Ketzoian C. Diagnostic yield and predictive factors of findings in small-bowel capsule endoscopy in the setting of iron-deficiency anemia. Endosc Int Open 2018; 6:E688-E693. [PMID: 29868633 PMCID: PMC5979215 DOI: 10.1055/a-0593-5915] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 02/20/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Despite the widespread use of small-bowel capsule endoscopy (CE), there is still limited data on its utility and effectiveness for the diagnosis and management of patients with iron-deficiency anemia (IDA). AIM To assess the diagnostic yield of CE and the factors predicting positive findings in patients with IDA. METHODS Patients with unexplained IDA and negative upper and lower endoscopy were included. A positive diagnostic yield was considered when CE diagnosed one or more lesions that could explain the IDA. Sex, age, NSAID consumption, blood transfusion requirement, and ferritin and hemoglobin levels were recorded. RESULTS In total, 120 CE were included (mean age 58.5 years; F/M 82:38). Mean hemoglobin levels were 9 g/dL and mean ferritin levels were 15.7 ng/mL. Positive findings were present in 50 % of patients. The most frequent was angiodysplasia (45 %). Despite several baseline variables being significantly associated with positive findings, using a logistic regression model, it was verified that male sex (OR 3.93; 95 %CI 1.57 - 9.86), age (OR 1.03; 95 %CI 1.00 - 1.06), and hemoglobin levels (OR 0.73; 95 %CI 0.57 - 0.94) were the variables having an independent effect on the probability of obtaining positive findings. Age older than 50 years (OR 14.05; 95 %CI 1.69 - 116.23) and male sex (OR 3.63; 95 %CI 1.29 - 10.17) were the variables which increased the risk of diagnosing angiodysplasia. CONCLUSIONS CE is a useful technique in patients with IDA. To improve its yield, it is necessary to select patients carefully. Male sex, older age, and low hemoglobin levels were associated with a risk of positive finding in this group of patients. The risk of diagnosing angiodysplasia increased with male sex and older age.
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Affiliation(s)
- Carolina Olano
- Clinica de Gastroenterología “Prof. Henry Cohen”, Hospital de Clínicas, UDELAR, Montevideo, Uruguay,Corresponding author Carolina Olano, MD MSc Hospital de ClinicasAv. Italia s/n CP 11600MontevideoUruguay+598-2-4872572
| | - Ximena Pazos
- Clinica de Gastroenterología “Prof. Henry Cohen”, Hospital de Clínicas, UDELAR, Montevideo, Uruguay
| | - Karla Avendaño
- Clinica de Gastroenterología “Prof. Henry Cohen”, Hospital de Clínicas, UDELAR, Montevideo, Uruguay
| | - Alfonso Calleri
- Clinica de Gastroenterología “Prof. Henry Cohen”, Hospital de Clínicas, UDELAR, Montevideo, Uruguay
| | - Carlos Ketzoian
- Clinica de Gastroenterología “Prof. Henry Cohen”, Hospital de Clínicas, UDELAR, Montevideo, Uruguay
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Rodrigues JP, Pinho R, Silva J, Ponte A, Sousa M, Silva JC, Carvalho J. Appropriateness of the study of iron deficiency anemia prior to referral for small bowel evaluation at a tertiary center. World J Gastroenterol 2017; 23:4444-4453. [PMID: 28706428 PMCID: PMC5487509 DOI: 10.3748/wjg.v23.i24.4444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/13/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the adequacy of the study of iron deficiency anemia (IDA) in real life practice prior to referral to a gastroenterology department for small bowel evaluation.
METHODS All consecutive patients referred to a gastroenterology department for small bowel investigation due to iron deficiency anemia, between January 2013 and December 2015 were included. Both patients referred from general practitioners or directly from different hospital departments were selected. Relevant clinical information regarding prior anemia workup was retrospectively collected from medical records. An appropriate pre-referral study was considered the execution of esophagogastroduodenoscopy (EGD) with Helicobacter pylori (H. pylori) investigation, colonoscopy with quality standards (recent, total and with adequate preparation) and celiac disease (CD) screening (through serologic testing and/or histopathological investigation).
RESULTS A total of 77 patients (58.4% female, mean age 67.1 ± 16.7 years) were included. Most (53.2%) patients were referred from general practitioners, 41.6% from other hospital specialties and 5.2% directly from the emergency department. The mean pre-referral hemoglobin concentration was 8.8 ± 2.0 g/dL and the majority of anemias had microcytic (71.4%) and hypochromic (72.7%) characteristics. 77.9% of patients presented with an incomplete pre-referral study: EGD in 97.4%, with H. pylori investigation in 58.3%, colonoscopy with quality criteria in 63.6%, and CD screening in 24.7%. Patients with an appropriate study at the time of referral were younger (48.7 ± 17.7 vs 72.3 ± 12.3 years, P < 0.001). Small bowel evaluation was ultimately undertaken in 72.7% of patients, with a more frequent evaluation in patients with a quality colonoscopy at referral (78.6% vs 23.8%); P < 0.001 (OR = 11.7, 95%CI: 3.6-38.6). The most common diagnosis regarded as the likely cause of IDA was small bowel angioectasia (18.2%) but additional causes were also found in the upper and lower gastrointestinal tracts of near 20% of patients. Small bowel studies detected previously unknown non-small bowel findings in 7.7% of patients.
CONCLUSION The study of anemia prior to referral to gastroenterology department is unsatisfactory. Only approximately a quarter of patients presented with an appropriate study.
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MESH Headings
- Age Factors
- Aged
- Aged, 80 and over
- Anemia, Iron-Deficiency/blood
- Anemia, Iron-Deficiency/diagnosis
- Anemia, Iron-Deficiency/etiology
- Angiodysplasia/complications
- Celiac Disease/blood
- Celiac Disease/diagnosis
- Celiac Disease/microbiology
- Celiac Disease/pathology
- Endoscopy, Digestive System
- Female
- Gastrointestinal Hemorrhage/blood
- Gastrointestinal Hemorrhage/complications
- Helicobacter pylori/isolation & purification
- Hemoglobins/analysis
- Humans
- Intestine, Small/blood supply
- Intestine, Small/diagnostic imaging
- Intestine, Small/microbiology
- Male
- Middle Aged
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/standards
- Referral and Consultation
- Retrospective Studies
- Social Validity, Research
- Telangiectasis
- Tertiary Care Centers/organization & administration
- Tertiary Care Centers/standards
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10
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Enns RA, Hookey L, Armstrong D, Bernstein CN, Heitman SJ, Teshima C, Leontiadis GI, Tse F, Sadowski D. Clinical Practice Guidelines for the Use of Video Capsule Endoscopy. Gastroenterology 2017; 152:497-514. [PMID: 28063287 DOI: 10.1053/j.gastro.2016.12.032] [Citation(s) in RCA: 255] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice. METHODS A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. RESULTS The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined. CONCLUSIONS CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.
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Affiliation(s)
- Robert A Enns
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Lawrence Hookey
- Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Teshima
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Sadowski
- Division of Gastroenterology, Royal Alexandria Hospital, Edmonton, Alberta, Canada
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11
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Abstract
Occult gastrointestinal bleeding is not visible and may present with a positive fecal occult blood test or iron deficiency anemia. Obscure bleeding can be overt or occult, with no source identified despite an appropriate diagnostic workup. A stepwise approach to this evaluation after negative upper and lower endoscopy has been shown to be cost effective. This includes repeat endoscopies if warranted, followed by video capsule endoscopy (VCE) if no obstruction is present. If the VCE is positive then specific endoscopic intervention may be possible. If negative, patients may undergo either repeat testing or watchful waiting with iron supplements.
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Affiliation(s)
- Edgar R Naut
- Saint Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105, USA.
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12
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Magalhães-Costa P, Bispo M, Santos S, Couto G, Matos L, Chagas C. Re-bleeding events in patients with obscure gastrointestinal bleeding after negative capsule endoscopy. World J Gastrointest Endosc 2015; 7:403-410. [PMID: 25901220 PMCID: PMC4400630 DOI: 10.4253/wjge.v7.i4.403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/27/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate long-term re-bleeding events after a negative capsule endoscopy in patients with obscure gastrointestinal bleeding (OGIB) and the risk factors associated with the procedure.
METHODS: Patients referred to Hospital Egas Moniz (Lisboa, Portugal) between January 2006 and October 2012 with OGIB and a negative capsule endoscopy were retrospectively analyzed. The following study variables were included: demographic data, comorbidities, bleeding-related drug use, hemoglobin level, indication for capsule endoscopy, post procedure details, work-up and follow-up. Re-bleeding rates and associated factors were assessed using a Cox proportional hazard analysis. The Kaplan-Meier method was used to estimate the cumulative incidence of re-bleeding at 1, 3 and 5 years, and the differences between factors were evaluated.
RESULTS: The study population consisted of 640 patients referred for OGIB investigation. Wireless capsule endoscopy was deemed negative in 113 patients (17.7%). A total of 64.6% of the population was female, and the median age was 69 years. The median follow-up was forty-eight months (interquartile range 24-60). Re-bleeding occurred in 27.4% of the cases. The median time to re-bleeding was fifteen months (interquartile range 2-33). In 22.6% (n = 7) of the population, small-bowel angiodysplasia was identified as the culprit lesion. A univariate analysis showed that age > 65 years old, chronic kidney disease, aortic stenosis, anticoagulant use and overt OGIB were risk factors for re-bleeding; however, on a multivariate analysis, there were no risk factors for re-bleeding. The cumulative risk of re-bleeding at 1, 3 and 5 years of follow-up was 12.9%, 25.6% and 31.5%, respectively. Patients who presented with overt OGIB tended to re-bleed sooner (median time for re-bleeding: 8.5 mo vs 22 mo).
CONCLUSION: Patients with OGIB despite a negative capsule endoscopy have a significant re-bleeding risk; therefore, these patients require an extended follow-up strategy.
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13
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The Utility of Capsule Endoscopy in Patients under 50 Years of Age with Recurrent Iron Deficiency Anaemia: Is the Juice Worth the Squeeze? Gastroenterol Res Pract 2015; 2015:948574. [PMID: 25922603 PMCID: PMC4397481 DOI: 10.1155/2015/948574] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/16/2015] [Indexed: 12/22/2022] Open
Abstract
Background and Aims. The role of capsule endoscopy (CE) in the <50 years of age patients with iron deficiency anaemia (IDA) remains unclear. We aim to assess its utility in this cohort. Methods. All patients referred for CE for recurrent IDA were included retrospectively. Patients were divided into Group 1 (<50 years) and Group 2 (≥50 years). Results. There were 971 patients with recurrent IDA and 28% belonged to Group 1. The mean age was 40 years in this group with a DY of 28% (n = 76). Significant diagnoses included erosions and ulcers (26%; n = 71), small bowel (SB) angioectasia (AE) (10%; n = 27), SB tumours (3%; n = 7), Crohn's disease (3%; n = 7), SB bowel strictures (1%; n = 3), and SB varices (1%; n = 2). On logistic regression, the presence of diabetes (P = 0.02) and the use of warfarin (P = 0.049) was associated with increased DY. The DY in Group 2 was 38% which was significantly higher than in Group 1 (P = 0.02). While SB tumours were equally common in both groups, AE was commoner in Group 2 (P < 0.001). Conclusion. A significant proportion of patients <50 years are referred for CE. Although the DY is lower compared to those ≥50 years, significant pathology is found in this age group. CE is advisable in patients <50 years old with recurrent IDA and negative bidirectional endoscopies.
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14
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Garrido Durán C, Iyo Miyashiro E, Páez Cumpa C, Khorrami Minaei S, Erimeiku Barahona A, Llompart Rigo A. [Diagnostic yield of video capsule endoscopy in premenopausal women with iron-deficiency anemia]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:373-8. [PMID: 25700804 DOI: 10.1016/j.gastrohep.2015.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 11/23/2014] [Accepted: 01/08/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Clinical practice guidelines recommend video capsule endoscopy (VCE) studies in patients with iron-deficiency anemia (IDA) after conventional upper and lower endoscopies but there is a need for studies demonstrating the diagnostic yield, clinical impact, and cost in some patient subgroups. OBJECTIVES 1.To determine the diagnostic yield of VCE in premenopausal women with IDA compared with that in men and postmenopausal women. 2. To identify the presence of VCE predictors in premenopausal women. 3. To estimate the cost-clinical impact relationship associated with VCE in this indication. MATERIAL AND METHOD We retrospectively analyzed 408 patients who underwent VCE. Patients with IDA were enrolled (premenopausal, postmenopausal women, and men), with previous normal work-up by conventional endoscopies. RESULTS A total of 249 patients were enrolled: 131 women (52.6%), of which 51 were premenopausal and 80 were post-menopausal, and 118 men. The mean age was 60.7±16 years. The diagnostic yield of VCE for the diagnosis of IDA was 44.6% (95% CI 39.9 - 50.8). Diagnostic yield was 50.8% vs 38.9% in men vs women (p=0.05) and was 55% vs 13.7% in postmenopausal vs premenopausal women (p<0.001). No predictors of small bowel lesions were found in premenopausal women. The most common findings in the postmenopausal group were angioectasias (70.5%) and erosions (57.1%) in the premenopausal group. The cost in premenopausal women was 44.727€ and 86.3% of the procedures had no clinical impact. CONCLUSIONS The diagnostic yield of VCE is low in the etiological study of IDA in premenopausal women and there is no cost-effectiveness in relation to clinical impact. No predictors of small bowel lesions were found in this group.
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Affiliation(s)
- Carmen Garrido Durán
- Servicio de Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, España.
| | - Eduardo Iyo Miyashiro
- Servicio de Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - Claudia Páez Cumpa
- Servicio de Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - Sam Khorrami Minaei
- Servicio de Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, España
| | | | - Alfredo Llompart Rigo
- Servicio de Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, España
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15
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Hosoe N, Naganuma M, Ogata H. Current status of capsule endoscopy through a whole digestive tract. Dig Endosc 2015; 27:205-15. [PMID: 25208463 DOI: 10.1111/den.12380] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023]
Abstract
More than a decade has passed since small-bowel capsule endoscopy (CE) was first reported. Small-bowel CE is a non-invasive tool that allows visualization of the entire small-intestinal mucosa and facilitates detection of small-intestinal abnormalities. Several studies have shown benefit of small-bowel CE for certain disorders. Because it is non-invasive, CE has been applied to other organs including the esophagus, stomach, and colon. The main indications for esophageal CE (ECE) are screening for gastroesophageal reflux disease/Barrett's esophagus, and esophageal varices. However, the clinical benefit of ECE is unconfirmed. Magnetically guided CE (MGCE) was developed to visualize the gastric mucosa. MGCE is a new concept with room for improvement of capsule navigation and the preparation protocol. Recently, two new small-bowel CE tools were released. First-generation colon CE (CCE-1) has moderate sensitivity and specificity compared with colonoscopy for colorectal neoplasia surveillance. To obtain higher accuracy, a second-generation CCE (CCE-2) was developed with a high sensitivity for detecting clinically relevant polypoid lesions. A possible application of CCE is for inflammatory bowel disease. In the near future, CE may include diagnostic and therapeutic functions such as magnifying endoscopy systems, targeted biopsy forceps, and drug delivery systems.
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Affiliation(s)
- Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
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16
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Rondonotti E, Koulaouzidis A, Silvia P, Franco R, Pennazio M. Obscure gastrointestinal bleeding and iron-deficiency anemia—Where does capsule endoscopy fit? TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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17
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Muhammad A, Vidyarthi G, Brady P. Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature. World J Gastroenterol 2014; 20:8416-8423. [PMID: 25024599 PMCID: PMC4093694 DOI: 10.3748/wjg.v20.i26.8416] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/30/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.
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18
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Koulaouzidis A, Rondonotti E, Plevris JN. Response. Gastrointest Endosc 2013; 78:801. [PMID: 24120342 DOI: 10.1016/j.gie.2013.07.016] [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: 07/05/2013] [Accepted: 07/09/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Anastasios Koulaouzidis
- Centre for Liver & Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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19
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Koh SJ, Im JP, Kim JW, Kim BG, Lee KL, Kim SG, Kim JS, Jung HC. Long-term outcome in patients with obscure gastrointestinal bleeding after negative capsule endoscopy. World J Gastroenterol 2013; 19:1632-1638. [PMID: 23539070 PMCID: PMC3602481 DOI: 10.3748/wjg.v19.i10.1632] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 01/08/2013] [Accepted: 01/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate long-term outcome in obscure gastrointestinal bleeding (OGIB) after negative capsule endoscopy (CE) and identify risk factors for rebleeding.
METHODS: A total of 113 consecutive patients underwent CE for OGIB from May 2003 to June 2010 at Seoul National University Hospital. Ninety-five patients (84.1%) with a subsequent follow-up after CE of at least 6 mo were enrolled in this study. Follow-up data were obtained from the patients’ medical records. The CE images were reviewed by two board-certified gastroenterologists and consensus diagnosis was used in all cases. The primary outcome measure was the detection of rebleeding after CE, and factors associated with rebleeding were evaluated using multivariate analysis.
RESULTS: Of the 95 enrolled patients (median age 61 years, range 17-85 years), 62 patients (65.3%) were male. The median duration of follow-up was 23.7 mo (range 6.0-89.4 mo). Seventy-three patients (76.8%) underwent CE for obscure-overt bleeding. Complete examination of the small bowel was achieved in 77 cases (81.1%). Significant lesions were found in 38 patients (40.0%). The overall rebleeding rate was 28.4%. The rebleeding rate was higher in patients with positive CE (36.8%) than in those with negative CE (22.8%). However, there was no significant difference in cumulative rebleeding rates between the two groups (log rank test; P = 0.205). Anticoagulation after CE examination was an independent risk factor for rebleeding (hazard ratio, 5.019; 95%CI, 1.560-16.145; P = 0.007), regardless of CE results.
CONCLUSION: Patients with OGIB and negative CE have a potential risk of rebleeding. Therefore, close observation is required and alternative modalities should be considered in suspicious cases.
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