Capsule Endoscopy Findings Research Articles

Rare findings of capsule endoscopy. Clinical observation

The article provides a brief overview of the frequency, prevalence of use, and results of video capsule endoscopy in patients with various indications after undergoing CT/MRI enterography or barium sulfate enterography. A clinical case is presented where a patient with symptoms of gastrointestinal bleeding underwent video capsule endoscopy, revealing a small bowel tumor, followed by surgical treatment. This non-invasive technique enables obtaining more accurate data for decision-making regarding further treatment strategies.

Clinical characteristics and long-term disease course in patients with Crohn's disease as diagnosed by video capsule endoscopy: a multicenter retrospective matched case-control study.

Video capsule endoscopy is rarely used to diagnose Crohn's disease in patients with negative ileocolonoscopy or cross-sectional image findings. We evaluated clinical characteristics and long-term outcomes of these rare cases. This multicenter study included patients with Crohn's disease from 3 tertiary hospitals from January 2007 to October 2022. Patients with normal findings on ileocolonoscopy and computed tomography (CT)/magnetic resonance (MR) enterography but had ulcerations at the small bowel detected by video capsule endoscopy were included. The controls were patients with abnormal findings on endoscopy or CT/MR enterography. Controls were case-matched in a ratio of 3:1 for sex, calendar year of diagnosis, and age at diagnosis. Among 3,752 patients, 24 (0.6%) were diagnosed with Crohn's disease using video capsule endoscopy findings. The disease location (P< 0.001) and behavior at diagnosis (P= 0.013) of the cases significantly differed from that of controls. The perianal fistula modifier (25.0% vs. 33.3%, P= 0.446) did not differ significantly between the 2 groups. Initial disease activity and C-reactive protein and fecal calprotectin levels were significantly lower in cases versus controls. The median Lewis score was 838 (interquartile range, 393-1,803). Over 10 years of follow-up, the cases showed significantly lower cumulative risk of complicated behavior, biologics use, Crohn's disease-related hospitalization, and surgeries (log-rank test P< 0.05). Patients with Crohn's disease whose lesions were observed only by video capsule endoscopy were rare, and exhibit different clinical characteristics and a more favorable long-term disease course compared to those who were conventionally diagnosed.

Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes

BackgroundPortal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes.MethodsThis retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23–87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups.ResultsOverall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037).ConclusionsExacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.

Video capsule endoscopy findings in dogs with chronic enteropathy and in healthy dogs.

Video capsule endoscopy is a noninvasive technique for evaluation of the gastrointestinal tract. To investigate the safety of using the video capsule ALICAM in dogs with chronic enteropathy (CE) >10 kg, and to compare macroscopic gastrointestinal morphology between CE dogs and healthy controls (HC). Fifteen CE dogs and 15 similarly breed, age and body weight matched HC. All dogs underwent a clinical work up including blood analyses, fecal samples, abdominal ultrasonographic examination, and blood pressure measurement. The dogs were withheld from food for 16 hours before and 8 hours after they PO received an ALICAM. All recordings were quality assessed, and blindly evaluated by 2 trained observers. The median age of CE dogs and HC was 3.3 (interquartile range [IQR] 2.5-5.9) years and 4.7 (IQR 3.3-5.6) years, respectively. The median body weight in the CE dogs and HC was 25.9 (IQR 20.6-30.9) kg, and 29 (IQR 16.2-30.5) kg, respectively. Complete recordings of the gastrointestinal tract were obtained from all dogs without complications. No significant differences were found between groups regarding number of abnormalities such as irregular mucosa, erythema, nonbleeding erosions, bleeding erosions, and dilated lacteals, as well as severity and extent of the abnormalities. The use of ALICAM for evaluation of the gastrointestinal tract in CE dogs and HC seems safe and feasible regarding gastrointestinal transit and macroscopic morphology assessment in dogs >10 kg. Abnormalities were found in similar proportions in CE dogs and HC.

Clinical usefulness and acceptability of small‐bowel capsule endoscopy with panoramic imaging compared with axial imaging in Japanese patients

AbstractObjectivesWe aimed to evaluate the usefulness and acceptability of CapsoCam Plus (CapsoCam) in Japanese patients.MethodsThis retrospective single‐center study enrolled 930 patients with suspected small‐bowel bleeding (SSBB) who underwent capsule endoscopy. Thirty‐three patients using CapsoCam and PillCam SB3 (SB3) were matched using propensity score matching. The diagnostic yield and the acceptability of CapsoCam were evaluated.ResultsThere was no SSBB case where capsule endoscopy was performed within 48 h of bleeding. CapsoCam had a significantly higher observation rate of the entire small bowel (97% vs. 73%, p = 0.006) and Vater's papilla (82% vs. 15%, p &lt; 0.001) than SB3. The reading time of CapsoCam was significantly longer than that of SB3 (30 vs. 25 min, p &lt; 0.001), and CapsoCam's time from the capsule endoscopy swallowing to read completion was longer than that of SB3 (37 vs. 12 h, p &lt; 0.001). The two groups showed no difference in the capsule endoscopy findings according to the P classification. Notably, 85% of the patients using CapsoCam reported examination distress as “not at all” or “almost not,” and 94% reported swallowing difficulty as “very easy” or “easy.”ConclusionsCapsoCam took time to read; however, it is a well‐tolerated examination with a high observation rate of Vater's papilla and entire small‐bowel mucosa. Detectability of bleeding sources was comparable in both modalities for cases of occult SSBB and overt SSBB more than 48 h after bleeding. CapsoCam is a useful modality for patients with SSBB.

DOP29 Capsule endoscopy-guided proactive treatment versus standard treatment of patients with quiescent Crohn’s Disease: The CURE-CD randomized controlled trial

Abstract Background Optimal strategies for treat-to-target in Crohn’s disease (CD) are still being sought. We aimed to examine the value of capsule endoscopy (CE) to guide proactive treatment optimization in patients with CD Methods A prospective randomized controlled clinical trial with temporally-restricted blinding. Patients with CD involving the small bowel who were in clinical remission (CDAI&amp;lt;150) for over three months were enrolled. Baseline clinical, biomarker, imaging, patency capsule and CE assessments were performed. ‘High risk’ patients, defined as CE Lewis score ≥350 were randomized to either proactive treatment optimization or continued standard care for 24 months. ‘Low risk’ patients with Lewis score&amp;lt;350 continued their standard care. All patients repeated CE every six months for 24 months. Primary outcome was the rate of clinical exacerbation (CDAI increase&amp;gt;70 points and CDAI&amp;gt;150 or hospitalization/surgery) in the standard-care versus the proactive-care sub-groups of high-risk patients, at 24 months. Secondary outcomes included risk of flare in the low-risk versus the standard-care high-risk arms, and predictive profiles for flare of calprotectin, MRI, intestinal ultrasound and Lewis score. Results Out of 118 screened patients, 60 were enrolled (20 in each of the three arms). Treatment intensification in CE-determined high-risk group, who were allocated to proactive treatment, comprised biologic dose-escalation (n=11/20), starting a biologic (8/20) or swapping a biologic (1/20) at study entry. Notably, 9/20 proactive-group patients underwent a second optimization following detected inflammation on subsequent semi-annual CE studies. Clinical exacerbation by 24 months (primary outcome) occurred in 5/20 (25%) of the high-risk proactive-treatment group versus 14/20 (70%) of the high-risk standard-care group (OR=0.14, 95%CI 0.04-0.57, p=0.006). For secondary outcomes, the rate of clinical flare in the standard-care low-risk group was numerically but not significantly lower than in standard-care high-risk group (9/20 versus 14/20, respectively, OR 0.3, 0.1-1.3, P=0.11). Among all patients continuing standard care, baseline CE Lewis score was higher among relapsers versus non-relapsers (median 450, IQR [225-900] versus 225, [135-600], respectively, p=0.03). Of 251 CE ingested, there was a single (0.4%) temporarily-retained CE, which resolved spontaneously. Conclusion In a randomized strategy-finding controlled trial, proactive treatment optimization based on CE findings in patients with CD in remission, proved safe and superior for prevention of disease exacerbation compared with continued standard care. NCT03555058

The role of video capsule endoscopy in the diagnosis of gastrointestinal diseases: experience of the Department of Diagnostic and Operative Endoscopy

Introduction. Video capsule endoscopy (VSE) is a gold standard diagnostic method for small bowel diseases and is widely used in clinical practice. The presented analysis of the VCE results demonstrates the possibilities of this diagnostic tool and is the largest one of the analysis that were recently published in Russia. Aim. To demonstrate the possibilities of video capsule endoscopy in the diagnosis of small bowel diseases. Materials and methods. A total of 300 video capsule endoscopies were performed in patients with suspected and already established small bowel diseases between 2014 and 2022. All patients who underwent a video capsule endoscopy in the settings of the National Medical Research Center of Coloproctology named after A.N. Ryzhikh were over 18 years old. The study cohort included 158 men and 142 women. The average age of patients at the time of the video capsule endoscopy was 42 ± 15.4 years. The patients were recommended a standard preparation regimen: 3 days before the study, a protein diet was prescribed, and the day before, a two-stage administration of a PEGbased drug (“split dose”). To reduce gas production and decrease the amount of foamy intestinal contents, which worsens the quality of the endoscopic image, oral administration of an antifoam agent simethicone was prescribed: 80 mg on the eve of the endoscopy and 80 mg on the day of the endoscopy. Results. The video capsule endoscopy demonstrated high information value in the diagnosis of inflammatory bowel diseases: its sensitivity was 86%, and specificity – 90%. Similar results were obtained during video capsule endoscopy used to diagnose the source of possible bleeding: sensitivity and specificity were 87 and 68%, respectively. Conclusion. Video capsule endoscopy is an effective, safe and well-tolerated tool for diagnosing small bowel diseases. The video capsule endoscopy findings contribute to establishing a correct diagnosis and selecting treatment strategies.

Construction of a prediction model for predicting rebleeding in patients with obscure gastrointestinal bleeding after capsule endoscopy

Objective: To explore the risk factors of rebleeding in patients with obscure gastrointestinal bleeding (OGIB) after capsule endoscopy (CE), and construct a model to predict rebleeding. Methods: The data of patients with OGIB who underwent CE in Zhongda Hospital Affiliated to Southeast University from July 2018 to September 2021 were retrospectively analyzed. Follow-up data were obtained via electronic medical records or telephone interviews. Univariate and multivariate Cox regression models were performed to figure out the risk factors of rebleeding in OGIB patients. Then the optimal prediction model was determined and presented as a nomogram. The model was evaluated by C statistic, calibration curve and decision curve analysis. Results: One hundred and thirty patients with OGIB were included, including 64 females and 66 males, aged (55.8±17.2) years (18-87 years), and 39 (30.0%) cases developed rebleeding during follow-up. Univariate and multivariate Cox regression model analysis showed the duration of more than 2 weeks OGIB (HR=3.70, 95%CI: 1.85-7.42, P<0.001), a history of previous gastrointestinal bleeding (HR=5.25, 95%CI: 2.00-13.81, P<0.001), positive CE findings (HR=3.72, 95%CI: 1.66-8.33, P=0.001), and the lowest hemoglobin level before CE<80 g/L (HR=2.00, 95%CI: 1.02-3.84, P=0.044) were risk factors for rebleeding, while specific treatment (HR=0.25, 95%CI: 0.11-0.54, P<0.001) was a protective factor. The corresponding scores of the above five predictive factors were: OGIB duration>2 weeks: 79 points; Previous history of gastrointestinal bleeding: 100 points; The result of CE was positive: 79 points; Specific treatment:-85 points; Minimum hemoglobin before CE<80 g/L: 41 points. The prediction model constructed from the above five variables had good discriminative capability (concordance index=0.798, 95%CI: 0.732-0.865). The calibration curves showed high consistency between nomogram-predicted probabilities and actual observations. The decision curves showed that when the threshold probability was above 0.04, the use of the nomogram to predict rebleeding provided a greater net benefit than the assumption of "all patients rebleeding or no patients rebleeding". Conclusion: The prediction model established in this study has a good ability to predic rebleeding in patients with OGIB after CE examination.

S1796 Diagnostic Yield and Clinical Predictors of Video Capsule Endoscopy Findings in Veterans

S1796 Diagnostic Yield and Clinical Predictors of Video Capsule Endoscopy Findings in Veterans

Small-bowel capsule endoscopy in patients with Meckel's diverticulum: clinical features, diagnostic workup, and findings. A European multicenter I-CARE study.

Meckel's diverticulum (MD) may remain silent or be associated with adverse events such as GI bleeding. The main aim of this study was to evaluate indicative small-bowel capsule endoscopy (SBCE) findings, and the secondary aim was to describe clinical presentation in patients with MD. This retrospective European multicenter study included patients with MD undergoing SBCE from 2001 until July2021. Sixty-nine patients with a confirmed MD were included. Median age was 32 years with a male-to-female ratio of approximately 3:1. GI bleeding or iron-deficiency anemia was present in nearly all patients. Mean hemoglobin was 7.63 ± 1.8 g/dL with a transfusion requirement of 52.2%. Typical capsule endoscopy (CE) findings were double lumen (n= 49 [71%]), visible entrance into the MD (n= 49 [71%]), mucosal webs (n= 30 [43.5%]), and bulges (n= 19 [27.5%]). Two or more of these findings were seen in 48 patients (69.6%). Ulcers were detected in 52.2% of patients (n= 36). In 63.8% of patients (n= 44), a combination of double lumen and visible entrance into the MD was evident, additionally revealing ulcers in 39.1% (n= 27). Mean percent SB transit time for the first indicative image of MD was 57% of the total SB transit time. Diagnosis of MD is rare and sometimes challenging, and a preoperative criterion standard does not exist. In SBCE, the most frequent findings were double-lumen sign and visible diverticular entrance, sometimes together with ulcers.

Endoscopic and video capsule endoscopic observation of Yersinia enterocolitis

A woman in her late 20s suffered from epigastralgia following lower abdominal pain with diarrhea. Kampo medicine relieved the complaints, but the pain recurred a month later. She had immigrated from Vietnam to Japan 6 months before the onset of the abdominal pain. Blood test findings were almost within normal limits, except for mild C-reactive protein elevation and positive Helicobacter pylori antibody findings. Colonoscopy revealed an edematous cobblestone-like appearance at the end of the ileum with irregular ulceration mimicking Crohn's disease. Video capsule endoscopy was performed to detect lesions in the small intestine and demonstrated irregular ileal ulcer, reminiscent of Crohn's disease. A biopsy performed during colonoscopy demonstrated granulomatous inflammation with a moderate accumulation of plasma cells and mononuclear cells. The bacterial culture of the biopsy specimen proved the growth of Yersinia enterocolitica. Levofloxacin 500 mg for 7 days rapidly relieved abdominal pain. Yersinia enterocolitis is rare in developed countries, but as a differential diagnosis for Crohn's disease, it is important to treat. This is the first case report of the video capsule endoscopy findings of Yersinia enterocolitis. Video capsule endoscopy can help to confirm the spread of the lesions of Yersinia enterocolitis.

Small Bowel CLEansing Assessment and Report (SB-CLEAR): Standardizing bowel preparation report in capsule endoscopy.

Small-bowel (SB) cleansing is crucial to assess the reliability of capsule endoscopy (CE) findings. However, the presence of multiple grading systems is hampering their use in clinical practice. In 2020, Colon CLeansing Assessment and Report (CC-CLEAR) was created and validated. We sought to develop and validate a new score for the evaluation of the SB cleansing, adapted from CC-CLEAR, aiming to standardize CE reporting regarding the quality of preparation. The new grading score, SB CLeansing Assessment and Report (SB-CLEAR), divided the SB into three tertiles, each being scored depending on the percentage of visualized mucosa (0, <50%; 1, 50%-75%; 2, >75%; 3, >90%). The overall classification was a sum of each segment score, graded between excellent, good, and inadequate (0-5). Any segment scoring ≤1 resulted in inadequate overall classification. CE videos were prospectively evaluated by two experienced CE readers blinded to each other. We included 52 CEs, 41(78.8%) female, with a mean age of 57.9±17.9years. Inter-observer agreement was very strong for each tertile (first: r=0.863; second: r=0.865; third: r=0.861; P<0.001), which resulted in overall excellent correlation when considering the quality of preparation in all tertiles (r=0.940; P<0.001). By applying final classifications of "inadequate," "good," and "excellent," correlation between observers was also very strong (r=0.875; P<0.001). SB-CLEAR is an innovative and reproducible grading score for evaluation of SB preparation quality in CE, with overall excellent inter-observer agreement. Along with CC-CLEAR, this may become a valuable tool to uniformize reporting of bowel preparation quality in CE.

Safety and efficacy of capsule endoscopy for patients with newly diagnosed Crohn’s disease: A multicenter retrospective study

Crohn's disease (CD) is a chronic inflammatory disease that develops at a young age and frequently leads to intestinal resection. Capsule endoscopy (CE) can directly and non-invasively inspect the entire small bowel mucosa. We suspected that CE could be a good diagnostic tool for detecting CD in young patients. The aim of this study was to investigate the safety and efficacy of CE in patients with newly diagnosed CD and to evaluate the CE findings, especially in the upper small bowel of young patients. We retrospectively investigated 32 patients with newly diagnosed CD from 5 institutions. Patient characteristics, clinical course, and characteristics of CE findings were analyzed. The total small intestine observation rate was 93%, and the retention rate was 3% (1/32). No abnormality was identified by ileocolonoscopy in 46% (15/32), and transition of small bowel lesions (TSL) was found in 35% (12/34) of the patients. The frequency of longitudinal ulcers and cobblestones in the upper small intestine was significantly higher in younger patients (≤20 years). Moreover, positive findings in the upper small intestine were predominantly observed in younger patients (≤20 years). CE for patients with newly diagnosed CD was safe and useful, especially for the detection of upper small bowel lesions in young patients.

Fecal calprotectin in predicting small bowel capsule endoscopy findings in pediatric patients with known Crohn's disease.

Fecal calprotectin (FC) has been proposed as a noninvasive surrogate marker of intestinal inflammation in inflammatory bowel disease. This study aimed to assess the capability of FC in predicting small bowel capsule endoscopy (SBCE) findings in pediatric patients with known Crohn’s disease (CD). We retrieved data of consecutive patients aged 2 to 17 years old with established CD who underwent SBCE from Janurary 2017 to April 2020 and had endoscopic remission on ileocolonoscopy. Sixty-eight patients were included in the analysis. There were 13 patients with a weighted pediatric CD activity index ≥ 12.5, 47 patients with FC ≥ 200 µg/g, and 45 patients with significant small bowel (SB) inflammation [Lewis score (LS) ≥ 135]. The LS correlated weakly with FC (R = 0.30, P < .05). The area under the curve of FC as a surrogate diagnostic test for LS ≥ 135 was 0.691, and the optimal FC cutoff values were 242 µg/g with the corresponding sensitivity and specificity of 78% and 65%, respectively. The area under the curve of FC for moderate-to-severe inflammatory activity in the SB was 0.718. In patients with FC level ≥ 670 µg/g, LS ≥ 790 was found in 33% (9/27) of patients, with the sensitivity and specificity of 69% and 67%, respectively. FC may be used to predict SB mucosal inflammation in pediatric patients with confirmed CD having endoscopic remission on ileocolonoscopy.

S1097 Clinical Outcomes of Double Balloon Enteroscopy: An 8-Year Tertiary Center Experience

Introduction: The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting 6-month readmission Methods: We conducted a retrospective cohort study of patients (n=1162) who underwent DBE at an academic tertiary care center between November to December 2020. Baseline patient data as well as DBE related variables were collected. Outcome variables included readmission rates, diagnostic and therapeutic yield. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and student 2 sample t-test were performed to compare patient characteristics. Logistic regression was used for outcome variable analysis. Results: Of the 1162 DBE procedures, 50.95% were male (n= 592) with a mean age of 61.29 (15.33, SD). The most common indications for procedure being GI bleed (61%) and abnormal video capsule endoscopy findings (30%). The cohort’s rate of positive diagnostic yield was 65% and 57% for therapeutic yield. The mean procedural time was 39.80 (21.31, SD) minutes, and 77% of DBE patients received anterograde procedures. Compared to retrograde procedures, a higher proportion of DBE patients with anterograde procedures had positive diagnostic yield (66% vs. 62%, p=.254) (Table). Readmission rates at 30 days and 6 months were 11% and 18% respectively. Anterograde procedures were more likely to be inpatient (37% vs 29%, p=0.018) and associated with shorter procedure time (38.67 ± 204.5 vs 43.7 ± 23.7 minutes, p=0.0008) and higher therapeutic yield (60% vs 46%, p=0.00) ( Figure). Univariate analysis depicted inpatient status, total procedure minutes, and anticoagulation use to be associated with 6-month readmission (all P< 0.05). After controlling for each variable through multivariable analysis, inpatient status [OR:3.56, 95% CI (2.59-4.89), p=0.00] and total procedure minutes [OR:1.01, 95% CI (1.00-1.01), p=0.03] remained significant predictors of 6-month readmission Conclusion: DBE procedures has high efficacy for both diagnostic and therapeutic yield while evaluating GI bleed, abdominal pain, iron deficiency anemia, as well as performing ERCP in patients with altered upper GI anatomy. Patients undergoing anterograde DBE are associated with shorter procedure time and higher therapeutic yield compared to patients undergoing retrograde DBE. DBE patients who are inpatients and higher procedural times are more likely to be readmitted in 6 months.Figure 1.: Univariate and Multivariable Logistic Regression Analysis predicting 6-month readmission rate Table 1. - Patient characteristics and outcome variables stratified based on procedure type (anterograde vs retrograde) Variable Anterograde (n=900) Retrograde(n=262) P-Value Sex Male 459 (51%) 133 (51%) .95 Female 441 (49%) 129 (49%) Age, Range: 35-93, Mean (SD) 61.17 (15.30) 61.69 (15.49) .629 Patient Type Outpatient 571 (63%) 187 (71%) .018 Inpatient 329 (37%) 75 (29%) BMI Less than 25 304 (34%) 77 (29%) .183 25 or more 596 (66%) 185 (71%) Altered Anatomy No 695 (77%) 234 (89%) .000 Yes 205 (23%) 28 (11%) Anticoagulation No 780 (87%) 230 (88%) .636 Yes 120 (13%) 32 (12%) ESRD No 858 (95%) 247 (94%) .485 Yes 42 (5%) 15 (6%) Anesthesia Type General 809 (90%) 97 (37%) .000 Mac 91 (10%) 165 (63%) Total procedural time Mean (SD) 38.67 (20.45) 43.70 (23.70) .0008 Therapeutic Yield No 361 (40%) 141 (54%) .000 Yes 539 (60%) 121 (46%) Positive Finding No 305 (34%) 99 (38%) .244 Yes 595 (66%) 163 (62%) Readmission 30-day No 791 (88%) 238 (91%) .187 Yes 109 (12%) 24 (9%) Readmission 6 Month No 731 (81%) 219 (84%) .383 Yes 169 (19%) 43 (16%)

Bedside Live-View Capsule Endoscopy in Evaluation of Overt Obscure Gastrointestinal Bleeding: A Pilot Point-of-Care Study

Background: Capsule endoscopy (CE) is an emerging tool in the diagnosis and management of occult bleeding and overt obscure gastrointestinal bleeding (OOGIB). Maximizing the efficiency of CE can lead to rapid bleeding localization and shorter time to therapy. We investigated whether a trained registered nurse (RN) can accurately interpret bleeding by observing the CE findings in real time by measuring inter-observer agreement between RN and physician interpretation. Methods: We conducted a prospective study of patients admitted for OOGIB who underwent live-view capsule endoscopy (LVCE) between December 2016 and November 2017. A matched control group who underwent standard CE was obtained through retrospective review. An RN received a 2-day training program for CE interpretation. RN bedside interpretation for bleeding was followed by interpretation by 2 gastrointestinal physicians blinded to LVCE findings. Outcomes were compared between groups using t-tests and χ² tests. Cohen’s kappa measured the agreement between the physicians and the RN. Results: Ten subjects were in the LVCE group, and 12 subjects were in the standard-of-care group. The agreement between the physicians and the RN was 9/10 (90%), with a kappa of 0.73 (95% CI: 0.26–1.00; p = 0.016). Patients in the LVCE group had shorter duration to physician interpretation (0.6 vs. 0.7 days [p = 0.50]), shorter duration to endoscopy (1.8 days vs. 3 days [p = 0.240]), and shorter length of stay (8.1 vs. 11.4 days [p = 0.26]) compared to the standard-of-care group. Conclusion: This study utilizing an RN for LVCE interpretation found inter-observer agreement between RN and physician findings. Larger studies are needed to assess whether this RN-physician team approach can translate to improved outcomes.

Long-term rebleeding rate and predictive factors of rebleeding after capsule endoscopy in patients with obscure GI bleeding

The incidence of rebleeding in obscure GI bleeding (OGIB) remains unclear. This study used capsule endoscopy (CE) to determine the long-term rebleeding rate and predictive factors for rebleeding in patients with OGIB. This single-center, observational study enrolled consecutive patients with OGIB who underwent CE as the first small intestinal examination between March 2004 and December 2015 and were followed up through medical records or letters. Three hundred eighty-nine patients were included in the analysis. Survival curve analysis showed that the overall cumulative rebleeding rate in OGIB during the 5 years was 41.7%. Multivariate analysis using the Cox proportional hazards model revealed that overt OGIB (hazard ratio [HR], 2.017; 95% confidence interval [CI], 1.299-3.131; P= .002), anticoagulants (HR, 1.930; 95% CI, 1.093-3.410; P= .023), positive balloon-assisted enteroscopy findings after CE (HR, 2.927; 95% CI, 1.791-4.783; P< .001), and iron supplements without therapeutic intervention (HR, 2.202; 95% CI, 1.386-3.498; P= .001) were associated with rebleeding, whereas a higher minimum hemoglobin level (HR, .902; 95% CI, .834-.975; P= .009) and therapeutic intervention (HR, .288; 95% CI, .145-.570; P< .001) significantly reduced the risk of rebleeding. Among the Charlson Comorbidity Index components, liver cirrhosis was an independent predictor associated with rebleeding in patients with OGIB (HR, 4.362; 95% CI, 2.622-7.259; P< .001) and in patients with negative CE findings (HR, 8.961; 95% CI, 4.424-18.150; P< .001). Rebleeding is common during the long-term follow-up of patients with OGIB. Careful follow-up is required for patients with liver cirrhosis or previous massive bleeding.

Hardly Ants-ipated Capsule Endoscopy Finding

Question: A 74-year-old man was referred for evaluation of weight loss and diarrhea. His past medical history included depression, hypertension, and atrial fibrillation. Additionally, he underwent an aortic valve replacement and mitral valve repair. Six years ago, the patient had an anterior resection owing to rectal carcinoma. Current medications were warfarin (Coumadin), ramipril, and dutasteride (Avodart). Blood and stool tests were nonrevealing. A computed tomography scan f the abdomen did not disclose any significant findings. Colonoscopy was normal except for a 3-mm tubular adenoma, which was resected. No random biopsies were taken. Gastroscopy showed a hyperemic mucosa in the antrum and nodular mucosa in the duodenal bulb. Random biopsies were taken from the antrum and the duodenum. Pathology revealed subtotal villous atrophy, represent Marsch 3A consistent with celiac disease. Tissue transglutaminase immunoglobulin A was twice the upper limit of normal. The patient was started on a gluten-free diet without any improvement. Considering his lack of improvement despite of a strict diet for 12 months with continuous positive serology, a video capsule endoscopy was performed after 12 hours of fasting. The findings are shown in Figure A and B. What are the findings on video capsule and how are they connected to the patient’s complaints? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The capsule endoscopy revealed several intact dead ants in the jejunum. The patient denied deliberate or inadvertent ingestion of ants. There are only a few cases of insects findings on endoscopy described in the literature, and most of them are bees or wasps.1Lynch J.P. Rothstein R.D. A gastric “bee-zoar”.N Engl J Med. 1997; 336: 1763-1764Crossref PubMed Scopus (7) Google Scholar,2Shah D. Tsang T.-K. Bee sting dysphagia.An Intern Med. 1998; 129: 253Crossref PubMed Scopus (5) Google Scholar A recent case report described an 80-year-old male whose upper endoscopy revealed a large peptic ulcer and, in its base, a dead intact ant.3Shaoul R. Rainis T. The new meaning of “ant-acid”.Gastrointest Endosc. 2008; 67: 748Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We believe this is likely an incidental finding that does not relate to the patient complaints. Nevertheless, this finding on capsule has not been described previously in the literature and needs to be recognized as yet another possible rare finding on capsule endoscopy.

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

Background and aim Direct oral anticoagulants (DOACs) became a widespread alternative in anticoagulant therapy. Nevertheless, concerns are raised about their safety, with increased gastrointestinal bleeding rates being described. There are scarce studies regarding DOACs effect on small-bowel capsule endoscopy (SBCE) findings. We aimed to assess if the detection of lesions with high bleeding potential on SBCE was significantly different in patients treated with DOACs when compared to non-anticoagulated patients and to patients anticoagulated with other agents. Methods Cohort study including consecutive patients who underwent SBCE for suspected mid-gastrointestinal bleeding (MGIB) in 2019 and 2020. Results From 148 patients, 38 (25.7%) were anticoagulated, of which 26 (68.4%) with DOACs. P2 lesions were detected in 36.5% (n = 54) of the patients. These lesions were more frequently detected in patients under DOACs treatment when compared to non-anticoagulated patients (69.2% vs. 29.1%; p=.001), and also when compared to patients treated with other anticoagulants (69.2% vs. 33.3%; p=.037). No differences in P2 lesions detection were observed between patients treated with other anticoagulants and non-anticoagulated patients (33.3% vs. 29.1%; p=.747). In multivariate analysis, DOACs usage was significantly associated with higher detection rates of P2 lesions on SBCE, when adjusted for classical risk factors for MGIB (OR: 3.38; 95%CI = 1.23–9.26; p=.018). Conclusions Despite their undeniable cardiovascular benefits and easy applicability, DOACs should still be considered with caution. These drugs were significantly associated with higher risk of potentially bleeding lesions on SBCE when compared to other anticoagulants and represent an independent risk factor for MGIB when adjusted for other variables.

Safety and efficacy of the patency capsule

Introduction and aimsThe patency capsule is an effective diagnostic method for preventing video capsule retention in the small bowel during capsule endoscopy. The most frequently associated complication when using the patency capsule is symptomatic retention. The aim of the present study was to evaluate the effectiveness and safety of patency capsules administered to patients at a tertiary care hospital center. Materials and methodsA retrospective observational study was conducted that included all the patients with confirmed Crohn’s disease that were administered a patency capsule, within the time frame of January 2019 and December 2020. PC diagnostic yield, sensitivity, specificity, positive predictive value, and negative predictive value were evaluated, in relation to capsule endoscopy and double-balloon endoscopy findings. Complications associated with the patency capsule were also identified. ResultsThirty patients were included, in whom the patency capsule had 83% sensitivity, 100% specificity, 100% positive predictive value, and 96% negative predictive value, with a diagnostic yield of 96.7%. There was one complication (3.3%) and it resolved spontaneously. ConclusionsThe patency capsule is a safe and effective method for reducing video capsule retention during capsule endoscopy in patients with Crohn’s disease.