Prospective Evaluation of Patients Referred for Obscure Bleeding: How Many Patients Actually Have Small Bowel Bleeding? Update At One Year

Abstract

Background: A large proportion of patients who undergo capsule endoscopy (CE) for obscure gastrointestinal bleeding (OGIB) are found to have culprit lesions within reach of standard endoscopic procedures. Moreover, many patients with OGIB initially referred for CE are found to have abnormalities on a repeat endoscopic examination, negating the need for subsequent study. Objectives: The aim of this study was to prospectively evaluate consecutive referrals for suspected OGIB and the subsequent investigations undertaken. The main focus was to identify the proportion of patients in whom CE was ultimately deemed necessary, and to determine the proportion of patients referred who actually had a small bowel lesion to account for their symptoms. Methods: We prospectively evaluated consecutive patients who were referred to our unit for a CE because of OGIB between July 1 2005 and June 30 2006. One center for CE serves the entire region of 3.5 million people. The number of patients who ultimately proceeded to CE was identified along with their final diagnoses. Other investigations were performed at the discretion of the principle investigator (RE), with follow up extending beyond one year in all patients. Results: One hundred patients (mean age 63 years, 49% females) met the entry criteria. 41 of these had overt blood loss. A total of 49 patients underwent investigations by the principle investigator prior to consideration of CE. Initial investigations included 33 enteroscopies, 26 colonoscopies, 14 esophagoduodenoscopies, and 15 “other” procedures (SBFT, barium enema, flexible sigmoidoscopy, CT scan, CT enteroclysis, RBC Scan, or Meckel's Scan). 37 patients did not undergo CE; 14 had a diagnosis established using initial non-CE investigations, and 21 of the patients without a diagnosis were managed expectantly. Of the 63 patients undergoing CE, 13 (21%) had a bleeding source visualized by capsule but within reach of traditional endoscopy. Of the 100 referrals for suspected OGIB, a small bowel bleeding source was ultimately identified in only 19 patients. No bleeding source was identified in 41 patients. Conclusions: From this ongoing study we have demonstrated that only 63% of patients referred for further investigation of suspected OGIB were felt to require CE, and a small bowel bleeding source was demonstrated in just 19% of referrals. A ‘direct to capsule’ method of investigating suspected OGIB may be an inefficient and ineffective use of resources. Selective repetition of specific tests should always be considered in these patients.