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Thakral D, Stein DJ, Saltzman JR. Diagnosis of Occult and Obscure Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:317-329. [PMID: 38395486 DOI: 10.1016/j.giec.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Occult and obscure bleeding are challenging conditions to manage; however, recent advances in gastroenterology and endoscopy have improved our diagnostic and therapeutic capabilities. Obscure gastrointestinal (GI) bleeding is an umbrella category of bleeding of unknown origin that persists or recurs after endoscopic evaluation of the entire bowel fails to reveal a bleeding source. This review details the evaluation of patients with occult and obscure GI bleeding and offers diagnostic algorithms. The treatment of GI bleeding depends on the type and location of the bleeding lesion and an overview of how to manage these conditions is presented.
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Affiliation(s)
- Durga Thakral
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Daniel Joseph Stein
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Hirata I, Tsuboi A, Matsubara Y, Sumioka A, Takasago T, Tanaka H, Yamashita K, Takigawa H, Kotachi T, Yuge R, Urabe Y, Oka S. Long-term outcomes of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. J Gastroenterol Hepatol 2024; 39:165-171. [PMID: 37837361 DOI: 10.1111/jgh.16379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND AND AIM Although small-bowel capsule endoscopy (CE) is widely used for obscure gastrointestinal bleeding (OGIB), long-term outcomes for OGIB patients after negative CE remain unclear. Herein, we defined negative CE as P0 (no bleeding potential) or P1 (less likely to bleed), based on the P classification using CE. We aimed to clarify long-term outcomes of patients with OGIB after negative CE. METHODS This single-center observational study enrolled 461 consecutive patients with OGIB who underwent CE from March 2014 to October 2021 and were followed up for >1 year. We examined rebleeding rates and predictive factors. RESULTS Two hundred and twenty-four (49%) patients had P0, and 237 (51%) had P1 findings. Rebleeding occurred in 9% and 16% of patients in the P0 and P1 groups, respectively. Two patients in the P0 group and 15 in the P1 group showed rebleeding from the small bowel. The rate of small-bowel rebleeding was significantly lower in the P0 group than that in the P1 group (1% vs 6%, P = 0.002), as was the cumulative rebleeding rate (P = 0.004). In the multivariate analysis, history of endoscopic hemostasis (hazard ratio [HR] = 15.958, 95% confidence interval [CI]:4.950-51.447, P < 0.001) and P1 CE findings (HR = 9.989, 95% CI: 2.077-48.030, P = 0.004) were independently predicted small-bowel rebleeding. CONCLUSIONS OGIB with P0 CE findings rarely showed rebleeding from the small bowel. Rebleeding may occur in patients with OGIB. Patients with history of endoscopic hemostasis for small-bowel lesions or P1 CE findings should be followed up intensively.
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Affiliation(s)
- Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahiro Kotachi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ryo Yuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastrointestinal Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Xing XC, Yang JL, Xiao X. Clinical features, treatments and prognosis of appendiceal bleeding: a case series study. BMC Gastroenterol 2023; 23:377. [PMID: 37924017 PMCID: PMC10625278 DOI: 10.1186/s12876-023-03025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/01/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Appendiceal bleeding is a rare cause of lower gastrointestinal bleeding, could be overlooked and diagnosed as obscure gastrointestinal bleeding. Due to limited real-world cases, the optimized management of appendiceal bleeding is unclear. We here shared our experiences in the past 20 years. METHODS A retrospective study was conducted at West China Hospital of Sichuan University. We reviewed data of 28,175 colonoscopies from 43,095 gastrointestinal bleeding patients between June 2003 and June 2023. Six patients diagnosed as appendiceal bleeding were included. Data including symptoms, laboratory tests, imaging results, endoscopic findings, treatment and prognosis were collected and analyzed. RESULTS Appendiceal bleeding accounts for 0.014% in gastrointestinal bleeding patients. Of the six patients, five were male, with a mean age of 48.5 years. Hematochezia was the most common symptom. The etiology included appendiceal angiodysplasia, appendicitis and appendectomy associated bleeding. Hemostasis was achieved by appendectomy, endoscopic therapy or medication according to different cases. One patient did not receive any treatment because of self-limiting bleeding. CONCLUSIONS The diagnosis of appendiceal bleeding is challenging, repeated flushing during endoscopy is helpful. Appendectomy is the priority option for treatment as well as the etiology clarification, therapeutic endoscopy and medication could be considered case by case.
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Affiliation(s)
- Xiao-Cun Xing
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer, Chengdu, China
| | - Jin-Lin Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer, Chengdu, China
| | - Xue Xiao
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China.
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer, Chengdu, China.
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Nakamura M, Yamamura T, Maeda K, Sawada T, Ishikawa E, Furukawa K, Iida T, Mizutani Y, Yamao K, Ishikawa T, Honda T, Ishigami M, Kawashima H. Clinical characteristics of Dieulafoy's lesion in the small bowel diagnosed and treated by double-balloon endoscopy. BMC Gastroenterol 2023; 23:290. [PMID: 37620810 PMCID: PMC10464443 DOI: 10.1186/s12876-023-02913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Obscure gastrointestinal bleeding refers to bleeding for which the source cannot be ascertained even through balloon-assisted endoscopy. In certain instances, Dieulafoy's lesion in the small bowel is presumed to be the underlying cause. AIM This retrospective study aimed to elucidate the clinical characteristics of Dieulafoy's lesion in the small bowel as diagnosed via double-balloon endoscopy while also exploring the feasibility of predicting bleeding from Dieulafoy's lesion prior to endoscopy in cases of obscure gastrointestinal bleeding. METHODS A comprehensive analysis of our database was conducted, identifying 38 patients who received a diagnosis of Dieulafoy's lesion and subsequently underwent treatment via double-balloon endoscopy. The clinical background, diagnosis, and treatment details of patients with Dieulafoy's lesion were carefully examined. RESULTS The median age of the 38 patients was 72 years, and 50% of the patients were male. A total of 26 (68%) patients exhibited a high comorbidity index. The upper jejunum and lower ileum were the most frequently reported locations for the occurrence of Dieulafoy's lesion in the small bowel. The detected Dieulafoy's lesions exhibited active bleeding (n = 33) and an exposed vessel with plaque on the surface (n = 5). Rebleeding after endoscopic treatment occurred in 8 patients (21%, median period: 7 days, range: 1-366 days). We conducted an analysis to determine the definitive nature of the initial double-balloon endoscopy diagnosis. Multivariate analysis revealed that hematochezia of ≥ 2 episodes constituted the independent factor associated with ≥ 2 double-balloon endoscopy diagnoses. Additionally, we explored factors associated with rebleeding following endoscopic treatment. Although the number of hemoclips utilized displayed a likely association, multivariate analysis did not identify any independent factor associated with rebleeding. CONCLUSION If a patient encounters multiple instances of hematochezia, promptly scheduling balloon-assisted endoscopy, equipped with optional instruments without delay is advised, after standard endoscopic evaluation with esophagogastroduodenoscopy and colonoscopy is unrevealing.
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Affiliation(s)
- Masanao Nakamura
- Department of Endoscopy, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Keiko Maeda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kentaro Yamao
- Department of Endoscopy, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Kim JH, Nam SJ. Prediction models for recurrence in patients with small bowel bleeding. World J Clin Cases 2023; 11:3949-3957. [PMID: 37388787 PMCID: PMC10303624 DOI: 10.12998/wjcc.v11.i17.3949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/10/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
Obscure gastrointestinal bleeding (OGIB) has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy. OGIB can present as overt bleeding or occult bleeding, and small bowel lesions are the most common causes. The small bowel can be evaluated using capsule endoscopy, device-assisted enteroscopy, computed tomography enterography, or magnetic resonance enterography. Once the cause of small-bowel bleeding is identified and targeted therapeutic intervention is completed, the patient can be managed with routine visits. However, diagnostic tests may produce negative results, and some patients with small bowel bleeding, regardless of diagnostic findings, may experience rebleeding. Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans. Several studies have identified different factors associated with rebleeding, and a limited number of studies have attempted to create prediction models for recurrence. This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding. These models may aid clinicians in forming tailored patient management and surveillance.
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Affiliation(s)
- Ji Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
| | - Seung-Joo Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
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Lee J, Kim S, Kim D, Lee S, Ryu K. Three cases of jejunal tumors detected by standard upper gastrointestinal endoscopy: A case series. World J Clin Cases 2023; 11:962-971. [PMID: 36818621 PMCID: PMC9928703 DOI: 10.12998/wjcc.v11.i4.962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/27/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In patients with obscure gastrointestinal bleeding, re-examination with standard upper endoscopes by experienced physicians will identify culprit lesions in a substantial proportion of patients. A common practice is to insert an adult-sized forward-viewing endoscope into the second part of the duodenum. When the endoscope tip enters after the papilla, which is a marker for the descending part of the duodenum, it is difficult to endoscopically judge how far the duodenum has been traversed beyond the second part.
CASE SUMMARY We experienced three cases of proximal jejunal masses that were diagnosed by standard upper gastrointestinal endoscopy and confirmed with surgery. The patients visited the hospital with a history of melena; during the initial upper gastrointestinal endoscopy and colonoscopy, the bleeding site was not confirmed. Upper gastrointestinal bleeding was suspected; thus, according to guidelines, upper endoscopy was performed again. A hemorrhagic mass was discovered in the small intestine. The lesion of the first patient was thought to be located in the duodenum when considering the general insertion depth of a typical upper gastrointestinal endoscope; however, during surgery, it was confirmed that it was in the jejunum. After the first case, lesions in the second and third patients were detected at the jejunum by inserting the standard upper endoscope as deep as possible.
CONCLUSION The deep insertion of standard endoscopes is useful for the diagnosis of obscure gastrointestinal bleeding.
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Affiliation(s)
- Jaesun Lee
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
| | - Sunmoon Kim
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
| | - Daesung Kim
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
| | - Sangeok Lee
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon 35365, South Korea
| | - Kihyun Ryu
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
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Boortalary T, Erwin R, Dong M, Shinn B, Infantolino A, Tofani C. RHEMITT Score Predicts Rebleed After Capsule Endoscopy: First Validation at a U.S. Tertiary Care Center. Dig Dis Sci 2023; 68:187-192. [PMID: 35543830 DOI: 10.1007/s10620-022-07527-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with obscure gastrointestinal bleeding undergo small bowel capsule endoscopy (SBCE), but often return for recurrent bleeding or anemia. The RHEMITT score evaluates patients based on 7 variables (heart failure, chronic kidney disease, Saurin P1/P2 lesions, major bleeding, incomplete SBCE, smoking status, and endoscopic treatment) and seeks to predict the risk of rebleeding. AIMS This study aims to perform an external validation of the RHEMITT score in the United States. METHODS SBCEs performed to evaluate anemia or GI bleeding from a tertiary-care center's PillCam database between 1/22/2018 and 7/21/2020 were reviewed. Variables based on the RHEMITT score were collected. The primary outcome was rebleeding, defined as (1) melena or hematochezia or (2) hemoglobin drop of 2 g/dL. Patient were categorized into low, intermediate, and high-risk categories based on RHEMITT score. The accuracy of the RHEMITT score for predicting rebleeding was assessed. RESULTS A total of 361 SBCEs were included in the study. Age, indication for SBCE, endoscopic treatment, antiplatelet use, cirrhosis, heart failure, chronic kidney disease, and major bleeding were significantly associated with risk of rebleed (p < 0.05). Each increasing risk category for the RHEMITT score predicted increased probability of this study's primary outcome, rebleeding (p < 0.001). There was a significant association between RHEMITT risk category and rebleeding-free survival (log-rank p < 0.001). An area under the receiver operating characteristic curve for the RHEMITT score was 0.790 (p < 0.001). CONCLUSION Our findings validate the RHEMITT score and confirm acceptable performance for predicting rebleeding at a tertiary referral center in the United States.
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Affiliation(s)
- Tina Boortalary
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Ryan Erwin
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Michael Dong
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Brianna Shinn
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Anthony Infantolino
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Christina Tofani
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA.
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Abstract
Background Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2 Methods We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE. Results 131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE. Conclusions Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.
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Affiliation(s)
- Irving Levine
- Division of Gastroenterology, Department of Medicine, Northwell Health, New York, NY, USA.
| | - Soonwook Hong
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dimpal Bhakta
- Division of Gastroenterology, Hepatology and Nutrition, UTHealth McGovern Medical School, Houston, USA
| | - Matthew B McNeill
- Division of Gastroenterology and Hepatology, New York University Langone Health, New York, NY, USA
| | - Seth A Gross
- Division of Gastroenterology and Hepatology, New York University Langone Health, New York, NY, USA
| | - Melissa Latorre
- Division of Gastroenterology and Hepatology, New York University Langone Health, New York, NY, USA
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Abstract
Background To identify the risk factors associated with rebleeding in obscure gastrointestinal bleeding (OGIB) patients from southern China. Methods This retrospective study involved 229 patients who underwent small bowel endoscopy in our hospital between 1 January 2018 and 1 December 2020. The clinical characteristics and risk factors related to rebleeding were retrospectively evaluated. Results Rebleeding patients were significantly older than non-rebleeding patients (53.0 ± 15.9 vs. 46.2 ± 17.8 years), had lower hemoglobin concentrations (89.2 ± 28.1 vs. 126.2 ± 25.1 g/L), and higher blood urea nitrogen concentrations (5.4 ± 2.6 vs. 4.5 ± 2.2 µmol/L), respectively. A higher percentage of rebleeding patients had diabetes mellitus (13.9% vs. 2.9%) and overt bleeding (70.4% vs. 38.6%), and required blood transfusions (43.1% vs. 8.0%), compared with non-rebleeding patients, respectively. Multivariate logistic analysis indicated that drinking alcohol (odds ratio (OR): 9.27; 95% confidence interval (CI) = 1.35–63.78), anemia (OR: 17.38; 95% CI = 5.48–55.10), and blood transfusion (OR: 3.76; 95% CI = 1.04–13.56) increased the risk of rebleeding in OGIB patients. Conclusion Our data suggested that OGIB patients who drink alcohol, have anemia, and require blood transfusion have an increased risk of rebleeding.
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Affiliation(s)
- Boying Liu
- Department of Gastroenterology, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, P. R. China
| | - Sudong Liu
- Research Experimental Center, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, P. R. China.,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou, P. R. China
| | - Pingwu Wen
- Department of Gastroenterology, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, P. R. China
| | - Shengbing Wang
- Department of Gastroenterology, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, P. R. China
| | - Fuqun Wang
- Department of Gastroenterology, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, P. R. China
| | - Xiaodong Gu
- Research Experimental Center, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, P. R. China.,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou, P. R. China
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Zhao R, Nakamura M, Wu S, Uchida G, Yamamura T, Gao YJ, Goto H, Fujishiro M, Ge ZZ. The role of early video capsule endoscopy in the diagnosis and prognosis of obscure gastrointestinal bleeding: A multi-center propensity score matching study. J Gastroenterol Hepatol 2021; 36:2540-2548. [PMID: 33724526 DOI: 10.1111/jgh.15491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/17/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Video capsule endoscopy (VCE) is a first-line procedure for the diagnosis of obscure gastrointestinal bleeding (OGIB). The opinions on the timing for such diagnostic evaluation remain unclear. We aimed to explore the role of early VCE in OGIB patients. METHODS A total of 997 patients that underwent VCE at Renji Hospital and Nagoya University from May 15, 2002, to December 28, 2016, were included in this study. We matched patients that underwent early VCE within 14 days of bleeding (early group, n = 678) to patients that did not (late group, n = 319) via 1:1 propensity score matching (PSM). We then compared VCE diagnostic rates and the prevalence of post-VCE rebleeding in patients with initial negative VCE findings within 1 year between these groups before and after PSM. RESULTS Following PSM, early VCE was associated with a significantly higher rate of OGIB diagnosis (56.4% vs 45.5%, P = 0.001) and with a significantly lower incidence of rebleeding within 1 year following treatment (24.7% vs 36.7%, P = 0.041). In univariate and multivariate analyses, VCE timing (odds ratio 0.648; 95% confidence interval 0.496-0.847, P = 0.001 and odds ratio 0.666; 95% confidence interval 0.496-0.894, P = 0.007, respectively) was found to be linked with a higher rate of positive findings. CONCLUSION Early VCE can improve the reliability of OGIB diagnosis while also reducing rates of post-VCE rebleeding. This suggests that timely and accurate diagnosis can help to improve OGIB patient treatment and prognosis.
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Affiliation(s)
- Ran Zhao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Shan Wu
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Genta Uchida
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Yun-Jie Gao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Zhi-Zheng Ge
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Jiao Tong University, Renji Hospital, Shanghai, China
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11
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Westrich D, Hachem C, Boumitri C. Iron Deficiency and the Small bowel. Curr Gastroenterol Rep 2021; 23:12. [PMID: 34236539 DOI: 10.1007/s11894-021-00812-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options. RECENT FINDINGS Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.
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Affiliation(s)
- David Westrich
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, 63104, USA
| | - Christine Hachem
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, 63104, USA
| | - Christine Boumitri
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, 63104, USA.
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12
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Harada A, Torisu T, Okamoto Y, Hirano A, Umeno J, Moriyama T, Washio E, Fuyuno Y, Fujioka S, Kitazono T, Esaki M. Predictive Factors for Rebleeding after Negative Capsule Endoscopy among Patients with Overt Obscure Gastrointestinal Bleeding. Digestion 2020; 101:129-136. [PMID: 30712034 DOI: 10.1159/000496826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/04/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although capsule endoscopy (CE) is useful to evaluate obscure gastrointestinal bleeding (OGIB), CE does not always identify the responsible lesions in patients with overt OGIB. OBJECTIVES To identify factors predictive of rebleeding after negative CE in patients with overt OGIB. METHODS We retrospectively analyzed the clinical data of 221 patients who underwent CE for overt OGIB. Among 120 patients with negative CE findings, clinical course of 112 patients after CE was followed-up. Clinical factors associated with rebleeding after negative CE and lesions responsible for rebleeding were investigated. RESULTS Rebleeding was identified in 37 patients (33.0%) during follow-up after negative CE, and 36 patients (32.1%) developed rebleeding within 24 months after negative CE. Multivariate analyses showed that ongoing overt OGIB (OR 2.67; 95% CI 1.07-5.80; p = 0.036) and severe anemia at the initial CE examination (OR 2.54; 95% CI 1.33-4.96; p = 0.005) were independent factors -associated with rebleeding. Rebleeding source was detected in 13 patients. CONCLUSIONS Rebleeding is not a rare condition among patients with overt OGIB after negative CE. Patients with ongoing overt OGIB or severe anemia at the initial CE examination seem to have a higher risk of rebleeding.
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Affiliation(s)
- Akira Harada
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Okamoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Atsushi Hirano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomohiko Moriyama
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ema Washio
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shin Fujioka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan, .,Department of Endoscopic Diagnostics and Therapeutics, Saga University Hospital, Saga, Japan,
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13
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Govindarajan KK, Ananthakrishnan R, Jacob S. Bowel Arteriovenous Malformation: An Unusual Cause of Lower Gastrointestinal Bleeding in a Child. GE Port J Gastroenterol 2020; 28:207-209. [PMID: 34056045 DOI: 10.1159/000510034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
In a child, lower gastrointestinal tract bleeding can be attributed to different etiologies. Unusually, the presence of bowel arteriovenous malformations can lead to multiple bouts of painless bright red bleeding per rectum, which develop into severe anemia. The article focuses on the diagnosis and management of bowel arteriovenous malformation in a child.
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Affiliation(s)
- Krishna Kumar Govindarajan
- Department of Pediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.,Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.,Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Ramesh Ananthakrishnan
- Department of Pediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.,Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.,Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Sajini Jacob
- Department of Pediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.,Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.,Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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14
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Fang Y, Gu W, Luo Y, Chen J. Obscure gastrointestinal bleeding caused by congenital enteropathy in a Chinese young child-a case report. BMC Pediatr 2020; 20:438. [PMID: 32943023 PMCID: PMC7500552 DOI: 10.1186/s12887-020-02333-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/08/2020] [Indexed: 11/30/2022] Open
Abstract
Background SLCO2A1 was recently reported to cause nonspecific ulcers at small bowel, it was named as chronic enteropathy associated with SLCO2A1 (CEAS). It was rarely reported beyond the Japanese population. Case presentation A 4-year-5-month old girl presented with intractable anemia since 1-year-3-month. Her stool occult blood test was positive and the result of esophagogastroduodenoscopy and colonoscopy were normal. She was considered as obscure gastrointestinal bleeding. The magnetic resonance enterography and ultrasound of small intestinal revealed segmental thickening of small bowel. The capsule endoscopy detected ulcers, erosion and slightly stenosis near the site of junction of jejunum and ileum. She was considered chronic non-specific multiple ulcers of the small intestine and was advised to have whole exon sequencing. She was treated with exclusive enteral nutrition and iron supplement for two months. However, she was not responsive to this treatment, then she had three doses of infliximab. At the same time, the next-generation sequencing of this patient revealed two novel compound heterozygous mutations in SLCO2A1. She was diagnosed with CEAS and was treated with oral mercaptopurine. Her hemoglobin level was stable and the serum albumin level was slightly decreased during the follow up. Conclusion CEAS may present as nonspecific small bowel ulcers, and misinterpret as small bowel Crohn’s disease. Genetic tests may help with the precise diagnosis of small bowel ulcers.
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Affiliation(s)
- Youhong Fang
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Bin Sheng RoadZhejiang Province, Hangzhou, 310052, China
| | - Weizhong Gu
- Department of Pathology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Youyou Luo
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Bin Sheng RoadZhejiang Province, Hangzhou, 310052, China
| | - Jie Chen
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Bin Sheng RoadZhejiang Province, Hangzhou, 310052, China.
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15
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Lim DH, Jung K, Lee SB, Park IK, Cha HJ, Park JH, Kim BG, Jung SW, In Du Jeong, Kim JH, Kim SE, Moon W, In Park M, Park SJ. Non-steroidal anti-inflammatory drug-induced enteropathy as a major risk factor for small bowel bleeding: a retrospective study. BMC Gastroenterol 2020; 20:178. [PMID: 32513198 PMCID: PMC7282042 DOI: 10.1186/s12876-020-01329-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background Small bowel (SB) bleeding accounts for 5% of all gastrointestinal (GI) bleeding cases and 80% of obscure GI bleeding cases. Although angioectasia is the common etiology of SB bleeding, nonsteroidal anti-inflammatory drug (NSAID)-induced SB lesions are also reported as a major cause in studies from Eastern countries. Herein, we assessed the frequency of occurrence of NSAID-induced SB lesions in Korean patients with obscure GI bleeding. Methods We retrospectively analyzed medical records of all consecutive patients aged ≥18 years who underwent capsule endoscopy from March 2018 to February 2019 at Ulsan University Hospital and Kosin University Gospel Hospital. Results Of the 83 subjects (all Korean; mean age ± standard deviation: 59 ± 18 years; age range: 18–84 years; men: n = 52; women: n = 31), 55 (66.2%) had stool with clear blood and 28 (33.8%) had normal stool with iron deficiency anemia. The detection rate of SB bleeding and lesions using capsule endoscopy was 72.3% (60 of 83 patients). A significantly higher frequency (40 of 51) of ulcerative/erosive lesions than other causes was observed in patients with inactive bleeding but visible SB lesions. As a result, NSAID-induced enteropathy accounted for 30.1% of 83 patients with obscure GI bleeding (25 of the all 60 SB bleeding cases). Conclusions Contrary to what is reported for patients in Western countries, this study in Korean patients showed an improved diagnostic yield of capsule endoscopy for obscure GI bleeding and that NSAID-induced enteropathy was the most common etiology of SB bleeding. Aggressive small intestine examination is required for patients with unexplained GI bleeding.
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Affiliation(s)
- Doo-Ho Lim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Seung Bum Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea.
| | - In Kyu Park
- Department of General Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Hee Jeong Cha
- Department of Pathology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Jae Ho Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Byung Gyu Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Seok Won Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - In Du Jeong
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
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16
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Kharazmi AA, Aslani S, Kristiansen MF, Dahl EE, Berner-Hansen M. Indications and diagnostic yield of small-bowel capsule endoscopy in a real-world setting. BMC Gastroenterol 2020; 20:177. [PMID: 32513115 PMCID: PMC7282185 DOI: 10.1186/s12876-020-01326-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 06/01/2020] [Indexed: 02/07/2023] Open
Abstract
Background Indications and diagnostic yield of small-bowel video capsule endoscopy (SB-VCE) are communicated in recent clinical academic guidelines. However, guidelines are based mainly on relatively few, small, selection-biased studies at experienced centers, and thus we lack information on indications and diagnostic yield of SB-VCE in the real-world community setting. The aim of the study was to evaluate indications and diagnostic yield of SB-VCE in the real-world community setting. Methods Our local VCE clinical database was used to identify patients undergoing SB-VCE procedures over a 7-year period (2011–2018). Patients were broadly referred and underwent SB-VCE using PillCam™ SB 2 and SB 3 capsule systems. Procedures were reviewed by local endoscopists, who had undergone similar formal SB-VCE review training. Medical reports of the procedures were composed as such. We retrospectively reviewed all reports and gathered data regarding indications and findings. Diagnostic yield was considered positive if SB-VCE visualized any type of clinically significant pathological finding. Results 536 SB-VCE procedures in 516 patients were included in final assessment. Patient mean (± SD) age was 50 ± 20 years with approximately even female/male ratio (275:241). The overall proportion of positive findings was 42% (225/536). The two main indications were obscure gastrointestinal bleeding (occult/anemia or overt/active, OGIB) of 46% (246/536) and definite/suspected Crohn’s disease (CD) of 39% (210/536). Positive SB-VCE findings were obtained in 44% (108/246) of procedures with indication of OGIB and in 50% (104/210) of procedures with indication of CD. Conclusions The indications for SB-VCE are largely consistent with guidelines but with an apparently relatively low diagnostic yield in our real-world community setting.
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Affiliation(s)
- André Artan Kharazmi
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen NV, Denmark.
| | - Saeid Aslani
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen NV, Denmark
| | - Malene Fey Kristiansen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen NV, Denmark
| | - Eva Efsen Dahl
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen NV, Denmark
| | - Mark Berner-Hansen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen NV, Denmark
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17
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Xiao NJ, Ning SB, Li T, Li BR, Sun T. Small intestinal hemolymphangioma treated with enteroscopic injection sclerotherapy: A case report and review of literature. World J Gastroenterol 2020; 26:1540-1545. [PMID: 32308353 PMCID: PMC7152520 DOI: 10.3748/wjg.v26.i13.1540] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemolymphangiomas are rare malformations composed of both lymphatic and vascular vessels and are located in the pancreas, spleen, mediastinum, etc. Small intestinal hemolymphangioma is extremely rare and often presents as obscure gastrointestinal bleeding. It is rarely diagnosed correctly before the operation. Endoscopic injection sclerotherapy is usually used as a management of bleeding in esophageal varices and was occasionally reported as a treatment of vascular malformation. The treatment of small intestinal hemolymphangioma with enteroscopic injection sclerotherapy has not been reported.
CASE SUMMARY A 42-year-old male complained of recurrent episodes of melena and dizziness, fatigue and reduced exercise capacity for more than 2 mo. Gastroduodenoscopy and blood test revealed a gastric ulcer and anemia. Treatment with oral proton-pump inhibitors and iron did not improve symptoms. We then performed a capsule endoscopy and anterograde balloon-assisted enteroscopy and revealed a hemolymphangioma. Considering it is a benign tumor without malignant potential, we performed enteroscopic injection sclerotherapy. He was discharged 4 days later. At follow-up 3 mo later, the melena disappeared. Balloon-assisted enteroscopy revealed an atrophied tumor atrophied and no bleeding. Argon plasma coagulation was applied to the surface of the hemolymphangioma to accelerated healing. When he returned for follow-up 1 year later, anemia was resolved and the tumor had been cured.
CONCLUSION Balloon-assisted enteroscopy and capsule endoscopy are effective methods for diagnosis of hemolymphangioma. Enteroscopic injection sclerotherapy is an effective treatment.
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Affiliation(s)
- Nian-Jun Xiao
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Shou-Bin Ning
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Teng Li
- Department of Pathology, Air Force Medical Center, Beijing 100142, China
| | - Bai-Rong Li
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Tao Sun
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
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18
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Tang CT, Zhang QW, Wu S, Tang MY, Liang Q, Lin XL, Gao YJ, Ge ZZ. Thalidomide targets EGFL6 to inhibit EGFL6/PAX6 axis-driven angiogenesis in small bowel vascular malformation. Cell Mol Life Sci 2020; 77:5207-21. [PMID: 32008086 DOI: 10.1007/s00018-020-03465-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Small bowel vascular malformation disease (SBVM) is the most common cause of obscure gastrointestinal bleeding (OGIB). Several studies suggested that EGFL6 was able to promote the growth of tumor endothelial cells by forming tumor vessels. To date, it remains unclear how EGFL6 promotes pathological angiogenesis in SBVM and whether EGFL6 is a target of thalidomide. METHODS We took advantage of SBVM plasma and tissue samples and compared the expression of EGFL6 between SBVM patients and healthy people via ELISA and Immunohistochemistry. We elucidated the underlying function of EGFL6 in SBVM in vitro and by generating a zebrafish model that overexpresses EGFL6, The cycloheximide (CHX)-chase experiment and CoIP assays were conducted to demonstrate that thalidomide can promote the degradation of EGFL6 by targeting CRBN. RESULTS The analysis of SBVM plasma and tissue samples revealed that EGFL6 was overexpressed in the patients compared to healthy people. Using in vitro and in vivo assays, we demonstrated that an EMT pathway triggered by the EGFL6/PAX6 axis is involved in the pathogenesis of SBVM. Furthermore, through in vitro and in vivo assays, we elucidated that thalidomide can function as anti-angiogenesis medicine through the regulation of EGFL6 in a proteasome-dependent manner. Finally, we found that CRBN can mediate the effect of thalidomide on EGFL6 expression and that the CRBN protein interacts with EGFL6 via a Lon N-terminal peptide. CONCLUSION Our findings revealed a key role for EGFL6 in SBVM pathogenesis and provided a mechanism explaining why thalidomide can cure small bowel bleeding resulting from SBVM.
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Arai M, Matsumura T, Ohta Y, Kiyono S, Hayashi M, Taida T, Saito K, Okimoto K, Maruoka D, Nakagawa T, Katsuno T, Kato N, Takiguchi Y. Long-Term Prognosis of Patients with Obscure Gastrointestinal Bleeding: A Retrospective Cohort Study. Digestion 2019; 100:37-44. [PMID: 30636251 DOI: 10.1159/000493854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/14/2018] [Indexed: 02/04/2023]
Abstract
AIMS We evaluated the long-term prognosis of patients with obscure gastrointestinal bleeding (OGIB) who underwent capsule endoscopy (CE). METHODS In our hospital, 429 patients underwent CE between November 2007 and March 2012. Among them, 259 patients underwent CE as the first examination for OGIB and were then followed at 77 clinics and hospitals. The clinical characteristics were investigated, including age, gender, overt/occult bleeding, the use of antithrombotic drugs and NSAIDs, complications (liver cirrhosis and hemodialysis), and CE. We asked the medical institutions for their survival data as of August 2017 (> 5 years after CE). RESULTS The prognoses of 240 patients (92.6%) were analyzed. The average follow-up period was 55.7 (1-115) months. During the follow-up period, 57 patients (23.8%) died and the survival rates were 90.5% at 1 year, 81.7% at 3 years, and 74.7% at 5 years. Age 65 years or older and liver cirrhosis were predictive factors for a poor prognosis. Rebleeding occurred in 42 patients (17.9%) and small bowel cancer and gastrointestinal stromal tumor were found at 12 and 21 months after CE, respectively. CONCLUSIONS Patients with OGIB showed a poor prognosis, especially those who were elderly or who had liver cirrhosis.
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Affiliation(s)
- Makoto Arai
- Department of Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan,
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masahiro Hayashi
- Department of Gastroenterology, Japan Community Health Care Organization, Chiba Hospital, Chiba, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keiko Saito
- Department of Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichiro Okimoto
- Department of Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tatsuro Katsuno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuichi Takiguchi
- Department of Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Wetwittayakhlang P, Wonglhow J, Netinatsunton N, Chamroonkul N, Piratvisuth T. Re-bleeding and its predictors after capsule endoscopy in patients with obscure gastrointestinal bleeding in long-term follow-up. BMC Gastroenterol 2019; 19:216. [PMID: 31842770 PMCID: PMC6916023 DOI: 10.1186/s12876-019-1137-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022] Open
Abstract
Background Capsule endoscopy (CE) is the preferred diagnostic test of choice in the investigation of obscure gastrointestinal bleeding (OGIB). Although, a conservative strategy is recommended in the short-term, for cases with a negative result from CE, the impact of CE on long-term re-bleeding still remains unclear. Hence, the aim of this study was to determine the long-term re-bleeding rate along with predictors after CE in patients with OGIB. Methods We retrospectively reviewed 216 patients with OGIB, whom had received a CE examination, so as to investigate the cause of obscure GI bleeding; between July 2008 and March 2018. The patient’s characteristics, medication use, CE finding, treatments strategy, re-bleeding episodes and follow-up information were collected from the institutional electronic medical chart and CE database. Re-bleeding free survival was evaluated using Kaplan-Meier curves with log rank test, whilst predictors associated with the re-bleeding episodes were analyzed via the use of Cox proportional hazard model. Results One hundred and thirty-three patients with OGIB, having received CE were enrolled in the analysis. The pool rate of re-bleeding was 26.3% (35/133) during a follow-up duration of 26 months after CE. Patients with positive CE study, without specific treatment, had higher rates of re-bleeding (47.6%) than those with positive study whom received specific treatment (25.7%), and negative study (20.8%) (p = 0.042). Although, the re-bleeding free survival was not significantly different among the groups (log rank test; P = 0.10). Re-bleeding events occurring within 6, 12, and 24 months after CE were 36, 64 and 92%, respectively. The high-frequency re-bleeding etiologies were the small bowel angiodysplasias and abnormal vascular lesions. Furthermore, independent predictors for re-bleeding after CE were patients with cirrhosis (hazard ratio, HR 4.06), incomplete CE visualization (HR 2.97), and a history of previous GI bleeding (HR 2.80). Conclusions The likelihood of re-bleeding after CE was higher in patients with positive CE study than those with negative study. Specific treatments, or therapeutic interventions for patients with detectable lesions reduced the probability of re-bleeding episodes in long-term follow-up. Close follow-up for recurrent bleeding is recommeded for at least 2 years after CE.
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Affiliation(s)
- Panu Wetwittayakhlang
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.
| | - Jirapat Wonglhow
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Nisa Netinatsunton
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Naichaya Chamroonkul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Teerha Piratvisuth
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
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Bhuller SB, Lieser M, Ismail N, Woods B. Obscure gastrointestinal bleeding localization using preoperative super-selective mesenteric angiography and intraoperative methylene blue injection: A case report and literature review. Int J Surg Case Rep 2019; 65:69-72. [PMID: 31689632 PMCID: PMC6838790 DOI: 10.1016/j.ijscr.2019.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/24/2019] [Accepted: 10/24/2019] [Indexed: 11/30/2022] Open
Abstract
OGIB can be a diagnostic challenge. Superselective mesenteric angiography with intraoperative methylene blue injection can be used as an adjunct to pre-existing diagnostic modalities. Superselective mesenteric angiography can guide surgical intervention to control hemorrhage and limit the amount of bowel resected.
Introduction Currently available diagnostic tests for localizing the source of gastrointestinal bleeding include esophagogastroduodenoscopy, colonoscopy, push enteroscopy, video capsule endoscopy, deep enteroscopy, nuclear scan, angiography, radiographic contrast studies of the small bowel, intraoperative enteroscopy, and computed tomography scanning. Despite these diagnostic modalities obscure gastrointestinal bleeding (OGIB) can be difficult to localize, making surgical intervention challenging. Presentation of case We report the case of a 78-year-old patient who presented with OGIB, melena and passing bright red blood per rectum, with a hemoglobin of 4.8 g/dl requiring multiple blood transfusions. Initially the source of the bleeding was difficult to identify. Eventually, a preoperative superior mesenteric angiogram was performed, identifying an arteriovenous malformation (AVM) within the small bowel as the source of OGIB. Intraoperative methylene blue was then injected through the previously placed angiogram catheter to further localize the bowel segment with the lesion. Discussion Despite multiple diagnostic modalities, OGIB, especially originating in the small bowel, is challenging to localize, making surgical intervention difficult. Methylene blue is frequently used intraoperatively to properly identify anatomic landmarks. Conclusion In cases of OGIB, superselective mesenteric angiography (SSMA) with intraoperative methylene blue injection can be used as an adjunct to routine diagnostic modalities to guide surgical interventions for controlling hemorrhage and for limiting the extent of bowel resection.
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Affiliation(s)
- Sidra B Bhuller
- Department of Surgery, Sky Ridge Medical Center, 10101 RidgeGate Parkway, Lone Tree, CO 80124, USA.
| | - Mark Lieser
- Department of Trauma Surgery, Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO 64132, USA
| | - Naveed Ismail
- Department of Surgery, Sky Ridge Medical Center, 10101 RidgeGate Parkway, Lone Tree, CO 80124, USA
| | - Bradley Woods
- Department of Trauma Surgery, Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO 64132, USA
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22
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Sakai E, Ohata K, Nakajima A, Matsuhashi N. Diagnosis and therapeutic strategies for small bowel vascular lesions. World J Gastroenterol 2019; 25:2720-2733. [PMID: 31235995 PMCID: PMC6580356 DOI: 10.3748/wjg.v25.i22.2720] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.
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Affiliation(s)
- Eiji Sakai
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
| | - Atsushi Nakajima
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Nobuyuki Matsuhashi
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
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23
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Teh JW, Fowler AL, Donlon NE, Khan W, Khan IZ, Waldron M, Barry K. Obscure gastrointestinal bleeding resulting from small bowel neoplasia; A case series. Int J Surg Case Rep 2019; 60:87-90. [PMID: 31207533 PMCID: PMC6580013 DOI: 10.1016/j.ijscr.2019.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/03/2019] [Indexed: 12/22/2022] Open
Abstract
Obscure GI bleeding can be a challenging diagnosis and is well acknowledged. Perseverance is required to achieve the correct diagnosis in obscured GI bleeding. Diagnostic overshadowing can halt investigations and delay diagnosis. Multidisciplinary team input is important in the diagnosis of obscured GI bleeding.
Introduction Undiagnosed gastrointestinal bleeding may originate in the small bowel. This presents a diagnostic challenge despite the advancement in contemporary imaging. We report two cases which highlight the limitations of routine investigation for obscure gastrointestinal bleeding. Presentation of case Patient A presented with a history of rectal bleeding, treated with interventional embolisation of caecal angiodysplasia. A diagnosis of neuroendocrine tumour (NET) was reached two years after presentation following intraoperative right hemicolectomy resection of a presumed recurrent angiodysplastic bleed. Patient B presented with recurrent melaena labelled as non-steroidal anti-inflammatory drug (NSAID) induced gastritis. After multiple endoscopic and radiological investigations, a 4.5 cm mass was visualised on imaging after three years, which was histologically proven as gastrointestinal stromal tumour (GIST) of the small bowel. Both patients experienced a delayed diagnosis despite multiple investigations and careful follow-up. Discussion Our case series discusses the benefits and limitations of investigation for gastrointestinal bleeding and suggests a need for continued multidisciplinary input in situations where the patient presumed diagnosis remains in question. Conclusion OGIB remains a diagnostic challenge and is attributable to small bowel pathology in 75% of cases. This suggests a need for continued investigation in situations where the patient presents multiple times despite adequate treatment for the presumed underlying condition.
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Affiliation(s)
- Jia Wei Teh
- Department of General Surgery, Mayo University Hospital, Westport Road, Curragh, Castlebar, Co. Mayo, Ireland.
| | - Amy L Fowler
- Department of General Surgery, Mayo University Hospital, Westport Road, Curragh, Castlebar, Co. Mayo, Ireland
| | - Noel E Donlon
- Department of General Surgery, Mayo University Hospital, Westport Road, Curragh, Castlebar, Co. Mayo, Ireland
| | - Waqar Khan
- Department of General Surgery, Mayo University Hospital, Westport Road, Curragh, Castlebar, Co. Mayo, Ireland
| | - Iqbal Z Khan
- Department of General Surgery, Mayo University Hospital, Westport Road, Curragh, Castlebar, Co. Mayo, Ireland
| | - Michael Waldron
- Department of General Surgery, Mayo University Hospital, Westport Road, Curragh, Castlebar, Co. Mayo, Ireland
| | - Kevin Barry
- Department of General Surgery, Mayo University Hospital, Westport Road, Curragh, Castlebar, Co. Mayo, Ireland
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24
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Abstract
The management of small bowel bleeding, also known as obscure gastrointestinal bleeding, has changed substantially over the past two decades due to revolutionary technological advances in small intestinal endoscopy. This clinical review will summarize the evolving definition of small bowel bleeding, how to perform a detailed initial assessment of patients with the condition, the strengths and limitations of small bowel endoscopy, and the treatment of small bowel bleeding.
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Affiliation(s)
- Michael Sai Lai Sey
- Division of Gastroenterology, London Health Sciences Centre, Canada; Schulich School of Medicine and Dentistry, Western University, Canada; Program for Experimental Medicine, Western University, Canada.
| | - Brian Michael Yan
- Division of Gastroenterology, London Health Sciences Centre, Canada; Schulich School of Medicine and Dentistry, Western University, Canada
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25
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Muftah M, Mulki R, Dhere T, Keilin S, Chawla S. Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease. Ann Gastroenterol 2018; 32:113-123. [PMID: 30837783 PMCID: PMC6394262 DOI: 10.20524/aog.2018.0341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/18/2018] [Indexed: 12/12/2022] Open
Abstract
Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.
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Affiliation(s)
- Mayssan Muftah
- Department of Medicine (Mayssan Muftah), Atlanta, United States
| | - Ramzi Mulki
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Tanvi Dhere
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Steven Keilin
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Saurabh Chawla
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States.,Grady Memorial Hospital (Saurabh Chawla), Atlanta, United States
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26
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Koffas A, Laskaratos FM, Epstein O. Non-small bowel lesion detection at small bowel capsule endoscopy: A comprehensive literature review. World J Clin Cases 2018; 6:901-907. [PMID: 30568944 PMCID: PMC6288513 DOI: 10.12998/wjcc.v6.i15.901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/11/2018] [Accepted: 11/24/2018] [Indexed: 02/05/2023] Open
Abstract
Small bowel capsule endoscopy is a minimally-invasive endoscopic investigation that is often used in clinical practice to investigate overt or occult gastrointestinal (GI) bleeding among other clinical indications. International guidance recommends small bowel capsule endoscopy as a first-line investigation to detect abnormalities in the small bowel, when gastroscopy and colonoscopy fail to identify a cause of GI bleeding. It can diagnose with accuracy abnormalities in the small bowel. However, there has been increasing evidence indicating that small bowel capsule endoscopy may also detect lesions outside the small intestine that are within the reach of conventional endoscopy and have been probably missed during prior endoscopic investigations. Such lesions vary from vascular deformities to malignancy and their detection often alters patient management, leading to further endoscopic and/or surgical interventions. The current study attempts to review all available studies in the literature and summarise their relevant findings.
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Affiliation(s)
- Apostolos Koffas
- Gastroenterology Department, University Hospital of Larisa, Mezourlo, Larisa 41110, Greece
| | | | - Owen Epstein
- Centre for Gastroenterology, Royal Free Hospital, Pond St, London NW3 2QG, United Kingdom
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27
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Frago S, Alcedo J, Martín Pena-Galo E, Lázaro M, Ollero L, de la Llama N. Long-term results with lanreotide in patients with recurrent gastrointestinal angiodysplasias bleeding or obscure gastrointestinal bleeding. Benefits in efficacy and procedures consumption. Scand J Gastroenterol 2018; 53:1496-1502. [PMID: 30621520 DOI: 10.1080/00365521.2018.1547921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIAD) bleeding and obscure gastrointestinal bleeding (OGIB) are increasing health problems. Somatostatin analogues have been proposed as rescue therapy, but data for lanreotide are scarce. OBJECTIVE To determine the efficacy, safety and resource saving of long-acting lanreotide for GIAD and OGIB. METHODS Retrospective study including adults with GIAD bleeding or OGIB and lanreotide treatment for at least 6 consecutive months. Demographics, comorbidities and treatments were collected. Anaemia and health resource consumption were analysed and compared between the year before and three years after starting lanreotide. Complete response was defined as a lack of new blood transfusion or endovenous iron dose need. RESULTS Twenty-seven patients (mean age 76.8 years) were included, 63% taking anticoagulants/antiplatelets. The bleeding was attributable to angiodysplasia in 85.2%, of whom half had multi-site lesions. Lanreotide was administered for a median of 27.1 months. During follow-up of up to 3 years (mean 32.5 months), 18.5% of patients achieved complete response and around 60% a 50% reduction of health resource consumption. Haemoglobin values improved (p = .007), while admission time, blood/iron infusions, and the number of endoscopies decreased significantly (p<.05) at least up to the second year. There were no relevant side effects during the follow-up period. CONCLUSION Long-term treatment with lanreotide significantly improves anaemia and decreases health resource consumption in patients with recurrent GIAD bleeding or OGIB.
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Affiliation(s)
- Santiago Frago
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Javier Alcedo
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragon)
| | - Edgar Martín Pena-Galo
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - María Lázaro
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Leticia Ollero
- a Department of Digestive Diseases , Miguel Servet University Hospital , Zaragoza , Spain
| | - Natalia de la Llama
- c Department of Pharmacy , Miguel Servet University Hospital , Zaragoza , Spain
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28
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Yang CW, Chen HW, Chen BC, Chen PJ, Shih YL, Chang WK, Hsieh TY, Huang TY. Is a bleeding scan prior to single-balloon enteroscopy necessary in patients with obscure gastrointestinal bleeding? J Formos Med Assoc 2018; 118:1031-1037. [PMID: 30473414 DOI: 10.1016/j.jfma.2018.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/20/2018] [Accepted: 11/07/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/PURPOSE To evaluate the efficacy and accuracy of bleeder localization in a pre-enteroscopic bleeding scan in patients with obscure gastrointestinal bleeding (OGIB). METHODS From January 2009 to December 2014, 98 patients with OGIB undergoing single-balloon enteroscopy (SBE) were enrolled. These patients were classified based on their history of a previous bleeding scan; 56 patients had undergone a previous bleeding scan, whereas 42 had not. The clinical characteristics, endoscopic findings, and rebleeding rate were compared between these two groups. The ability of the bleeding scan to localize the bleeding site was analyzed. RESULTS The mean age of patients was 56 ± 22 years; final diagnostic yield, 65.3%; and the most common etiology of OGIB, angiodysplasia (29.6%). There was no significant difference in demographic characteristics, OGIB etiologies, and final diagnostic yields (67.9% vs. 61.2%, bleeding scan vs. control group) between groups. In the bleeding scan group, the rate of positive detection was approximately 80.4%. However, only 26.7% patients with a positive bleeding scan showed correct localization of bleeding. Moreover, the bleeding scan delayed SBE (8.9 days vs. 3.0 days, p < 0.001). During the 24 months of follow-up, 15 patients (15.3%) exhibited rebleeding and needed to be hospitalized, but there was no significant difference between the groups. CONCLUSION In our study, bleeding scans in patients with OGIB revealed poor localization of the bleeder and delay in performing SBE. Thus, a bleeding scan prior to SBE showed a limited role for patients with OGIB.
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Affiliation(s)
- Chih-Wei Yang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Hsuan-Wei Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Bao-Chung Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Peng-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Yu-Lueng Shih
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Tsai-Yuan Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan.
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29
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Silva JC, Pinho R, Rodrigues A, Ponte A, Rodrigues JP, Sousa M, Gomes C, Carvalho J. Yield of capsule endoscopy in obscure gastrointestinal bleeding: A comparative study between premenopausal and menopausal women. World J Gastrointest Endosc 2018; 10:301-307. [PMID: 30364830 PMCID: PMC6198313 DOI: 10.4253/wjge.v10.i10.301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 07/25/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate differences in capsule endoscopy (CE) performed in the setting of obscure gastrointestinal bleeding (OGIB) among premenopausal women (PMW) and menopausal women (MW).
METHODS Retrospective, single-center study, including female patients submitted to CE in the setting of OGIB between May 2011 and December 2016. Patients were divided into 2 groups according to age, considering fertile age as ≤ 55 years and postmenopausal age as > 55 years. The diagnostic yield (DY), the rebleeding rate and the time to rebleed were evaluated and compared between groups. Rebleeding was defined as a drop of Hb > 2 g/dL or need for transfusional support or presence of melena/hematochezia.
RESULTS A hundred and eighty three female patients underwent CE for OGIB, of whom 30.6% (n = 56) were PMW and 69.4% (n = 127) were MW. The DY was 30.4% in PMW and 63.8% in MW. The most common findings were angiodysplasias in both groups (PMW: 21.4%, MW: 44.9%) (P = 0.003). In PMW, only 1.8% required therapeutic endoscopy. In 17.3% of MW, CE findings led to additional endoscopic treatment. Rebleeding at 1, 3 and 5 years in PMW was 3.6%, 10.2%, 10.2% and 22.0%, 32.3% and 34.2% in MW. Postmenopausal status was significantly associated with higher DY (P < 0.001), TY (P = 0.003), rebleeding (P = 0.031) and lower time to rebleed (P = 0.001).
CONCLUSION PMW with suspected OGIB are less likely to have significant findings in CE. In MW DY, need for endoscopic treatment and rebleeding were significantly higher while time to rebleed was lower.
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Affiliation(s)
- João Carlos Silva
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
| | - Rolando Pinho
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
| | - Adélia Rodrigues
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
| | - Ana Ponte
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
| | - Jaime Pereira Rodrigues
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
| | - Mafalda Sousa
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
| | - Catarina Gomes
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
| | - João Carvalho
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto 4434-502, Portugal
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30
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Otani K, Watanabe T, Shimada S, Hosomi S, Nagami Y, Tanaka F, Kamata N, Taira K, Yamagami H, Tanigawa T, Shiba M, Fujiwara Y. Clinical Utility of Capsule Endoscopy and Double-Balloon Enteroscopy in the Management of Obscure Gastrointestinal Bleeding. Digestion 2018; 97:52-58. [PMID: 29393257 DOI: 10.1159/000484218] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Obscure gastrointestinal bleeding (OGIB) is a common but embarrassing problem for gastroenterologists. Most bleeding lesions associated with OGIB are present in the small intestine and sometimes cannot be identified due to the difficulty associated with physical accessibility. Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) have enabled in the process of diagnosing and have evolved to become approaches to treating OGIB. SUMMARY CE is a minimally invasive procedure and has a high diagnostic yield in patients with OGIB. DBE offers additional advantage of biopsy collection for pathological diagnosis and therapeutic intervention, but it should be noted that it sometimes causes severe adverse events such as acute pancreatitis, intestinal bleeding, and intestinal perforation. CE should be performed early in the workup course of OGIB. Positive CE findings enhance the diagnostic yield of subsequent DBE, and the effective therapeutic intervention improves the clinical outcomes of OGIB patients. On the contrary, there are no clear guidelines for further investigation of patients with negative CE findings at the present. Although patients in stable general condition may only require follow-up, repeated CE is useful to detect positive findings in patients with evidence of sustained bleeding and progressing anemia. We have revealed that repeated CE has higher positive finding rate than DBE in OGIB patients with negative CE findings in a preliminary study. Key Messages: CE and DBE have complementary roles in the management of OGIB, and the precise timing and proper sequence may be important for the approach to treating OGIB.
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Affiliation(s)
- Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Samurai International GI Research Centre, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Sunao Shimada
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Samurai International GI Research Centre, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masatsugu Shiba
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Samurai International GI Research Centre, Osaka City University Graduate School of Medicine, Osaka, Japan
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31
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Otani K, Watanabe T, Shimada S, Nadatani Y, Hosomi S, Nagami Y, Tanaka F, Kamata N, Taira K, Yamagami H, Tanigawa T, Shiba M, Fujiwara Y. Usefulness of small bowel reexamination in obscure gastrointestinal bleeding patients with negative capsule endoscopy findings: Comparison of repeat capsule endoscopy and double-balloon enteroscopy. United European Gastroenterol J 2018; 6:879-887. [PMID: 30023065 DOI: 10.1177/2050640618767600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 03/04/2018] [Indexed: 12/16/2022] Open
Abstract
Background Although capsule endoscopy (CE) is a noninvasive diagnostic tool for patients with obscure gastrointestinal bleeding (OGIB), bleeding lesions are often not detected. No strategies have been established to determine whether CE or double-balloon enteroscopy (DBE) should be performed after negative CE. Methods Among 652 patients who underwent CE for OGIB, a total of 359 patients had negative findings. Of these, 41 and 48 patients underwent repeat CE and DBE for small bowel reexamination, respectively. We compared the rate of positive findings between the two groups. The findings were considered positive if mucosal break, vascular lesion, tumor, or active bleeding was observed. Results The rate of positive findings in the repeat CE group was significantly higher than that in the DBE group (73.2% vs. 39.6%; p = 0.001). Logistic regression analysis showed that the repeat CE group was significantly associated with positive findings (odds ratio (OR), 4.2; 95% confidence interval (CI), 1.7-10.2; p = 0.002). Inverse probability of treatment-weighted analysis revealed that repeat CE was significantly associated with positive findings (OR, 4.4; 95% CI, 1.6-12.2; p = 0.004). Conclusions Reexamination via CE appears to have more diagnostic value than DBE for OGIB patients with negative CE findings.
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Affiliation(s)
- Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Sunao Shimada
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuji Nadatani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masatsugu Shiba
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Gravito-Soares E, Gravito-Soares M, Almeida N, Lopes S, Figueiredo P. Clinical impact of small bowel capsule endoscopy in the era of antithrombotic therapy. Clin Res Hepatol Gastroenterol 2018; 42:e41-4. [PMID: 29551614 DOI: 10.1016/j.clinre.2017.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/09/2017] [Accepted: 12/22/2017] [Indexed: 02/04/2023]
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Tsai AJ. Effective utilization of non-invasive enteroscopy. Am J Surg 2018; 217:809-810. [PMID: 29789124 DOI: 10.1016/j.amjsurg.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/06/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Allen J Tsai
- Northeast Ohio Medical University College of Medicine, 4209 St. Rt. 44, Rootstown, OH 44272, USA.
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Abstract
BACKGROUND AND AIMS Melena is a symptom of upper gastrointestinal bleeding and usually indicates bleeding proximal to the ligament of Treitz. However, whether melena predicts bleeding in the proximal small intestine in patients with obscure gastrointestinal bleeding (OGIB) is unknown and the objective of this study. METHODS A retrospective cohort study of consecutive patients undergoing capsule endoscopy for OGIB between July 2009 and May 2016 was conducted. Subjects were categorized based on the presence of melena, and the primary outcome was identification of a bleeding source within the proximal 2/3 of the small intestine. Multi-variable regression was performed to control for confounders. RESULTS During the study, 288 patients met the eligibility criteria. Subjects with melena accounted for 37.1% of the cohort and were more likely to be older (mean age 66.9 vs. 63.9, p = 0.0457), take warfarin (15.1 vs. 9.4%, p = 0.0122), and have a lower 12-month hemoglobin nadir (7.3 vs. 8.3 g/dL, p = 0.0002). On crude analysis, 56.1% of patients with melena had a bleeding source within the proximal small intestine compared to 34.8% for those without (RR 1.61, 95% CI 1.24-2.09, p = 0.0004). On multi-variable analysis, the presence of melena doubled the odds of finding a bleeding site within the proximal small intestine (OR 1.97, 95% CI 1.17-3.33, p = 0.010). CONCLUSIONS The presence of melena doubles the odds of finding a bleeding site within the proximal small intestine among patients with OGIB, and deep enteroscopy, if performed before a capsule study, should begin with an antegrade approach in these patients.
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Affiliation(s)
- Cindy Ningfu Zhu
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Joshua Friedland
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Brian Yan
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Aze Wilson
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Jamie Gregor
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
- Robarts Clinical Trials, London, Canada
| | - Michael Sey
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada.
- London Health Sciences Centre-Victoria Hospital, 800 Commissioners Rd. E., London, ON, N6A 5W9, Canada.
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Tziatzios G, Gkolfakis P, Hassan C, Toth E, Zullo A, Koulaouzidis A, Dimitriadis GD, Triantafyllou K. Meta-analysis shows similar re-bleeding rates among Western and Eastern populations after index video capsule endoscopy. Dig Liver Dis 2018; 50:226-239. [PMID: 29396130 DOI: 10.1016/j.dld.2017.12.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/27/2017] [Accepted: 12/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Video capsule endoscopy (VCE) is the first-line diagnostic procedure for investigating obscure gastrointestinal bleeding (OGIB). Different re-bleeding rates following index VCE have been reported among Western and Eastern studies. METHODS We conducted a comprehensive literature search to identify studies examining re-bleeding rates after VCE for OGIB. Meta-analysis assessed the pooled proportion of re-bleeding events after VCE for OGIB according to study's origin (Western vs. Eastern) and according to the length of follow-up (≥24 months vs. <24 months). We also calculated the re-bleeding odds ratios (OR; 95% CI) after positive vs. negative index VCE, overt vs. occult initial presentation of bleeding and after interventional treatment for positive index cases, according to the study's origin. RESULTS We included 46 (30 Western and 16 Eastern) studies with 5796 patients. Significant heterogeneity was detected among meta-analyzed studies. Overall, the pooled re-bleeding rate was similar between Western (29%; 95% CI: 23-34) and Eastern (21%; 95% CI: 15-27) populations, irrespective of the length of follow-up. The odds of re-bleeding was significantly higher after positive as compared to negative index VCE in Eastern studies (OR: 1.77; 95% CI: 1.07-2.94). Application of specific treatment after positive index VCE was associated with lower re-bleeding odds in both Western (OR: 0.37; 95% CI: 0.16-0.87) and Eastern (OR: 0.39; 95% CI: 0.21-0.72) populations. CONCLUSIONS Patients undergoing VCE for OGIB have similar re-bleeding rates in the East and the West, regardless of the length of follow-up. However, increased re-bleeding odds after positive index VCE is observed in Eastern studies.
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Affiliation(s)
- Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Cesare Hassan
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Anastasios Koulaouzidis
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - George D Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece.
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Pérez-Cuadrado-Robles E, Zamora-Nava LE, Jiménez-García VA, Pérez-Cuadrado-Martínez E. Indications for and diagnostic yield of capsule endoscopy in the elderly. Rev Gastroenterol Mex (Engl Ed) 2018; 83:238-244. [PMID: 29456092 DOI: 10.1016/j.rgmx.2017.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 08/08/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND AIMS The growing elderly population and wide use of capsule endoscopy have led to a higher number of procedures in those patients. The aim of the present study was to assess the usefulness of capsule endoscopy in older patients. MATERIALS AND METHODS All consecutive patients undergoing capsule endoscopy at our center within the time frame of 2004-2016 were classified as older (≥75 years of age) and younger. Findings and diagnostic yield were comparatively assessed. RESULTS Of 2311 patients (mean age: 59.5 ± 19.23 years, 44.48% male), 648 were in the older group and 1663 in the younger group. Gastric transit time was shorter in the older patients (p=0.001), whereas small bowel transit time was shorter in the younger patients (p<0.001). Overall diagnostic yield in the elderly was higher (50.66% vs. 41.19%, p<0.001). Obscure gastrointestinal bleeding was the most frequent indication for capsule endoscopy in the elderly (90.4% vs. 53.77%, p<0.001), achieving a higher diagnostic yield than in the younger population (51.47% vs. 42.76%, p=0.002), whereas Crohn's disease, suspected or known neoplasms/polyps, malabsorption syndrome, and abdominal pain were the indications in the younger patient group. Such indications were rare in the older group. Vascular lesions and active bleeding were more frequently diagnosed in the older patients, whereas ulcers/erosions and mucosal atrophy were more common in the younger patients (p<0.001). CONCLUSIONS Capsule endoscopy achieved a higher overall diagnostic yield in the elderly patients. Obscure gastrointestinal bleeding indication for capsule endoscopy was much more frequent in the advanced-age group and had a higher diagnostic yield.
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Affiliation(s)
| | - L E Zamora-Nava
- Departamento de Endoscopia, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
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He B, Yang J, Xiao J, Gu J, Chen F, Wang L, Qian J, Gong S. Accuracy of Computed Tomographic Enterography for Obscure Gastrointestinal Bleeding: A Diagnostic Meta-analysis. Acad Radiol 2018; 25:196-201. [PMID: 29122470 DOI: 10.1016/j.acra.2017.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/31/2017] [Accepted: 09/02/2017] [Indexed: 12/22/2022]
Abstract
RATIONALE AND OBJECTIVES Obscure gastrointestinal bleeding (OGIB) is the bleeding from the gastrointestinal tract without definite source that persists and recurs after a negative endoscopic evaluation. The study aimed to systematically evaluate the diagnostic accuracy of computed tomography enterography on OGIB detection by meta-analysis. MATERIALS AND METHODS Studies were searched in relevant databases. With predefined inclusion criteria, eligible studies were included, followed by quality assessment using the Quality Assessment of Diagnostic Accuracy Studies scoring system. The Meta-DiSc software was used to implement the meta-analysis, and sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio with their 95% confidence intervals (CIs) were used as the effect size. Publication bias was determined by Egger test. RESULTS A set of nine studies was included in this meta-analysis, having a relatively high quality. Under the random effects model, the pooled sensitivity and specificity were 0.724 (95% CI: 0.651-0.789) and 0.752 (95% CI: 0.691-0.807), respectively. Under the fixed effects model, the pooled positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 2.949 (95% CI: 2.259-3.850), 0.393 (95% CI: 0.310-0.497), and 9.452 (95% CI: 5.693-15.692), respectively. The area under curve of the summary receiver operating characteristic curve was 0.7916 (95% CI: 0.723-0.860). No obvious publication bias was detected (t = 1.62, P = .181). CONCLUSIONS Computed tomography enterography might be used as a complementary to video capsule endoscopy instead of an alternative for the detection of OGIB.
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Sheba E, Farag A, Aref W, Elkholy S, Ashoush O. Double-balloon enteroscopy (DBE) in patients presenting with obscure gastrointestinal bleeding (OGIB). Arab J Gastroenterol 2017; 18:228-33. [PMID: 29325750 DOI: 10.1016/j.ajg.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/07/2017] [Accepted: 11/12/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND STUDY AIMS Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of unknown origin that persists or recurs after an initial negative investigation. Identifying the source of OGIB represents a diagnostic challenge that is frequently focused on visualizing the small intestine. Conventional diagnostic methods, such as push enteroscopy, small-bowel follow-through, radionuclide scanning, and angiography, each exhibit inherent limitations. Double balloon enteroscopy (DBE) was designed specifically to evaluate the entire small bowel. DBE allows for better visualization, biopsy of the identified lesions and application of therapeutic techniques. This study sought to assess the role of DBE in the diagnosis and management of patients with OGIB. PATIENTS AND METHODS This prospective study was conducted to analyse data from 31 patients presenting with OGIB referred for DBE in the Endoscopy Unit at the Internal Medicine Department of the Faculty of Medicine, Cairo University. RESULTS Five patients had lesions in locations other than the small intestine that accounted for GI bleeding. Thus, the potential source of OGIB was defined as the small intestine in 18 of 26 patients (69.2%), and negative DBE findings were noted in eight patients (30.8%). Major findings included small intestinal tumours in eight patients, vascular bleeding lesions in 8 patients and ulcerations in 2 patients. Endoscopic haemostasis was performed in eight patients with vascular lesions. The three patients with Petuz-Jegher syndrome underwent polypectomy of their major polyps. Patients with gastrointestinal tumours were referred for surgery. CONCLUSION DBE is an excellent endoscopic procedure that has a relatively high diagnostic and therapeutic yield. The procedure is feasible and exhibits a high safety profile with a low complication rate when performed by an experienced endoscopist.
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Chung CS, Chen KC, Chou YH, Chen KH. Emergent single-balloon enteroscopy for overt bleeding of small intestinal vascular malformation. World J Gastroenterol 2018; 24:157-160. [PMID: 29358892 PMCID: PMC5757121 DOI: 10.3748/wjg.v24.i1.157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/01/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023] Open
Abstract
A 28-year-old man presented with anemia symptoms and intermittent tarry stool passage for three days. No stigmata of hemorrhage were identified using esophagogastroduodenoscopy, ileocolonoscopy, and contrast-enhanced computed tomography. He then developed massive tarry stool passage with profound hypovolemic shock and hypoxic respiratory failure. Emergent angiography revealed active bleeder, probably from the jejunal branches of the superior mesenteric artery, but embolization was not performed due to possible subsequent extensive bowel ischemia. His airway was secured via endotracheal intubation with ventilator support, and emergent antegrade single-balloon enteroscopy was performed at 8 h after clinical overt bleeding occurrence; the procedure revealed a 2-cm pulsating subepithelial tumor with a protruding blood plug at the distal jejunum. Laparoscopic segmental resection of the jejunum with end-to-end anastomosis was performed after emergent endoscopic tattooing localization. Pathological examination revealed a vascular malformation in the submucosa with an organizing thrombus. He was uneventfully discharged 5 d later. This case report highlights the benefit of early deep enteroscopy for the treatment of small intestinal bleeding.
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Affiliation(s)
- Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City 22060, Taiwan
- College of Medicine, Fu Jen Catholic University, New Taipei City 24205, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City 33305, Taiwan
| | - Kuan-Chih Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City 22060, Taiwan
| | - Yueh-Hung Chou
- Department of Anatomical Pathology, Far Eastern Memorial Hospital, New Taipei City 22060, Taiwan
| | - Kuo-Hsin Chen
- Department of Surgery, Far Eastern Memorial Hospital, New Taipei City 22060, Taiwan
- Department of Electrical Engineering, Yuan Ze University, New Taipei City 22060, Taiwan
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Zikos TA, Pan J, Limketkai B, Banerjee D, Fernandez-Becker N. Efficacy of Video Capsule Endoscopy in the Management of Suspected Small Bowel Bleeding in Patients With Continuous Flow Left Ventricular Assist Devices. Gastroenterology Res 2017; 10:280-287. [PMID: 29118868 PMCID: PMC5667693 DOI: 10.14740/gr908w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 10/11/2017] [Indexed: 12/16/2022] Open
Abstract
Background Continuous flow left ventricular assist device (CF-LVAD) patients have a high prevalence of gastrointestinal bleeding from the small bowel. Video capsule endoscopy (VCE) is often used for diagnosis in these patients, but efficacy has yet to be determined. In this study, we evaluated the efficacy of VCE in the management of CF-LVAD patients with suspected small bowel bleeding by comparing to a non-VCE CF-LVAD control group. Methods We retrospectively reviewed the charts of all patients with CF-LVADs implanted at Stanford Hospital from January 2010 to October 2015. Patients were included in the study if there was a clinical suspicion of small bowel bleeding and either a negative upper endoscopy or colonoscopy. Results A total of 26 patients met inclusion criteria for a total of 15 encounters where VCE was done, and 25 where VCE was not done. There were no statistical differences when comparing these groups in terms of medical therapy use (thalidomide or octreotide), enteroscopy use (double-balloon or push), intervention on lesions, or any 30-day outcomes. There was no advantage to VCE with regard to the composite endpoint time to re-bleed or death related to re-bleeding (median 114 vs. 161 days, P = 0.15) after removing patients who did not get a VCE due to death or critical illness. Conclusions We did not find VCE changed management or outcomes in CF-LVAD patients with suspected small bowel bleeding at our institution when compared to a non-VCE control group. Our experience is small and single center, and larger, multi-center studies could further elucidate the utility of VCE in this patient population.
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Affiliation(s)
- Thomas A Zikos
- Department of Gastroenterology, Stanford University School of Medicine, 300 Pasteur Dr., Stanford, CA 94305, USA
| | - Jennifer Pan
- Department of Gastroenterology, VA Palo Alto Health Care System, 3018 Miranda Ave, Palo Alto, CA 94304, USA
| | - Berkeley Limketkai
- Department of Gastroenterology, Stanford University School of Medicine, 300 Pasteur Dr., Stanford, CA 94305, USA
| | - Dipanjan Banerjee
- Department of Cardiology, Stanford University School of Medicine, 300 Pasteur Dr., Stanford, CA 94305, USA
| | - Nielsen Fernandez-Becker
- Department of Gastroenterology, Stanford University School of Medicine, 300 Pasteur Dr., Stanford, CA 94305, USA
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Dohan A, Boudiaf M, Dray X, Samaha E, Cellier C, Camus M, Eveno C, Dautry R, Soyer P. Detection of small-bowel tumours with CT enteroclysis using carbon dioxide and virtual enteroscopy: A preliminary study. Eur Radiol 2017; 28:206-213. [PMID: 28710577 DOI: 10.1007/s00330-017-4927-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE The aim of this prospective study was to evaluate the feasibility, tolerance and performance of virtual enteroscopy (VE) using carbon dioxide for small-bowel distension in patients with suspected small-bowel tumours (SBTs). PATIENTS AND METHODS After IRB approval, 17 patients with suspected SBTs were prospectively included. Radiation dose was compared to 34 matched patients (2 for 1) for age, gender and body weight, who had undergone CT-enteroclysis with neutral contrast (CTE). Performance of VE was evaluated through comparison with the current standard of reference, including surgery and/or enteroscopy and/or follow-up. RESULTS Tolerance was excellent in 16/17 patients (94%). The radiation dose was lower for VE than for CTE (533 ± 282 vs. 974 ± 505 mGy.cm; p = 0.002). With VE, a total of 25 polyps >5 mm in size were depicted in 12/17 patients. On a per-lesion analysis, sensitivity and positive predictive value of VE were 92.0% and 92.0%, respectively. On a per-segment analysis VE had a sensitivity and specificity of 95.0% and 87.0%, respectively. CONCLUSION Our preliminary study suggests that VE is a feasible and well-tolerated technique with high sensitivity and specificity for the diagnosis of SBT. KEY POINTS • Virtual enteroscopy is feasible and well tolerated. • Virtual enteroscopy appears to be accurate for detection of small-bowel tumours. • Sensitivity and PPV of virtual enteroscopy is 92.0% and 92.0%. • Radiation dose is lower with virtual enteroscopy compared to MDCT-enteroclysis.
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Affiliation(s)
- Anthony Dohan
- Department of Body and Interventional Imaging, Hôpital Lariboisière - Assistance Publique-Hôpitaux de Paris, 2 Rue Ambroise Paré, 75010, Paris, France. .,Université Sorbonne Paris Cité, Paris Diderot, INSERM UMR 965, 2 Rue Ambroise Paré, 75010, Paris, France.
| | - Mourad Boudiaf
- Department of Body and Interventional Imaging, Hôpital Lariboisière - Assistance Publique-Hôpitaux de Paris, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Xavier Dray
- Department of Digestive Diseases, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.,Sorbonne Université, Paris, France
| | - Elia Samaha
- Gastroenterology and Endoscopy Unit, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy Unit, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France.,Université Sorbonne Paris Cité, Paris Descartes, Paris, France
| | - Marine Camus
- Université Sorbonne Paris Cité, Paris Descartes, Paris, France.,Department of Gastroenterology, Hôpital Cochin - Assistance Publique-Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Clarisse Eveno
- Université Sorbonne Paris Cité, Paris Diderot, INSERM UMR 965, 2 Rue Ambroise Paré, 75010, Paris, France.,Department of Surgical Oncologic and Digestive Unit, Hôpital Lariboisière - Assistance Publique-Hôpitaux de Paris, 2 Rue Ambroise Paré, 75475, Paris, France
| | - Raphael Dautry
- Department of Body and Interventional Imaging, Hôpital Lariboisière - Assistance Publique-Hôpitaux de Paris, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Philippe Soyer
- Université Sorbonne Paris Cité, Paris Diderot, INSERM UMR 965, 2 Rue Ambroise Paré, 75010, Paris, France.,Department of Body and Interventional Imaging, Hôpital Cochin - Assistance Publique-Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
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Manatsathit W, Khrucharoen U, Jensen DM, Hines OJ, Kovacs T, Ohning G, Jutabha R, Ghassemi K, Dulai GS, Machicado G. Laparotomy and intraoperative enteroscopy for obscure gastrointestinal bleeding before and after the era of video capsule endoscopy and deep enteroscopy: A tertiary center experience. Am J Surg 2017. [PMID: 28629608 DOI: 10.1016/j.amjsurg.2017.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND To evaluate roles of intraoperative endoscopy (IOE) in management of severe obscure GI bleeding (OGIB) before vs. after introduction of video capsule endoscopy (VCE) and deep enteroscopy (DE). METHODS We retrospectively reviewed prospectively collected data of patients undergoing IOE for severe OGIB in a tertiary referral center. RESULTS 52 patients had laparotomy/IOE for OGIB, 11 pre and 41 post VCE/DE eras. In the pre VCE/DE era, 36.4% (4/11) had preoperative presumptive diagnoses while in the post VCE/DE era presumptive diagnoses were made in 48.8% (20/41) (p = 0.18). Preoperative evaluation led to correct diagnoses in 18.2% (2/11) in the pre and 51.2% (21/41) in the post VCE/DE era (p = 0.09). Vascular lesions and ulcers were the most common diagnoses, but rebleeding was common. No rebleeding was found among patients with tumors, Meckel's diverticulum, and aortoenteric fistula. CONCLUSIONS Presumptive diagnoses in the post VCE/DE era were usually accurate. If VCE or DE are negative, the probability of negative IOE is high. Patients with tumors and Meckel's diverticulum were the best candidates for IOE.
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Affiliation(s)
- Wuttiporn Manatsathit
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, United States; CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States
| | - Usah Khrucharoen
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Dennis M Jensen
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States.
| | - O Joe Hines
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Thomas Kovacs
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Gordon Ohning
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Rome Jutabha
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Kevin Ghassemi
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Gareth S Dulai
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Gustavo Machicado
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
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Takase N, Fukui K, Tani T, Nishimura T, Tanaka T, Harada N, Ueno K, Takamatsu M, Nishizawa A, Okamura A, Kaneda K. Preoperative detection and localization of small bowel hemangioma: Two case reports. World J Gastroenterol 2017; 23:3752-3757. [PMID: 28611528 PMCID: PMC5449432 DOI: 10.3748/wjg.v23.i20.3752] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 02/06/2023] Open
Abstract
Among the various diagnostic modalities for small bowel hemangioma, video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) can be recommended as part of the work-up in patients with obscure gastrointestinal bleeding (OGIB). DBE is superior to VCE in the accuracy of diagnosis and therapeutic potential, while in most cases total enteroscopy cannot be achieved through only the antegrade or retrograde DBE procedures. As treatment for small bowel bleeding, especially spout bleeding, localization of the lesion for the decision of DBE insertion facilitates early treatment, such as endoscopic hemostatic clipping, allowing patients to avoid useless transfusion and the worsening of their disease into life-threatening status. Applying endoscopic India ink marking prior to laparoscopic surgical resection is a particularly useful technique for more minimally invasive treatment. We report two cases of small bowel hemangioma found in examinations for OGIB that were treated with combination of laparoscopic and endoscopic modalities.
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Girelli CM, Soncini M, Rondonotti E. Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding. World J Gastroenterol 2017; 23:697-702. [PMID: 28216977 PMCID: PMC5292344 DOI: 10.3748/wjg.v23.i4.697] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 11/27/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.
METHODS Small-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.
RESULTS We retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 ± 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P < 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P < 0.001). Age and small-bowel transit time were correlated (P < 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).
CONCLUSION In this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.
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Law R, Varayil JE, WongKeeSong LM, Fidler J, Fletcher JG, Barlow J, Alexander J, Rajan E, Hansel S, Becker B, Larson JJ, Enders FT, Bruining DH, Coelho-Prabhu N. Assessment of multi-modality evaluations of obscure gastrointestinal bleeding. World J Gastroenterol 2017; 23:614-621. [PMID: 28216967 PMCID: PMC5292334 DOI: 10.3748/wjg.v23.i4.614] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/16/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.
METHODS Retrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1st, 2002 to June 30th, 2013 at a single tertiary center.
RESULTS Four hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging vs 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, P = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, P < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.
CONCLUSION DBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.
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Voron T, Rahmi G, Bonnet S, Malamut G, Wind P, Cellier C, Berger A, Douard R. Intraoperative Enteroscopy: Is There Still a Role? Gastrointest Endosc Clin N Am 2017; 27:153-170. [PMID: 27908515 DOI: 10.1016/j.giec.2016.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.
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Affiliation(s)
- Thibault Voron
- Department of General and Digestive Surgery, Georges Pompidou European AP-HP University Hospital, 20-40 rue Leblanc, 75908 Paris Cedex 15, France; Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France
| | - Gabriel Rahmi
- Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France; Department of Gastroenterology and Endoscopy, Georges Pompidou European AP-HP University Hospital, 20-40, rue Leblanc, 75908 Paris Cedex 15, France
| | - Stephane Bonnet
- Department of Digestive Surgery, Percy University Military Hospital, 101 Avenue Henri Barbusse, Clamart 92140, France
| | - Georgia Malamut
- Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France; Department of Gastroenterology and Endoscopy, Georges Pompidou European AP-HP University Hospital, 20-40, rue Leblanc, 75908 Paris Cedex 15, France
| | - Philippe Wind
- Department of Digestive Surgery, Avicenne AP-HP University Hospital, 125 Rue de Stalingrad, Bobigny 93000, France; UFR SMBH, Paris-Nord University, 74, rue Marcel Cachin, 93017 Bobigny cedex, France
| | - Christophe Cellier
- Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France; Department of Gastroenterology and Endoscopy, Georges Pompidou European AP-HP University Hospital, 20-40, rue Leblanc, 75908 Paris Cedex 15, France
| | - Anne Berger
- Department of General and Digestive Surgery, Georges Pompidou European AP-HP University Hospital, 20-40 rue Leblanc, 75908 Paris Cedex 15, France; Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France
| | - Richard Douard
- Department of General and Digestive Surgery, Georges Pompidou European AP-HP University Hospital, 20-40 rue Leblanc, 75908 Paris Cedex 15, France; Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France.
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Abstract
Video capsule endoscopy (VCE) has completed the endoscopic visualization of the entire luminal gastrointestinal tract. VCE can be performed in inpatients and outpatients, requires appropriate bowel preparation before the study, and can be administered via oral swallowing or endoscopic device placement into the small bowel based on outlined patient-dependent factors. Current commercially available VCE systems were reviewed and compared for individual features and attributes. This article focuses on preparation for VCE, currently available VCE technology, how to read a VCE study, and risks and contraindications to VCE.
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Affiliation(s)
- Jodie A Barkin
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, 1120 North West 14th Street, Clinical Research Building, Suite 1116 (D-49), Miami, FL 33136, USA.
| | - Jamie S Barkin
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, 1120 North West 14th Street, Clinical Research Building, Suite 1116 (D-49), Miami, FL 33136, USA
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Romero-Espinosa L, Souza-Gallardo LM, Martínez-Ordaz JL, Romero-Hernández T, de la Fuente-Lira M, Arellano-Sotelo J. [ Obscure gastrointestinal bleeding due to gastrointestinal stromal tumors]. CIR CIR 2017; 85:214-9. [PMID: 27855991 DOI: 10.1016/j.circir.2016.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 09/08/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND The gastrointestinal stromal tumours (GIST) are the most common soft tissue sarcomas of the digestive tract. They are usually found in the stomach (60-70%) and small intestine (25-30%) and, less commonly, in the oesophagus, mesentery, colon, or rectum. The symptoms present at diagnosis are, gastrointestinal bleeding, abdominal pain, abdominal mass, or intestinal obstruction. The type of symptomatology will depend on the location and size of the tumour. The definitive diagnosis is histopathological, with 95% of the tumours being positive for CD117. CLINICAL CASES This is an observational and descriptive study of 5cases of small intestinal GIST that presented with gastrointestinal bleeding as the main symptom. The period from the initial symptom to the diagnosis varied from 1 to 84 months. The endoscopy was inconclusive in all of the patients, and the diagnosis was made using computed tomography and angiography. Treatment included resection in all patients. The histopathological results are also described. CONCLUSION GIST can have multiple clinical pictures and unusual symptoms, such as obscure gastrointestinal bleeding. The use of computed tomography and angiography has shown to be an important tool in the diagnosis with patients with small intestine GISTs.
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Abstract
AIM To assess the diagnostic value of capsule endoscopy (CE) and computed tomography (CT) enteroclysis in obscure gastrointestinal bleeding (OGIB).
METHODS We retrospectively analyzed the clinical data for 70 patients with OGIB who underwent capsule endoscopy and CT enteroclysis between January 2011 and June 2016 at Jiangsu People's Hospital. The detection rates, disease diagnosis rates and diagnostic coincidence between the two modalities were analyzed.
RESULTS The overall detection rate of OGIB by capsule endoscopy was much higher than that by CT enteroclysis [90.00% (63/70) vs 22.86% (16/70), P = 0.000]. Further study showed that the etiological diagnosis rate of OGIB by capsule endoscopy was higher than that by CT enteroclysis (61.43% vs 10.00%, P = 0.000). The diagnosis coincidence between these two was only 27.14%. The overall detection rate and etiological diagnosis rate of OGIB by combination capsule endoscopy with CT enteroclysis were slightly superior to capsule endoscopy, but there was no significance (P > 0.05). The overall detection rate by capsule endoscopy in patients with overt bleeding was higher than that in patients with occult bleeding (94.83% vs 66.67%, P = 0.015). The diagnosis of vascular lesions, erosion/ulcer and diverticulum by capsule endoscopy was superior to that of CT enteroclysis. It was worth mentioning that the diagnosis of intestinal tumor by CT enteroclysis was higher than that by capsule endoscopy (4 cases found by CT enteroclysis were confirmed by surgery. Only 2 of them were also found by capsule endoscopy).
CONCLUSION Both capsule endoscopy and CT enteroclysis are safe and effective in diagnosing OGIB. The diagnostic rate of OGIB by capsule endoscopy is significantly higher than that by CT enteroclysis. Although the value of capsule endoscopy combined with CT enteroclysis is not superior to capsule endoscopy alone, it may be complimentary in some cases when there is no finding checked by capsule endoscopy in OGIB patients, especially in the diagnosis of small intestinal tumors.
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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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