A prospective, comparative study between push enteroscopy and wireless video capsule in patients with obscure digestive bleeding

Abstract

Dear Sir: I read with interest the study that has been recently published by Costamagna et al.1Costamagna G. Shah S.K. Riccioni M.E. Foschia F. Mutignani M. Perri V. Vecchioli A. Brizi M.G. Picciocchi A. Marano P. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease.Gastroenterology. 2002; 123: 999-1005Abstract Full Text Full Text PDF PubMed Scopus (780) Google Scholar comparing the small bowel follow-through and the newly designed video-capsule (M2A, Given Imaging) in patients with suspected small bowel disorders. In this paper, the authors showed that the diagnostic yield of the video-capsule was higher than for the barium follow-through. In the Discussion, they claimed that the video-capsule could become the first-line procedure for exploring the small bowel. There is not doubt that the video-capsule provides nice pictures of the intestinal mucosa and is a very exciting tool for the gastroenterologist. However, I have some concern about the author’s statements after reading this study. Indeed, they reported 20 patients with suspected small bowel disorders but they mixed patients with obscure bleeding (n = 13) and some others with miscellaneous disorders (n = 7). When we only consider the subgroup of patients with the so-called obscure bleeding (n = 13), the definitive diagnostic yield reached 5% for the small bowel follow-through and 31% for the video-capsule (P < 0.05). In fact, this study confirms the well-known low diagnostic yield of the small bowel follow-through series in case of obscure bleeding.2Van Gossum A. Obscure digestive bleeding.Best Pract Res Clin Gastroenterol. 2001; 15: 155-174Abstract Full Text PDF PubMed Scopus (58) Google Scholar Interestingly, 6 of 13 patients had a lesion that was located in the upper GI tract. In this condition, the true question is to compare the diagnostic yield of the video-capsule to the push-enteroscopy and the preoperative enteroscopy. Some studies comparing the video-capsule and the push-enteroscopy are now available.3Ell C. Remke S. May A. Helou L. Henrich R. Mayer G. The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding.Endoscopy. 2002; 34: 685-689Crossref PubMed Scopus (662) Google Scholar, 4Lewis B.S. Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding results of a pilot study.Gastrointest Endosc. 2002; 56: 349-353Abstract Full Text Full Text PDF PubMed Scopus (529) Google Scholar, 5Van Gossum A, François E, Hittelet A, Schmit A, Devière J. A prospective comparative study between push enteroscopy and wireless video capsule in patients with obscure digestive bleeding. Am J Gastroenterol (submitted).Google Scholar The results are encouraging for the video-capsule, but all the reported series included only a few patients. Moreover, there is a need to show not only the diagnostic yield of the video-capsule but also the cost-effectiveness and the clinical impact of this new method. When we consider the other suspected small bowel diseases, the authors reported only 7 patients. In this subgroup, the video-capsule and the small-bowel follow-through provided a definitive diagnosis in 5 and 3 patients, respectively. We can’t draw any conclusion from this small group of patients. Moreover, we have to take into consideration that 2 of 22 patients who were initially enrolled in this comparative study were excluded because of the presence of subclinical intestinal stenosis that was diagnosed by the radiologic examination. Due to the risk of obstructive of the video-capsule in case of intestinal stricture and the small number of patients who have been explored, it seems too early to recommend the video-capsule as the first-line method for investigating the small bowel. Larger series in different clinical settings are needed to define the place of the video-capsule in a cost-effective diagnostic algorithm.