Investigation Of Obscure Gastrointestinal Bleeding Research Articles

A118 BALLOON-ASSISTED ENTEROSCOPY TIMING INCREASES DIAGNOSTIC YIELD IN PATIENTS WITH OVERT OBSCURE GASTROINTESTINAL BLEEDING: A RETROSPECTIVE STUDY

Abstract Background Obscure gastrointestinal bleeding (OGIB) is defined as bleeding from an unknown etiology despite initial investigations with upper endoscopy and colonoscopy, of which 75-80% is attributed to a small bowel (SB) source. OGIB poses a significant diagnostic and therapeutic challenge, resulting in high morbidity and mortality with increased utilization of health care resources. Balloon-assisted enteroscopy (BAE) is a useful procedure for the evaluation and management of small bowel bleeding, with reported diagnostic and therapeutic rates up to 87% and 80%, respectively. Purpose This retrospective study aims to evaluate the diagnostic and therapeutic yields in a large cohort of adult patients presenting with different subtypes of OGIB who have undergone BAE, as well as to assess for association between various patient and disease factors, and clinical outcomes. Method We performed a retrospective review of 1057 cases of BAE at a large quaternary referral centre between 2016 to 2021 and 158 OGIB cases were identified. Sex, age, and, preprocedural variables including indication, time from video capsule endoscopy (VCE) to BAE and subclassification of SB bleed were collected. Endoscopic modality, findings, and therapeutic interventions were used to calculate diagnostic and therapeutic yields. The association between the timing of BAE relative to VCE and clinical outcomes including rebleeding rate, diagnostics and therapeutic yields were assessed. Bleeding free-survival was estimated using Kaplan-Meier function. All data analyses were performed with SPSS. Result(s) The overall diagnostic yield of BAE was 74%. Patients with active overt bleeding were found to have a statistically significant higher yield compared to those with inactive overt bleeding (94% vs 67%, P= 0.03). The therapeutic yield was 51%, with a significantly higher rate of injection therapy and hemoclip placement in those with active overt bleeding compared to those with inactive overt and occult bleeding (P< 0.001). BAE performed within 72 hours of overt GI bleeding was found to have a statistically significant higher diagnostic yield when compared to procedures performed after 72 hours (94% vs 67%, p =0.05). Univariable analysis revealed higher diagnostic yield in patients requiring transfusion within the past 12 months (P= 0.02) Finally, rebleeding-free survival in all patients at 1 year and 5 years was 98% and 68%, respectively. Image Conclusion(s) Balloon-assisted enteroscopy continues to be an effective diagnostic and therapeutic modality for the investigation of obscure gastrointestinal bleeding. Our retrospective study shows a higher diagnostic yield in those presenting with active overt GI bleed as well as those who underwent BAE within 72 hours of overt GI bleeding. Furthermore, patients who required transfusion within the past 12 months are more likely to have a positive BAE finding. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A116 CLINICAL OUTCOMES OF PATIENTS UNDERGOING BALLOON-ASSISTED ENDOSCOPY FOR SUSPECTED SMALL BOWEL BLEEDING

Abstract Background Obscure gastrointestinal bleeding (OGIB) accounts for approximately 50% of all GI bleeds. This refers to bleeding from an unknown etiology despite initial investigations with upper endoscopy and colonoscopy, of which 75–80% is attributed to a small bowel source, also termed as small bowel bleeding. Various diagnostic and therapeutic modalities have been used to investigate sources of OGIB. Balloon-assisted enteroscopy (BAE) is a useful procedure for managing small bowel bleeding, with reported diagnostic and therapeutic rates up to 87% and 80%, respectively. Aims The aims of this study are to evaluate the outcomes of patients with OGIB who have undergone BAE, as well as to explore correlations between the timing of BAE and clinical outcomes. Methods We performed a retrospective review of 342 patients who underwent BAE at a tertiary referral centre between 2016 to 2021, of which 116 underwent evaluation for OGIB. Aside from gender and age, preprocedural variables including endoscopy indication, timing from video capsule endoscopy (VCE) and overt GI bleed were collected to allow for further stratification of data. Endoscopic variables including modality, findings, and therapeutic interventions were used to calculate diagnostic and therapeutic yields. Furthermore, the association between timing of BAE after VCE and clinical outcomes including rebleeding rate, diagnostics and therapeutic yields were assessed. All data analyses were performed with SPSS. Results The overall diagnostic yield was 70.3%. Patients with active overt bleeding were found to have a higher yield compared to those with occult and inactive overt bleeding (78.6% vs 72.5% vs 64.6%, respectively). Amongst all OGIB presentations, the most common findings were vascular lesions including angiodysplasia, arteriovenous malformations, and dieulafoy lesions. The majority of lesions were found within the proximal jejunum. Subgroup analysis did not show a statistically significant difference in diagnostic yields between BAE with and without prior VCE (75.9% vs 77.8, P = 0.605). The therapeutic yield was 51.1% with a higher yield found in those presenting with active overt bleeds compared to occult and inactive overt cases. Compared to BAE performed after 30 days of overt GI bleeding, those completed within 30 days was found to have a higher diagnostic and therapeutic rate (80.0% vs 60.0%, 70.0 vs 30.0%, respectively). Conclusions Balloon-assisted enteroscopy continues to be an effective diagnostic and therapeutic modality for the investigation of obscure gastrointestinal bleeding. Our retrospective study shows a higher diagnostic and therapeutic rate in those presenting with active overt GI bleed as well as those who underwent BAE within 30 days of overt GI bleeding Funding Agencies None

S558 Artificial Intelligence and Capsule Endoscopy: Automatic Detection of Gastric Vascular Lesions Using a Convolutional Neural Network

Introduction: Capsule endoscopy (CE) is the main diagnostic modality for the investigation of obscure gastrointestinal bleeding. Although it is designed to identify small bowel pathology, lesions (particularly vascular lesions) are frequently documented in locations within reach of conventional endoscopy. However, the performance of CE for detection of gastric lesions has been shown to be suboptimal. Studies on the development of artificial intelligence (AI) systems, particularly convolutional Neural Networks (CNN), for automatic analysis of CE images have provided promising results. To date, performance of these automated algorithms for detection of gastric vascular lesions in CE images has not been evaluated. We aimed to develop and test a CNN-based algorithm for automatic detection of gastric vascular lesions (angiectasia, gastric antral vascular ectasia, varices, and red spots). Methods: A total of 1275 CE images were included for construction of the CNN, 470 containing vascular lesions and 805 showing normal mucosa. For automatic detection of gastric lesions, these images were inserted into a CNN model with transfer learning. A training dataset comprising 80% of the total pool of images was defined. Subsequently, we evaluated the performance of the network using an independent test dataset (20% of total image pool). The output provided by the CNN was compared to a consensus classification provided by two endoscopists experienced in CE (more than 1000 CE videos each). We calculated the sensitivity, specificity, accuracy, positive predictive and negative predictive values (PPV and NPV, respectively), and area under the curve (AUC). Results: After optimization of the neural architecture of the algorithm, our model was able to detect detected gastric vascular lesions with a sensitivity, specificity, PPV and NPV of 86.2%, 98.1%, 96.4% and 92.4%, respectively. The algorithm had an overall accuracy of 93.7%. The AUC was 0.97. The CNN read the validation dataset in 6 seconds (average processing speed of 45 images per second). Conclusion: This is the first report of a deep learning system for automatic detection of gastric vascular lesions in CE images. The implementation of these systems may potentiate the ability of CE for exploration of suspected upper gastrointestinal disease, which may be particularly helpful in patients with limited tolerance to EGD.

Capsule enteroscopy versus radionuclide scintigraphy for the diagnosis of obscure gastrointestinal bleeding.

capsule enteroscopy (CE) and 99mTc red blood cell (RBC) scintigraphy are frequently used in the investigation of obscure gastrointestinal bleeding (OGIB). There are few data comparing both diagnostic modalities. This study aimed to assess the performance of CE and scintigraphy for the diagnosis of OGIB. patients who underwent CE and scintigraphy for OGIB were selected and analyzed retrospectively. The hemorrhagic potential of CE findings was rated using Saurin's classification. The concordance between both diagnostic techniques for bleeding detection and localization was analyzed. eighty-five patients (62 % female), with a median age of 63 years, were included in the study. Capsule enteroscopy identified 37 patients (43 %) with high hemorrhagic potential (P2) lesions. Most scintigraphy exams were positive for gastrointestinal bleeding (82 %). No concordance was found in the detection of lesions with hemorrhagic potential between CE and scintigraphy (kappa < 0). The distribution of P0, P1 and P2 findings was similar in patients with positive or negative scintigraphy (p = 0.526). There was no agreement regarding the location of P2 findings in CE and the bleeding detected by scintigraphy (kappa < 0). Patients with P2 lesions had significantly lower median levels of hemoglobin (p = 0.002) at presentation. No significant differences were found in hemoglobin values between patients with positive and negative scintigraphy (p = 0.058). significant diagnostic discrepancy was observed between CE and scintigraphy. The findings of CE correlated better with hemoglobin values at presentation than scintigraphy results. Therefore, scintigraphy does not appear to be useful in the diagnostic workup of OGIB.

Non-small-bowel lesions identification by capsule endoscopy: A single centre retrospective study

Capsule endoscopy has been considered the first-line approach for the investigation of obscure gastro-intestinal bleeding since its approval in 2001. Our study aims to evaluate the diagnostic yield of capsule endoscopy in the investigation of this condition. We also analyse the incidence of non-small-bowel lesions missed after conventional endoscopy and later detected by capsule endoscopy in patients with suspected obscure bleeding. A total of 290 patients with negative conventional endoscopy referred to our centre to undergo a capsule endoscopy examination for the investigation of obscure gastro-intestinal bleeding. We considered as non-small-bowel lesions those outside the tract between the second duodenal portion and the ileocecal valve. We also looked for actively bleeding lesions at the time of the exam. Intestinal preparation was good, adequate or poor in 74.1%, 8.4%, and 17.5% of the tests, respectively. Caecum was reached in 92.4%. Capsule retention occurred in 0.7%. Mean small bowel transit time was 5hours and 13minutes. Diagnostic yield was 73.8%. An actively bleeding lesion was noticed in 39.3% of positive tests. Capsule endoscopy revealed clinically significant non-small-bowel lesions missed at gastroscopy or colonoscopy in 30.3% of patients, 43.2% of which were bleeding. Capsule endoscopy has high diagnostic yield and safety in the investigation of obscure gastro-intestinal bleedings. Given the high percentage of non-small-bowel lesions detected, it may be appropriate to consider an endoscopic second look before performing a capsule endoscopy study.

Re-bleeding and its predictors after capsule endoscopy in patients with obscure gastrointestinal bleeding in long-term follow-up

BackgroundCapsule 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.MethodsWe 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.ResultsOne 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).ConclusionsThe 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.

The role of capsule endoscopy in the diagnosis and treatment of obscure gastrointestinal bleeding in older individuals.

Capsule endoscopy (CE) is currently recommended as the first-line diagnostic modality for the investigation of obscure gastrointestinal bleeding (OGIB). This study aimed to evaluate the diagnostic efficacy of CE and to determine the subsequent impacts on the treatment of the OGIB episode in older individuals. Eight hundred and fifty-three patients who underwent CE for the indication of OGIB were investigated in a single center between January 2004 and December 2015. Patients were divided into two groups: those 65 years of age and older and those younger than 65 years of age. There were no significant differences between older patients and younger patients with respect to the CE completion rate. The diagnostic yield was significantly higher in older patients than in younger patients (55.1 vs. 46.6%, P=0.021). Vascular lesions were the main cause of bleeding in the elderly, whereas ulcerated/erosive lesions were found most frequently in younger patients. Furthermore, 56.0% of older patients with positive CE results had relevant changes in their management plans and received specific treatment on the basis of CE findings. Our study confirmed the important role of CE in the diagnosis of OGIB and its huge impact on decision making in the management plan for older patients.

Risk factors for small bowel angioectasia: The impact of visceral fat accumulation.

To investigate visceral fat accumulation in association with the risk of small bowel angioectasia. We retrospectively investigated 198 consecutive patients who underwent both capsule endoscopy and CT for investigation of obscure gastrointestinal bleeding (OGIB) from January 2009 to September 2013. The visceral fat area (VFA) and subcutaneous fat area were measured by CT, and information on comorbidities, body mass index, and medications was obtained from their medical records. Logistic regression analysis was used to evaluate associations. Capsule endoscopy revealed small bowel angioectasia in 18/198 (9.1%) patients with OGIB. Compared to patients without small bowel angioectasia, those with small bowel angioectasia had a significantly higher VFA (96 ± 76.0 cm(2) vs 63.4 ± 51.5 cm(2), P = 0.016) and a higher prevalence of liver cirrhosis (61% vs 22%, P < 0.001). The proportion of patients with chronic renal failure was higher in patients with small bowel angioectasia (22% vs 9%, P = 0.11). There were no significant differences in subcutaneous fat area or waist circumference. The prevalence of small bowel angioectasia progressively increased according to the VFA. Multivariate analysis showed that the VFA [odd ratio (OR) for each 10-cm(2) increment = 1.1; [95% confidence interval (CI): 1.02-1.19; P = 0.021] and liver cirrhosis (OR = 6.1, 95%CI: 2.2-18.5; P < 0.001) were significant risk factors for small bowel angioectasia. VFA is positively associated with the prevalence of small bowel angioectasia, for which VFA and liver cirrhosis are independent risk factors in patients with OGIB.

Diagnostic modalities for the evaluation of small bowel disorders.

This review summarizes the recent developments in the evaluation of small bowel disorders using videocapsule endoscopy (VCE) and serological and breath-test biomarkers. The ability to visualize the small bowel was revolutionized with the introduction of VCE technology. VCE allows for accurate, noninvasive visualization of the small bowel mucosa. This device is invaluable in the investigation of obscure gastrointestinal bleeding (OGIB), occult bleeding with iron deficiency anaemia, small bowel Crohn's disease (CD), small bowel neoplasms and other mucosal disorders. Recent studies underscored the utility of VCE for documenting the extent and severity of small bowel CD as well as monitoring activity after therapy. The accuracy of the discrimination between small bowel tumours and benign bulges has been improved by a novel endoscopic algorithm. The accuracy of VCE was also evaluated as a potential noninvasive alternative to small bowel biopsies in suspected celiac disease. New findings have been made using breath tests and other biomarkers for the diagnosis of celiac disease, irritable bowel syndrome and bacterial overgrowth. VCE as well as breath-test biomarkers play a major and expanding role in the diagnosis and monitoring of various small bowel disorders.

Predictors of double balloon endoscopy outcomes in the evaluation of gastrointestinal bleeding.

To identify patients' characteristics associated with double balloon endoscopy (DBE) outcomes in investigation of obscure gastrointestinal bleeding (OGIB). Retrospective study performed at an academic tertiary referral center. Evaluated endpoints were clinical factors associated with no diagnostic yield or non-therapeutic intervention of DBE performed for OGIB evaluation. We included fifty-five DBE between August 2010 and April 2012. The mean age of the sample was 67 with 32 males (58.2%). Twenty-four DBE had no diagnostic yield and 30 DBE did not require therapy. Non-diagnostic yield was associated with performing two or more DBE studies in one day [odds ratio (OR): 13.72, P = 0.008], absence of blood transfusions within a year of the DBE (OR: 7.16, P = 0.03) and absence of ulcers or arteriovenous malformations (AVMs) on prior esophagogastroduodenoscopy (EGD) or colonoscopy (OR: 19.30, P = 0.033). Non-therapeutic DBE was associated with performing two or more DBE per day (OR: 18.579, P = 0.007), gastrointestinal bleeding episode within a week of the DBE (OR: 11.48, P = 0.003), fewer blood transfusion requirements prior to DBE (OR: 4.55, P = 0.036) and absence of ulcers or AVMs on prior EGD or colonoscopy (OR: 8.47, P = 0.027). Predictors of DBE yield and therapeutic intervention on DBE include blood transfusion requirements, previous endoscopic findings and possibly endoscopist fatigue.

Sa1630 Factors Predicting the Presence of Small Bowel Lesions in Patients With Obscure Gastrointestinal Bleeding

Capsule endoscopy (CE) is established as the first examination for the investigation of Obscure gastrointestinal bleeding (OGIB). However, clinical characteristics including comorbidity and meditation use that are relevant to the diagnostic yield of CE in patients with OGIB have been rarely reported. In addition, these reports did not consider type of OGIB (overt or occult). Therefore we conducted this study to define the predictive factors for the presence of small bowel lesions (vascular and erosive/ulcerated lesions) in patients with overt and occult OGIB.

A case of malignant lymphoma diagnosed by capsule endoscopy

Recently, capsule endoscopy has evolved as a non-invasive method for examining obscure gastro-intestinal bleeding (OGIB) in the gastrointestinal tract. Herein we report a case of malignant lymphoma which was diagnosed by capsule endoscopy.A 68-year-old man with atrial fibrillation felt dizzy and was diagnosed with anemia (Hb 8.2g/dl). Gastrointestinal bleeding was detected by fecal occult blood test, and the patient was referred to the department of gastroenterology. Upper endoscopy and colonoscopy were unable to identify the source of the bleeding. To further investigate the OGIB, the capsule endoscopy test was selected, showing a type 2 tumor at the distal ileum. Single-balloon enteroscopy showed a near-circumferential tumor and stenosis. The histological findings of the tumor with single balloon enteroscopy contained only lymphoid cell lines, hence the tumor could not be diagnosed as malignant lymphoma. A partial ileal resection of the tumor was performed. Histological diagnosis of the resected lesion was diffuse large B-cell lymphoma.It is reported that between 2 and 9％ of small intestinal tumors are diagnosed by capsule endoscopy during investigation of OGIB. We conclude that capsule endoscopy may be useful for the diagnosis of OGIB potentially leading to the discovery of malignant lymphomas.

Differences in the severity of small bowel mucosal injury based on the type of aspirin as evaluated by capsule endoscopy

BackgroundThe differences in the small intestinal toxicity of low-dose aspirin based on the type of aspirin used remains unclear. The purpose of this study was to evaluate the differences in the small bowel mucosal injury between buffered and enteric-coated aspirin users by capsule endoscopy. MethodsWe retrospectively reviewed the findings in chronic low-dose aspirin users (>3months) who underwent capsule endoscopy for the investigation of obscure gastrointestinal bleeding. The patients were classified into two groups based on the type of low-dose aspirin that they had been prescribed (enteric-coated aspirin group or buffered aspirin group), and evaluated the numbers of small bowel lesions and the Lewis score. ResultsCapsule-endoscopic findings of a total of 70 patients taking low-dose aspirin were reviewed. Significant differences in the number of erosions and ulcers were observed between the buffered and enteric-coated aspirin groups (P=0.017 and P=0.037, respectively). The median Lewis score for the small bowel mucosal inflammatory change was significantly higher in the enteric-coated aspirin group than in the buffered aspirin group (P=0.035). ConclusionsThe results of this study suggested that enteric-coated aspirin might be more injurious to the small bowel mucosa than buffered aspirin.

PTU-144 Small-bowel capsule endoscopy for iron deficiency anaemia alone; experience from a tertiary centre

IntroductionSmall-Bowel Capsule Endoscopy (SBCE) is a useful diagnostic modality in the investigation of Obscure Gastrointestinal Bleeding (OGIB). Its role though in Iron Deficiency Anaemia (IDA) is less clear.AimTo assess the...

Review article: the diagnosis and investigation of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is a commonly encountered clinical problem in gastroenterology and is associated with significant morbidity and mortality. The investigation and management of OGIB has changed dramatically over the past decade with the advent of newer gastroenterological and radiological technologies. To review the current evidence on the diagnosis and investigation of OGIB. We searched the PubMed database (1985-2010) for full original articles in English-language journals relevant to the investigation of OGIB. The search terms we used were 'gastrointestinal bleeding' or 'gastrointestinal hemorrhage' or 'small bowel bleeding' each in combination with 'obscure', or 'capsule endoscopy', or 'enteroscopy' or 'enterography' or 'enteroclysis'. Capsule endoscopy (CE) or double balloon enteroscopy (DBE) should be first line investigations. They are complimentary procedures with comparable high diagnostic yields. DBE is also able to provide therapeutic intervention. Newer technologies such as single balloon and spiral enteroscopy are currently being evaluated. Radiological and nuclear medicine investigations, such as CT enterography and CT enteroclysis, are alternative diagnostic tools when CE or DBE are contraindicated. Repeating the gastroscopy and/or colonoscopy may be considered in selective situations. An algorithm for investigation of obscure bleeding is proposed. The development of capsule endoscopy and double balloon enteroscopy has transformed the approach to the evaluation and management of obscure gastrointestinal bleeding over the past decade. Older diagnostic modalities still play a complementary, but increasingly selective role.

Are repeat upper gastrointestinal endoscopy and colonoscopy necessary within six months of capsule endoscopy in patients with obscure gastrointestinal bleeding?

Medicare reimbursement for capsule endoscopy for the investigation of obscure gastrointestinal bleeding in Australia requires endoscopy and colonoscopy to have been performed within 6 months. This study aims to determine the diagnostic yield of repeating these procedures when they had been non-diagnostic more than 6 months earlier. Of 198 consecutive patients who were referred for the investigation of obscure gastrointestinal bleeding, 50 underwent repeat endoscopy and colonoscopy solely to enable reimbursement (35 females and 15 males; mean age 59.4 [range: 21-82] years). The average duration of obscure bleeding was 50.16 (range: 9-214) months. The mean number of prior endoscopies was 3 (median: 2) and 2.8 colonoscopies (median: 2). The most recent endoscopy had been performed 18.9 (median: 14; range: 7-56) months, and for colonoscopy, 19.1 (median 14; range 8-51) months earlier. A probable cause of bleeding was found at endoscopy in two patients: gastric antral vascular ectasia (1) and benign gastric ulcer (1). Colonoscopy did not reveal a source of bleeding in any patient. Capsule endoscopy was performed in 47 patients. Twenty four (51%) had a probable bleeding source identified, and another five (11%) a possible source. These included angioectasia (17 patients), mass lesion (2), non-steroidal anti-inflammatory drug enteropathy (2), Cameron's erosions (2), and Crohn's disease (1). Four patients undergoing repeat capsule endoscopy had a probable bleeding source detected. The yield of repeat endoscopy and colonoscopy immediately prior to capsule endoscopy is low when these procedures have previously been non-diagnostic. Such an approach is also not cost-effective.

Capsule endoscopy in the evaluation of gastrointestinal disease

The small bowel has been a technically difficult area to examine. Indirect modalities such as barium follow-through have the disadvantage of attendant radiation exposure. Capsule endoscopy, a novel wireless method of investigation of the small bowel, has acquired an important role in both adult and paediatric medicine. The clinical utility of capsule endoscopy has rapidly expanded since its approval by the Food & Drug Administration in the USA in 2001. It has developed an established role in adults, in the investigation of obscure gastrointestinal bleeding, small bowel Crohn's disease, complications of coeliac disease and surveillance of polyposis syndromes. Despite a lag in its use in paediatrics, capsule endoscopy offers an accurate and effective means of investigating the small bowel in children. It has opened up new horizons and permitted a noninvasive approach to identifying occult lesions in the small bowel of children when conventional imaging has been unhelpful. This review appraises the current literature to define the clinical indications and practical aspects of capsule endoscopy that are of interest to the paediatrician.

Capsule Endoscopy Retention: Is it a Complication?

Capsule endoscopy has been found superior to barium x-rays and push enteroscopy in the investigation of obscure gastrointestinal bleeding and in the evaluation of suspected Crohn's disease. Currently, small bowel obstruction and strictures are considered by many physicians to be a contraindication to capsule endoscopy for fear of capsule retention or impaction. The goal of this study was to reassess this conventional wisdom that capsule endoscopy is contraindicated in small bowel obstruction and to determine the safety and efficacy of capsule endoscopy in the evaluation of patients with suspected stricture or small bowel obstruction. A retrospective chart review was performed using a database of 568 capsule endoscopy cases performed between August 2001 and November 2003. Cases of suspected small bowel obstruction were selected and reviewed. Nineteen cases were identified in which capsule endoscopy was used in the setting of suspected small bowel obstruction. The diagnosis of suspected small bowel obstruction was based on symptoms alone in 8 cases and on symptoms plus abnormal radiographs in the remaining 11 cases. Capsule endoscopy made a definitive diagnosis in 5 of the 19 cases (26%): 2 Crohn's strictures, 1 radiation induced stricture, 1 nonsteroidal anti-inflammatory drug induced stricture, and 1 MALT lymphoma. The capsule was retained proximal to a stricture in 4 cases, in which the obstructing lesions were electively resected without complications. There was no case in which administration of the capsule led to an acute small bowel obstruction. Capsule endoscopy can be safely used to help identify the etiology and site of a small bowel obstruction. Retention of the capsule may indicate the presence of a lesion requiring surgery, but small bowel obstruction or strictures are not in themselves contraindications to the procedure. It is understood, however, that retention may lead to surgery in a patient who otherwise may have been treated medically without surgery for the same illness (eg, Crohn's disease and nonsteroidal anti-inflammatory drug enteropathy).

The Effect of Patient Positioning on Complete Small Bowel Examination Rates with Wireless Capsule Endoscopy

Purpose: To evaluate (1) the effect on the gastric emptying time(GET), (2) the proportion of complete SI studies and (3) the diagnostic yield of WCE in patients placed in the right lateral position (RLP) compared with the standing/sitting position post CE ingestion (SSP). Methods: 67 consecutive studies in patients undergoing WCE for investigation of Obscure Gastrointestinal Bleeding (OGIB) from 9/03 – 9/04 were analyzed retrospectively. 9 patients were excluded, 5 (endoscopic placement of the CE), 3 (h/o gastric surgery), 1 (gastroparesis). Patients remained in the RLP or in the sitting/standing position for 30 mins post CE ingestion. Major findings were defined as ulcers, AVMs, strictures, and active bleeding. Results: The 58 remaining studies (31 men, 27 women, age range 16–80), included 35 patients from the RLP group and 23 from the SSP group. The mean GET (time from the first image of the stomach to the first image of the duodenum) in the RLP grp was 27 mins compared with 52 mins in the SSP grp(P < 0.05). The mean small intestinal emptying time was similar in both groups, RLP 207 mins and SSP 203 mins. Major findings were reported in 57% of the RLP grp and 43% of the SSP grp(NS). Stricturing of the SI precluding passage of the CE occurred in 4 cases and 1 case in the RLP and SSP grps respectively. 2 battery failures occurred in the SSP. Otherwise incomplete examinations of the SI were reported in 6% of the RLP grp and 9% of the SPP grp(NS). Conclusions: Positioning patients to the RLP facilitated passage of the CE into the SI without need for promotility agents and should be considered an initial option in the clinical setting. Although there was a numerical trend toward increased diagnostic yield and complete examations of the SI in the RLP grp these were not significant.

Video Capsule Endoscopy for Investigation of Obscure Gastrointestinal Bleeding: Feasibility, Results, and Interobserver Agreement

The aim of the study was to assess the feasibility, diagnostic yield, and interobserver agreement of capsule endoscopy in the investigation of patients with obscure or occult gastrointestinal bleeding. A total of 64 consecutive patients with occult bleeding (31 %) or overt bleeding (69 %) were assessed using capsule endoscopy after negative upper and lower endoscopy and small-bowel radiology. The quality of visualization of the small-bowel mucosa was scored from 1 (poor) to 4 (excellent). Thirty video capsule recordings with normal or abnormal findings were blindly assessed by four independent endoscopists. Interobserver agreement was evaluated using the kappa index. The small bowel was completely visualized in 57/64 patients (89 %). Incomplete small-bowel transit was most commonly due to prolonged gastric retention (five patients). The mucosa visualization scores (means) for the proximal, middle, and distal thirds of the small bowel were 3.7, 3.3, and 2.2 respectively. Visualization of the distal ileum was good (> or = 3) in 38 % and a bleeding site was found in 45 % of patients. Push-enteroscopy was also performed in 56 patients. The results of the two techniques were similar in 37 patients, capsule endoscopy was superior in 12 patients, and push-enteroscopy was superior in seven patients. Interobserver agreement was good for bleeding and for angiodysplasia, but poor for ulcers and tumors. Mean interobserver agreement was better among experienced endoscopists than among junior endoscopists. Capsule endoscopy allowed the whole small intestine to be explored in 89 % of patients, with good visualization of the mucosa, except distally. Interobserver agreement was better among the experienced endoscopists and was better for red-colored abnormalities (bleeding and angiodysplasia) than for ulcers and tumors.