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]

The Role of Capsule Endoscopy in the Diagnosis and Management of Small Bowel Tumors: A Narrative Review

Small bowel tumors (SBT) are relatively rare, but have had a steadily increasing incidence in the last few decades. Small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy are the main endoscopic techniques for the study of the small bowel, the latter additionally providing sampling and therapeutic options, and hence acting complementary to SBCE in the diagnostic work-up. Although a single diagnostic modality is often insufficient in the setting of SBTs, SBCE is a fundamental tool to drive further management towards a definitive diagnosis. The aim of this paper is to provide a concise narrative review of the role of SBCE in the diagnosis and management of SBTs.

Small Bowel Capsule Endoscopy: Experience from a single large tertiary care centre

Background and study aims Capsule endoscopy (CE) has transformed examination of the small bowel (SB), once considered a dark continent. The present study aimed to describe the indications, diagnostic yield, practical issues and complications of CE in one of the largest tertiary center in India. Patients and methods This retrospective analysis from a prospectively maintained database, conducted from January 2013 to June 2021 included 1155 CEs performed during this period. Patient medical records were reviewed for indications, results, and complications of CE. Results A total of 1154 patients (809 males and 345 females), mean age 53 years (range 6-87 years), one capsule got stuck in the esophagus, were included in the study. Active SB bleeding had no effect on SB transit time (324.7±161 minutes, n = 137 patients with active bleed vs 310.6±166.9 minutes, n = 1017 patients without active bleed; P = 0.35). The indication and diagnostic yield (DY) of CE were potential overt SB bleed (68.6% & 43.9%), potential occult SB bleed (8.2% and 40%), chronic diarrhea (7.9% and 28.4%), abdominal pain (6.5% and 21.3%), anemia (5.9% and 57.9%), and suspected/known case of Crohn's disease (2.3% & 56.5%) respectively. The DY for patients with age ≥60 years was similar to those with age < 60 years (61.9% vs. 51.8% respectively; P = 0.4). 21 patients (1.8%) had capsule retention of which six (0.5%) had to be referred for surgery. Conclusions CE is a safe and effective investigation with ever increasing range of indications. Potential SB bleed remains the most common indication for CE with high detection rate.

Small Bowel Bleeding: Clinical Diagnosis and Management in the Elderly

INTRODUCTION

With the global increase in life expectancy, there is an increase in gastrointestinal presentations in the elderly. Small bowel bleeding (SBB) is a cause of significant morbidity in the elderly requiring multiple hospital visits, investigations and potentially expensive therapy.

AREAS COVERED

In this review we will outline the different modalities which are used for the diagnosis and management of SBB. We will also discuss the common causes of SBB in the elderly.

EXPERT OPINION

SBB in elderly has a significant impact on the quality of life of the elderly. Larger randomized studies in the elderly are urgently required to help guide clinicians on the best and most cost-effective treatment algorithm in this challenging cohort.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia

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.

British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA-for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease- with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.

Role of Video Capsule in Small Bowel Bleeding

Video capsule endoscopy has an essential role in the diagnosis and management of small bowel bleeding and is the first-line study recommended for this purpose. This article reviews the risk factors for small bowel bleeding, optimal timing for video capsule endoscopy testing, and algorithms recommended for evaluation. Used primarily for the assessment of nonacute gastrointestinal blood loss, video capsule endoscopy has an emerging role for more urgent use in emergency settings and in special populations. Future software incorporation of neural networks to enhance lesion detection will likely result in an augmented role of video capsule endoscopy in small bowel bleeding.

The Use of Capsule Endoscopy For Diagnosis of Iron Deficiency Anemia: A Retrospective Analysis

BACKGROUND

There was some ambiguity in the recent guidelines on the use of capsule endoscopy (CE) in cases of iron deficiency anemia (IDA).

GOAL

We aimed to examine the yield of CE in diagnosing the cause of IDA and to define clinical parameters that predict higher diagnostic yields.

MATERIALS AND METHODS

A total of 1351 individuals underwent CE in Winnipeg between 2005 and 2016. All studies were reported by 1 reading physician. Data included demographics and requested information on medication use, prior imaging studies, and hemoglobin and ferritin levels. In a total of 620 (46%) patients, CE was indicated for occult gastrointestinal bleeding or IDA. Positive findings on CE were separated into "definite" and "possible." Multinomial regression analysis was used to determine the variables correlated with definite CE findings. A survey analysis was then used to assess how the study results impacted further management.

RESULTS

With regard to the 620 patients, the mean age was 62.9 years, mean hemoglobin level was 89 g/L, and median ferritin level was 9 μg/L. A total of 210 (33.9%) patients had positive findings (definite: 23%, possible: 10.8%). Vascular ectasias were the majority of definite findings (47.5%). Predictors of definite findings were age (relative risk ratio: 1.04; 95% confidence interval: 1.02-1.06) and male sex (relative risk ratio: 1.88; 95% confidence interval: 1.25-2.83). An overall 12.7% of positive studies required therapeutic intervention, with 65.8% undergoing further workup.

CONCLUSION

We report a 33.9% positive yield, with 65.8% of patients undergoing further workup as a result of CE and 12.7% requiring therapeutic intervention. We conclude that CE plays an important role in the investigation of IDA and occult gastrointestinal bleeding and has important implications on further management.

IMPACT OF SMALL BOWEL CAPSULE ENDOSCOPY IN IRON DEFICIENCY ANEMIA: INFLUENCE OF PATIENT’SAGE ON DIAGNOSTIC YIELD

ABSTRACT BACKGROUND: Iron deficiency anemia remains one of the main indications to perform small bowel capsule endoscopy. Literature suggests that diagnostic yield is influenced by patient’s age but with conflicting results regarding age cutoff. OBJECTIVE: We aimed to clarify the differences in diagnostic yield and incidence of specific findings according to age. METHODS: Retrospective single-center study including 118 patients performing small bowel capsule endoscopy in the study of iron deficiency anemia. Videos were reviewed and small bowel findings that may account for anemia were reported. Incomplete examinations were excluded. Findings were compared between patients ≤60 and >60 years. RESULTS: Patients had a mean age of 58 years old (SD ±17.9) with 69.5% females (n=82). The overall diagnostic yield was 49% (58/118), being higher among patients >60 years (36/60, diagnostic yield 60%) than those ≤60 years (20/58, diagnostic yield 34%), (P<0.01). Angioectasias were more frequent in patients >60 years (45% vs 9%, P<0.01). Patients ≤60 years presented more frequently significant inflammation (Lewis score >135 in 10.3% vs 1.7%, P<0.05) and other non-vascular lesions (24% vs 10%, P=0.04). CONCLUSION: In our cohort small bowel capsule endoscopy diagnosed clinically relevant findings in the setting of iron deficiency anemia in almost half the patients. Diagnostic yield was higher in patients older than 60 years (60%), with vascular lesions being more frequent in this age group. Despite the lower diagnostic yield in patients ≤60 years, significant pathology was also found in this age group, mainly of inflammatory type.

Multiple gastric erosions diagnosed by means of capsule endoscopy in a dog

CASE DESCRIPTION A 6-year-old spayed female Golden Retriever was evaluated for a 2-week history of progressive hyporexia, signs of abdominal pain, and weight loss. CLINICAL FINDINGS Physical examination findings included mild signs of pain on palpation of the cranial part of the abdomen and a body condition score of 4 (scale, 1 to 9). A CBC revealed mild microcytosis and hypochromasia; results of serum biochemical analysis were within the respective reference ranges, and abdominal ultrasonography revealed no abnormalities. Capsule endoscopy was performed, and numerous gastric erosions and hemorrhages were detected, with rare dilated lacteals in the proximal aspect of the small intestine. TREATMENT AND OUTCOME Treatment was initiated with omeprazole and sucralfate for 6 weeks, and the dog was transitioned to a novel protein diet. Capsule endoscopy was repeated at the end of the initial treatment course and revealed overall improvement, with a few small erosions remaining; medical treatment was continued for an additional 2 weeks. At last follow-up 9 months after treatment ended, the dog was clinically normal. CLINICAL RELEVANCE Capsule endoscopy was useful for initial detection and subsequent reevaluation of gastrointestinal lesions in this patient without a need for sedation or anesthesia. Information obtained in the follow-up evaluation was valuable in identifying a need to extend the duration of medical treatment.

Small bowel malignancy in patients undergoing capsule endoscopy at a tertiary care academic center: Case series and review of the literature

BACKGROUND AND STUDY AIMS

Small bowel cancer is rare, accounting for < 5 % of all gastrointestinal neoplasms. Capsule endoscopy has become the procedure of choice for non-invasive diagnosis of small bowel diseases. Data on capsule endoscopy diagnosis of small bowel cancer are limited. The objective of the study was to determine the frequency, indications and diagnostic work-up of patients with small bowel malignancy found by capsule endoscopy at a Scottish tertiary center.

PATIENTS AND METHODS

In this retrospective study, records all patients who underwent small bowel capsule endoscopy at our center over a 10-year period were reviewed for possible malignancy. Further data were gathered on preceding and subsequent investigations, management and outcome of these patients.

RESULTS

From 1949 studies, small bowel malignancies were diagnosed in only 7 patients (0.36 %; 2F/5M; median age 50, range 34 - 67). The main indication was iron-deficiency anemia (n = 5). Prior to capsule endoscopy, 6 of 7 patients had bidirectional endoscopies and one had gastroscopy. All prior investigations were normal or nondiagnostic. Two of 7 experienced capsule retention. Five of 7 underwent surgery. Four patients died, giving a 5-year survival rate of 42.9 %.

CONCLUSION

 Small bowel malignancies diagnosed by capsule endoscopy are rare, and the median age of 50 indicates they are more common in relatively younger patients. Capsule endoscopy is effective at diagnosing a rare malignancy when other imaging modalities have failed.

Capsule endoscopy in young patients with iron deficiency anaemia and negative bidirectional gastrointestinal endoscopy

Background

Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology.

Materials and methods

This was a retrospective, multicentre study (2010-2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age <19 or >50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression.

Results

Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn's disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3-11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92-0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn.

Conclusion

In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.

Uncovering the uncertainty: Risk factors and clinical relevance of P1 lesions on small bowel capsule endoscopy of anemic patients

AIM

To identify risk factors for P1 lesions on small bowel capsule endoscopy (SBCE) and to describe the natural history of anemic patients with such type of lesions.

METHODS

One hundred patients were consecutively selected for a case-control analysis performed between 37 cases with P1 lesions and 63 controls with negative SBCE. Age, gender, comorbidities and regular medication were collected. Rebleeding, further investigational studies and death were also analyzed during the follow-up.

RESULTS

No significant differences on gender, median age or Charlson index were found between groups. Although no differences were found on the use of proton pump inhibitors, acetylsalicylic acid, anticoagulants or antiplatelet agents, the use of non-steroidal anti-inflammatory drugs (NSAID) was associated with a higher risk of P1 lesions (OR = 12.00, 95%CI: 1.38-104.1). From the 87 patients followed at our center, 39 were submitted to additional studies for investigation of iron-deficiency anemia (IDA), and this was significantly more common in those patients with no findings on SBCE (53.7% vs 30.3%, P = 0.033). A total of 29 patients had at least one rebleeding or IDA recurrence episode and 9 patients died of non-anemia related causes but no differences were found between cases and controls.

CONCLUSION

P1 lesions are commonly found in patients with IDA submitted to SBCE. The use of NSAID seems to be a risk factor for P1 lesions. The outcomes of patients with P1 lesions do not differ significantly from those with P0 lesions or normal SBCE.