Video capsule endoscopy as the initial examination for overt obscure gastrointestinal bleeding can efficiently identify patients who require double-balloon enteroscopy

Examining the Impact of a GI Hospitalist Model on the Outcomes of Double-Balloon Enteroscopy: A Single-Center Retrospective Study

BACKGROUND

A GI hospitalist (GIH) is a physician who practices in the inpatient setting performing consultations and endoscopic procedures. Obscure small bowel bleeding is a common inpatient diagnosis that is difficult to manage and associated with longer hospitalizations. Having an onsite GIH physician with expertise in video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) has the potential to improve patient outcomes.

AIMS

This study will be the first to explore how implementing a GIH model and providing a GIH with training in DBE can affect the outcomes of patients with small bowel pathology.

METHODS

We performed a retrospective study of patients who received an inpatient DBE at an academic medical center before and after initiation of a GIH model and credentialing of a GIH in DBE. We compared outcomes, including procedure volumes, diagnostic and therapeutic yields, procedure duration, time to procedure, and length of stay.

RESULTS

There was a 46.5% increase in the number of DBEs performed by the GIH. The diagnostic yield increased from 56.3 to 74.0% (OR 2.2, 95% CI 1.2-4.2), and the proportion of DBEs with a therapeutic intervention increased from 38.0 to 65.4% (OR 3.1, 95% CI 1.4-7.0). The total procedure time increased from 77.8 to 96.4 min (p < 0.05) with a GIH.

CONCLUSION

Having a GIH perform inpatient DBEs was associated with an increased number of procedures, duration of procedures, diagnostic yield, and therapeutic interventions. The onsite presence of a GIH with competency in DBE improves the care of hospitalized patients with small bowel pathology.

Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis

Background and Aim

Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding.

Methods

We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test.

Results

A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009).

Conclusion

Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

Evaluation and Validation of a New Score to Measure the Severity of Small Bowel Angiodysplasia on Video Capsule Endoscopy

INTRODUCTION

Angiodysplasias are responsible of 50% of small bowel bleeding. An endoscopic method that allows measuring its severity is not available.

AIMS

The aim of the study was to validate a new endoscopic score with VCE to measure the severity of small bowel angiodysplasias (SBAD).

METHODS

Four endoscopists independently reviewed VCE videos of 22 patients with SBAD. The score graded 3 variables: A - extent of lesions: E1, located in one half of the intestine and E2, in both halves; B - number of lesions: N1, <5; N2, 5-10; and N3, >10 lesions; C - probability of bleeding: P1, pale red spots; P2, bright red spots; P3, bleeding stigmata; and P4, active bleeding. Capsule Endoscopy Small Bowel Angiodysplasia Activity Index (CESBAI) was calculated as follows: E × 1 + N × 2 + P × 3. Interobserver variability was analyzed by Spearman's correlation and agreement Kappa statistic tests.

RESULTS

The mean CESBAI scores by observers were O1= 11.6 ± 4.1; O2 = 11.3 ± 4.8; O3 = 11.1 ± 4.9; and O4 = 11.8 ± 4.2 (p > 0.05). Spearman's correlation values of CESBAI between every 2 observers were from 0.61 to 0.94 (p < 0.001) with a global correlation of 0.73 among all observers. Kappa values of CESBAI between every 2 observers ranged from 0.42 to 0.87 (p < 0.001) with a global agreement of 0.57 among all observers. All evaluators stated that the method was easy to use.

CONCLUSIONS

CESBAI is a reliable and reproducible score. Nevertheless, these results must be validated in other studies with larger population before assessing its power for predicting bleeding recurrence.

Scoring systems in clinical small-bowel capsule endoscopy: all you need to know!

Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.

Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.

Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update

BACKGROUND

One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities.

METHODS

As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined).

RESULTS

The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition.

CONCLUSIONS

Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.

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.

Capsule endoscopy transit-related indicators in choosing the insertion route for double-balloon enteroscopy: a systematic review

Background and study aims  When capsule endoscopy (CE) detects a small bowel (SB) target lesion that may be manageable with enteroscopy, the selection of the insertion route is critical. Time- and progression-based CE indices have been proposed for localization of SB lesions. This systematic review analysed the role of CE transit indicators in choosing the insertion route for double-balloon enteroscopy (DBE). Methods  A comprehensive literature search identified papers assessing the role of CE on the choice of the route selection for DBE. Data on CE, criteria for route selection, and DBE success parameters were retrieved and analyzed according to the PRISMA statement. Risk of bias was assessed through the STROBE assessment. The primary outcome evaluated was DBE success rate in reaching a SB lesion, measured as the ratio of positive initial DBE to the number of total DBE. Results  Seven studies including 262 CEs requiring subsequent DBE were selected. Six studies used time-based indices and one used the PillCam Progress indicator. SB lesions were identified and insertion route was selected according to a specific cut-off, using fixed landmarks for defining SB transit except for one study in which the mouth-cecum transit was considered. DBE success rate was high in all studies, ranging from 78.3 % to 100 %. Six of seven studies were high quality. Conclusions  The precise localization of SB lesions remains an open issue, and larger studies are required to determine the most accurate index for selecting the DBE insertion route. In the future, 3 D localization technologies and tracking systems will be essential to accomplish this tricky task.

Ingestible Sensors and Sensing Systems for Minimally Invasive Diagnosis and Monitoring: The Next Frontier in Minimally Invasive Screening

Ingestible electronic systems that are capable of embedded sensing, particularly within the gastrointestinal (GI) tract and its accessory organs, have the potential to screen for diseases that are difficult if not impossible to detect at an early stage using other means. Furthermore, these devices have the potential to (1) reduce labor and facility costs for a variety of procedures, (2) promote research for discovering new biomarker targets for associated pathologies, (3) promote the development of autonomous or semiautonomous diagnostic aids for consumers, and (4) provide a foundation for epithelially targeted therapeutic interventions. These technological advances have the potential to make disease surveillance and treatment far more effective for a variety of conditions, allowing patients to lead longer and more productive lives. This review will examine the conventional techniques, as well as ingestible sensors and sensing systems that are currently under development for use in disease screening and diagnosis for GI disorders. Design considerations, fabrication, and applications will be discussed.

Clinical Utility of Emergency Capsule Endoscopy for Diagnosing the Source and Nature of Ongoing Overt Obscure Gastrointestinal Bleeding

Background and Aims

In patients with ongoing overt obscure gastrointestinal bleeding (OGIB), prompt detection of the bleeding source is crucial to treatment success. However, there is no consensus on the optimal timing of diagnostic capsule endoscopy (CE). We investigated the clinical utility of emergency CE for detecting the source of ongoing overt OGIB.

Methods

We retrospectively evaluated 146 consecutive patients who, between February 2009 and July 2018, underwent emergency CE at Hiroshima University Hospital to detect the source of ongoing overt OGIB. Patients with a bleeding source located outside the small bowel were excluded. The remaining 127 patients were stratified according to the timing of CE relative to the onset of bleeding: patients in group A (n = 15, 12 men; mean age: 75 years; age range: 62–83 years) underwent CE within 48 hours of bleeding onset, whereas patients in group B (n = 112, 73 men; mean age: 65 years; age range: 17–88 years) underwent CE at >48 hours after bleeding onset. All patients underwent double-balloon endoscopy, and the final diagnosis was compared against the CE findings.

Results

The CE lesion detection rate was significantly higher in group A (12/15 patients, 80%) than in group B (53/112 patients, 47%) (p = 0.0174). There was no significant difference between the two groups regarding the patients' background characteristics. Vascular lesions were the most frequent finding in both groups. The diagnostic concordance rate between emergency CE and double-balloon endoscopy was 100% in group A and 92.9% in group B. Rebleeding after endoscopic treatment was confirmed in only one patient in group B.

Conclusions

Emergency CE represents a useful diagnostic modality in patients with ongoing overt OGIB, potentially improving detection rates and reducing rebleeding risk.

Experiencia con videocápsula endoscópica en el estudio y diagnóstico de enfermedades del intestino delgado en un hospital de alta complejidad en Medellín, Colombia

Introducción: el intestino delgado (ID) es un órgano difícil de estudiar debido a su gran tamaño y ubicación anatómica; los estudios endoscópicos convencionales (esofagogastroduodenoscopia y colonoscopia) no logran evaluarlo en su totalidad y la enteroscopia con balón es más invasiva, con mayores efectos adversos y tasas de complicaciones. La videocápsula endoscópica (VCE) es una tecnología mínimamente invasiva que permite visualizar de forma dinámica y completa la mucosa del ID; es el método directo más seguro y con menos tasas de complicaciones.Metodología: se realizó un estudio descriptivo de corte transversal, para describir la experiencia clínica en la utilización de la VCE en un hospital de alta complejidad en Medellín, Colombia; asimismo, determinar las indicaciones, síntomas más comunes y hallazgos anormales.Resultados: se realizaron 374 VCE en el período de estudio: 282 ambulatorias (75,4 %) y 92 hospitalizados (24,6 %). En ambos grupos la indicación más frecuente fue sangrado digestivo oscuro (38,65 % y 53,26 %, respectivamente), seguidos por anemia crónica en el 27,65 % de ambulatorios y por enfermedad inflamatoria intestinal (EII) en 21,74 % de los hospitalizados. Los hallazgos anormales fueron más frecuentes en el yeyuno y las lesiones más comunes fueron angiodisplasias y lesiones inflamatorias.Conclusiones: en las indicaciones más frecuentes (sangrado digestivo oscuro y anemia) se documentaron potenciales fuentes de sangrado en más del 70 % de los casos; siendo las lesiones vasculares e inflamatorias los hallazgos más comunes. En seguimiento o evaluación de EII se documentaron en más del 50 % lesiones inflamatorias. La VCE es muy segura, no se presentó ninguna complicación relacionada con la VCE.

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: A systematic review and meta-analysis

AIM

To compare the diagnostic accuracy of video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) in cases of obscure gastrointestinal bleeding (OGIB) of vascular origin.

METHODS

MEDLINE (via PubMed), LILACS (via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.

RESULTS

In the per-patient analysis, 17 studies (1477 lesions) were included. We identified 3150 exams (1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864 (58.5%) were diagnosed by VCE, and 613 (41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84% (95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was 92% (95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29 (95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20 (95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to 90%.

CONCLUSION

The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Evidence-Based Guide on Capsule Endoscopy for Small Bowel Bleeding

Capsule endoscopy is the diagnostic test of choice for the evaluation of overt and occult small bowel bleeding. Its yield is higher in patients presenting with overt bleeding. The yield is also improved if the capsule is performed soon after the presentation of bleeding. Capsule endoscopy has a complementary role with cross-sectional imaging to triage patients for appropriate management, including deep enteroscopy, surgery, or, if negative, conservative management. Although capsule endoscopy is useful to detect vascular and inflammatory lesions, it appears to have a significant miss rate for solitary small bowel lesions, including tumors. The main adverse event is capsule retention in patients with underlying small bowel obstruction.

A Therapeutic Wireless Capsule for Treatment of Gastrointestinal Haemorrhage by Balloon Tamponade Effect

OBJECTIVE

Wireless capsule endoscope (WCE) is a revolutionary approach to diagnose small bowel pathologies. Currently available WCEs are mostly passive devices with image capturing function only, while on-going efforts have been placed on robotizing WCEs or to enhance them with therapeutic functions. In this paper, the authors present a novel inflatable WCE for haemostasis in the gastrointestinal (GI) tracts by balloon tamponade effect.

METHODS

The proposed wireless capsule consists of a balloon that can be inflated using the endothermic reaction of acid and base. When the balloon reached a precalculated pressure level, it is able to stop at a bleeding site in the bowel, and achieve haemostasis by tamponade effect. The prototype is 14 mm in diameter, with three sections of 13, 35, and 12 mm in length, respectively. The three sections are linked together with flexible joints and enclosed in a silicone balloon. The prototypes were tested in ex vivo porcine intestine models.

RESULTS

In the ten ex vivo trials conducted, the inflatable wireless capsule achieved average balloon pressure of 46.0 mmHg and withstood average maximum longitudinal pulling force at 1.46 N. An in vivo study was carried out as a proof-of-concept for treating bleeding in a porcine model. The proposed inflatable WCE succeeded in the animal test by controlling haemostasis within 5 min. No rebleeding was observed in the next 20 min.

CONCLUSION

The results suggested that the inflatable capsule with a real-time bleeding detection algorithm can be implemented. Moreover, the proposed inflatable WCE prototype can achieve haemorrhage control in the lower GI.

SIGNIFICANCE

To our best knowledge, this is the first study that demonstrated the potential to treat GI haemorrhage by an inflatable WCE. The proposed capsule enables the development of a closed-loop system based on a body sensor network to provide early treatment of GI bleeding for p-medicine.