Small-Bowel Lesions in Patients Taking Direct Oral Anticoagulants Detected Using Capsule Endoscopy

Capsule endoscopy in hemodialysis versus non-hemodialysis patients with suspected small bowel bleeding: a prospective cross-sectional study

Background

Gastrointestinal (GI) bleeding is common among hemodialysis (HD) patients. Endoscopic examination of the upper and lower GI tract often fails to identify hemorrhagic lesions in anemic HD patients. The study aims to evaluate lesions of the small bowel mucosa in HD vs non-HD patients with suspected small-bowel bleeding (SSBB) using capsule endoscopy (CE) after negative upper and lower GI endoscopies.

Methods

This prospective cross-sectional study included all consecutive patients presenting with occult GI bleeding at the Dialysis Unit (HD patients) and the Gastroenterology Outpatient Clinic (non-HD patients) of the University Hospital of Alexandroupolis. Within a pre-specified period of 13 months (01/07/2022 to 31/07/2023), we collected all relevant demographic data, laboratory parameters, comorbidity records, treatment profiles, and endoscopic findings. We used univariate and optimal scaling multivariate analyses to evaluate all parameters correlating with CE findings and Rhemitt score.

Results

The study included 100 patients (25 HD and 75 non-HD). Considering any lesion (oozing blood, red spots, angiodysplasias, and erosive/ulcerative lesions) at any site (duodenum, jejunum, and ileum) as separate binary variables, the prevalence per patient was superior in HD patients (3.8 ± 1.6 vs 1.3 ± 1.4; p <0.001). More specifically, endoscopic capsule findings in HD vs non-HD patients identified oozing blood (28 % vs 15 %; p =0.133), red spots (96 % vs 44 %; p <0.001), angiodysplasias (32 % vs 9 %; p =0.006), and erosive/ulcerative lesions (64 % vs 24 %; p <0.001). In 25 non-HD patients, no findings were observed (p =0.001). The number of total endoscopic findings was independently correlated with dialysis (p <0.001), male sex (p =0.048), dyslipidemia (p =0.004), liver disease (p =0.001), and mean corpuscular volume (MCV) (p =0.015). Lastly, we found that HD patients rebleed more often (Rhemitt score 6.5 ± 1.4 vs 2.9 ± 2.1; p <0.001). The Rhemitt score was independently correlated with dialysis (p <0.001), body mass index (p =0.024), MCV (p <0.001), smoking (p <0.001), dyslipidemia (p =0.007), GI bleeding (p <0.001), Calcium channel blockers (p =0.023), and preparation (p =0.001).

Conclusion

Compared with non-HD patients, HD patients who were investigated for potential GI bleeding demonstrated more severe and frequent small intestinal lesions with a higher probability of rebleeding. HIPPOKRATIA 2024, 28 (1):22-28.

Direct oral anticoagulants are associated with potentially bleeding lesions in suspected mid-gastrointestinal bleeding

BACKGROUND AND AIM

Direct oral anticoagulants (DOACs) became a widespread alternative in anticoagulant therapy. Nevertheless, concerns are raised about their safety, with increased gastrointestinal bleeding rates being described. There are scarce studies regarding DOACs effect on small-bowel capsule endoscopy (SBCE) findings. We aimed to assess if the detection of lesions with high bleeding potential on SBCE was significantly different in patients treated with DOACs when compared to non-anticoagulated patients and to patients anticoagulated with other agents.

METHODS

Cohort study including consecutive patients who underwent SBCE for suspected mid-gastrointestinal bleeding (MGIB) in 2019 and 2020.

RESULTS

From 148 patients, 38 (25.7%) were anticoagulated, of which 26 (68.4%) with DOACs. P2 lesions were detected in 36.5% (n = 54) of the patients. These lesions were more frequently detected in patients under DOACs treatment when compared to non-anticoagulated patients (69.2% vs. 29.1%; p=.001), and also when compared to patients treated with other anticoagulants (69.2% vs. 33.3%; p=.037). No differences in P2 lesions detection were observed between patients treated with other anticoagulants and non-anticoagulated patients (33.3% vs. 29.1%; p=.747). In multivariate analysis, DOACs usage was significantly associated with higher detection rates of P2 lesions on SBCE, when adjusted for classical risk factors for MGIB (OR: 3.38; 95%CI = 1.23-9.26; p=.018).

CONCLUSIONS

Despite their undeniable cardiovascular benefits and easy applicability, DOACs should still be considered with caution. These drugs were significantly associated with higher risk of potentially bleeding lesions on SBCE when compared to other anticoagulants and represent an independent risk factor for MGIB when adjusted for other variables.

Clinical impact of videocapsule and double balloon enteroscopy on small bowel bleeding: Results from a large monocentric cohort in the last 19 years

BACKGROUND

Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center.

METHODS

We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE-DBE concordance, hemoglobin (Hb) values before and after DBE, and complications.

RESULTS

807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1-5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients.

CONCLUSION

VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.