Negative Bidirectional Endoscopy Research Articles

AI-assisted capsule endoscopy reading in suspected small bowel bleeding: a multicentre prospective study

Capsule endoscopy reading is time consuming, and readers are required to maintain attention so as not to miss significant findings. Deep convolutional neural networks can recognise relevant findings, possibly exceeding human performances and reducing the reading time of capsule endoscopy. Our primary aim was to assess the non-inferiority of artificial intelligence (AI)-assisted reading versus standard reading for potentially small bowel bleeding lesions (high P2, moderate P1; Saurin classification) at per-patient analysis. The mean reading time in both reading modalities was evaluated among the secondary endpoints. Patients aged 18 years or older with suspected small bowel bleeding (with anaemia with or without melena or haematochezia, and negative bidirectional endoscopy) were prospectively enrolled at 14 European centres. Patients underwent small bowel capsule endoscopy with the Navicam SB system (Ankon, China), which is provided with a deep neural network-based AI system (ProScan) for automatic detection of lesions. Initial reading was performed in standard reading mode. Second blinded reading was performed with AI assistance (the AI operated a first-automated reading, and only AI-selected images were assessed by human readers). The primary endpoint was to assess the non-inferiority of AI-assisted reading versus standard reading in the detection (diagnostic yield) of potentially small bowel bleeding P1 and P2 lesions in a per-patient analysis. This study is registered with ClinicalTrials.gov, NCT04821349. From Feb 17, 2021 to Dec 29, 2021, 137 patients were prospectively enrolled. 133 patients were included in the final analysis (73 [55%] female, mean age 66·5 years [SD 14·4]; 112 [84%] completed capsule endoscopy). At per-patient analysis, the diagnostic yield of P1 and P2 lesions in AI-assisted reading (98 [73·7%] of 133 lesions) was non-inferior (p<0·0001) and superior (p=0·0213) to standard reading (82 [62·4%] of 133; 95% CI 3·6-19·0). Mean small bowel reading time was 33·7 min (SD 22·9) in standard reading and 3·8 min (3·3) in AI-assisted reading (p<0·0001). AI-assisted reading might provide more accurate and faster detection of clinically relevant small bowel bleeding lesions than standard reading. ANKON Technologies, China and AnX Robotica, USA provided the NaviCam SB system.

S3438 Malignant Gastrointestinal Neuroectodermal Tumor of the Small Intestine: A Rare Cause of Iron Deficiency Anemia

Introduction: Gastrointestinal neuroectodermal tumors (GNET) are a type of high-grade sarcoma of the gastrointestinal (GI) tract that share features with clear cell carcinoma of tendon sheaths and aponeuroses. Patients typically present with clinical signs and symptoms of small bowel obstruction, intussusception or abdominal mass. These tumors can arise in the stomach, colon, as well as metastasis to liver or regional lymph nodes. We present a case of ileal GNET in an otherwise asymptomatic patient with Iron-deficiency Anemia (IDA) diagnosed using video capsule endoscopy (VCE). Case Description/Methods: A 58-year-old Hispanic male with a past medical history of GERD and obesity presented for evaluation of chronic microcytic anemia. Workup revealed: hemoglobin 8.6 g/dl, MCV 62.2, iron saturation 2.6%, transferrin 307 mg/dl, ferritin < 5 ng/ml, reticulocyte index of 1.34; serum folate, vitamin B12 and TSH levels were within normal limits. He was taking oral ferrous sulfate and vitamin C for IDA. He reported heartburn but denied melena, hematochezia, hematemesis, weight loss and had an unremarkable colonoscopy four years prior. Upper endoscopy revealed mild erosive esophagitis and mild chronic active gastritis with negative biopsies. Colonoscopy was unremarkable in the setting of optimal bowel preparation. VCE revealed an ulcerated mass occupying 35% of the ileal lumen. CT of the abdomen noted asymmetric wall thickening with enhancement of the small bowel. The patient underwent laparoscopy-assisted enteroscopy with rendezvous technique allowing direct visualization of a 3 cm proximal ileum mass requiring open segmental resection with primary anastomosis. Pathology suggested malignant GNET or clear cell sarcoma-like tumor of the GI tract. Immunohistochemistry was positive for neural crest markers (S100, SOX10) and Vimentin; negative for CD117, DOG1, HMB45, MART1, MAA, chromogranin, and synaptophysin. Fluorescence in-situ hybridization was positive for EWSR1 (22q12) rearrangement. Given the clear surgical margins, absent regional lymph node spread and lack of standard guidelines for this rare pT1N0M0 tumor, surveillance imaging every three months without adjuvant radiation or systemic chemotherapy was recommended. (Figure) Discussion: This case highlights the importance of VCE for small bowel assessment after negative bidirectional endoscopy to identify the etiology of IDA per American Gastroenterology Association guidelines. In this case, an ulcerated GNET was the etiology of IDA persisting despite iron supplementation.Figure 1.: A-Luminal view of small bowel tumor on Video Capsule Endoscopy (VCE) B–Close up view of ulceration of small bowel tumor on VCE C–Histopathology slide showing epithelioid cells with eosinophilic cytoplasm, pleomorphic nuclei with prominent nucleoli and vesicular nucleoli. Scattered mitotic figures identified.

Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia.

Small bowel malignancies are rare and usually asymptomatic or symptoms are nonspecific. Therefore, small bowel tumors are difficult to diagnose. In patients with iron deficiency anemia (IDA) who have negative bidirectional endoscopy results, the small bowel may be considered the source of bleeding. However, in asymptomatic IDA patients with negative bidirectional endoscopy results, evidence supporting the routine use of capsule endoscopy (CE) is insufficient. CE can be considered in selected patients with recurrent or persistent IDA. The frequency of small bowel malignancies is low in patients undergoing CE for IDA, but the usefulness of CE for the diagnosis of small bowel malignancies in younger age groups with IDA has been reported. For patients with risk factors for small bowel malignancy, investigation of the small bowel should be considered. Efforts should be made to prevent adverse events, such as capsule retention or capsule aspiration, through meticulous history taking and endoscopic capsule delivery as necessary.

604 Outcomes of Long-Term Follow-Up in Patients With Iron Deficiency Anemia and Initial Negative Upper Endoscopy, Colonoscopy, and Video Capsule Endoscopy

INTRODUCTION: Iron Deficiency Anemia (IDA) occurs in 2-5% of adults and requires workup including upper esophagogastroduodenoscopy (EGD) and/or colonoscopy.1 However, in 10-41% of patients a source of bleeding is not identified,2–5 which requires investigation of the small bowel using video capsule endoscopy (VCE). This study aims to determine the long-term outcomes in patients with IDA and a pan endoscopy-negative IDA, which entails negative EGD, colonoscopy and VCE. METHODS: Medical records at the VA NY Harbor were queried for patients with IDA and having an EGD, colonoscopy, and VCE between 2005-2015. Anemia was defined as hemoglobin less than 13 g/dL in men and 12 g/dL in women; IDA was confirmed using serum ferritin less than 100 ng/mL. Exclusion criteria included underlying causes for IDA such as pre-menopausal women or history of ulcerative colitis. Biographical, laboratory and endoscopic data were obtained. Baseline hemoglobin and ferritin levels were recorded, and subsequently followed at 1, 3, and 6-year intervals. RESULTS: A total of 7,000 records were reviewed, 311 patients had EGD, colonoscopy and VCE; 67 of these patients were excluded. Of the remaining patients, 99 patients (13 females, 86 males) had a negative initial workup and were included in analysis. The mean age was 68.2 (±11.1). IDA resolved in 37 (37.4%) patients, 49 (49.5%) patients had persistent anemia, and 13 (13.1%) patients had recurrent anemia. Of the 99 patients with negative workup, 80 (80.8%) patients went on to have subsequent EGD, colonoscopy or VCE. 62 (62.6%) patients had subsequent EGD with 12 (19.4%) patients having positive findings such as gastric ulcers. 64 (64.7%) patients had subsequent colonoscopies, 7 (10.9%) of these patients had positive findings such as chronically bleeding hemorrhoids. 18 (18.2%) patients had subsequent VCEs, and 5 (27.8%) of these patients had findings such as angioectasias. CONCLUSION: Our findings are consistent with previous reports suggesting that the majority of elderly patients who have an initial negative workup for IDA tend to have favorable outcomes. 21 of 80 patients (26.25%) had some findings on subsequent workup to explain IDA, however those findings were benign. In addition to previous published data, our study highlights the significance of VCE as a tool for identifying a bleeding source. Our study also emphasizes the need for randomized control studies to determine the optimal workup strategy for patients with initially negative bidirectional endoscopy and VCE.

Benefit of Capsule Endoscopy in the Setting of Iron Deficiency Anemia in Patients Above Age 65.

BackgroundIron deficiency anemia (IDA) is a common indication for a capsule endoscopy (CE), which is often offered after a negative bidirectional endoscopy. Since malignancy is a concern in the older population with IDA, upper and lower endoscopic exams are typically performed. If these tests are negative, CE may be offered to evaluate the small intestine. However, choosing the ideal candidates who are most likely to benefit from a CE study is challenging.AimsThe goal of this study was to assess the outcomes for CE in patients with IDA over age 65 and assess which factors are more likely to contribute to a positive CE yield.MethodsA retrospective review of all CE studies at St. Paul’s Hospital from January 2010 to June 2016 was conducted after ethics approval. Inclusion criteria included the following: age >65, hemoglobin <120 g/L, serum ferritin <70 μg/L, and at least one high-quality complete EGD/colonoscopy performed before CE. Variables to assess factors that are more likely to contribute to a positive capsule yield included use of anticoagulation medications, NSAIDs, PPIs, transfusion burden and cardiac disease. A Chi-Square test was then used to determine clinical predictive factors of a positive and negative study.ResultsThere were 1149 CE studies that were reviewed, of which 130 CE studies met inclusion criteria. Fifty-one studies (40.6%) had positive findings, and from this group, 30 (58.8%) recommended active intervention (i.e., EGD, n = 8; colonoscopy, n = 12; push enteroscopy, n = 3; double-balloon [DB] enteroscopy, n = 2; small bowel resection, n = 3; escalation of Crohn’s therapy, n = 2), while 21 (41.2%) were managed supportively, typically with iron supplementation. Most negative studies (73 of 79) recommended supportive therapy (other recommendations included hematological workup, n = 3; hiatal hernia repair, n = 1; proton-pump inhibitors [PPI] initiation, n = 1; stop donating blood, n = 1).A history of cardiac disease had a significant association with positive findings (0.54 versus 0.33, P = 0.001). Conversely, a known history of low ferritin levels (0.84 versus 0.68, P = 0.046) and a known history of hiatal hernia (0.25 versus 0.08, P = 0.012) were associated with a negative study.ConclusionsThese findings suggest that the clinical yield of CE in IDA in patients above age 65 is relatively low. The majority of all CE studies recommended supportive therapy or repeat endoscopic exams (EGD/colonoscopy) of areas previously assessed and lesions missed. Provided that initial endoscopic exams were thorough and Crohn’s disease management was optimized, the overall rate of changing management significantly was low at five of 130 studies (two DB enteroscopies and three resections) or 3.8%. Clinical factors focusing on cardiac history, ferritin levels and the presence of a hiatal hernia may be of utility to predict benefit of CE. Emphasis on these data may help select more appropriate patients for capsule endoscopy.

Unsuspected Small-Bowel Crohn's Disease in Elderly Patients Diagnosed by Video Capsule Endoscopy.

Background Video capsule endoscopy (VCE) is increasingly performed among the elderly for obscure bleeding. Our aim was to report on the utility of VCE to uncover unsuspected Crohn's disease (CD) in elderly patients. Methods Retrospective review of VCE performed in elderly patients (≥70 y) at a tertiary hospital (2010–2015). All underwent prior negative bidirectional endoscopies. CD diagnosis was based on consistent endoscopic findings, exclusion of other causes, and a Lewis endoscopic score (LS) > 790 (moderate-to-severe inflammation). Those with lower LS (350–790) required histological confirmation. Known IBD cases were excluded. Results 197 VCE were performed (mean age 78; range 70–93). Main indications were iron deficiency anemia (IDA), occult GI bleeding (OGIB), chronic abdominal pain, or diarrhea. Eight (4.1%) were diagnosed as CD based on the aforementioned criteria. Fecal calprotectin (FCP) was elevated in 7/8 (mean 580 μg/g). Mean LS was 1824. Small-bowel CD detected by VCE led to a change in management in 4/8. One patient had capsule retention secondary to NSAID induced stricture, requiring surgical retrieval. Conclusions VCE can be safely performed in the elderly. A proportion of cases may have unsuspected small-bowel CD despite negative endoscopies. FCP was the best screening test. Diagnosis frequently changed management.

Capsule endoscopy in young patients with iron deficiency anaemia and negative bidirectional gastrointestinal endoscopy.

Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology. This was a retrospective, multicentre study (2010-2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age <19 or >50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression. Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn's disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3-11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92-0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn. In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.

PTU-011 Small Bowel Malignancy in Patients Undergoing Capsule Endoscopy in A Tertiary Care Academic Institution

Introduction Cancer of the small-bowel (SB) is rare accounting for Methods Retrospective study; the records of all patients who underwent SBCE at our centre from Mar 2005 – Oct 2015 were reviewed; we retrieved those whose CEs were reported as suggestive of neoplasia. Further data was gathered on preceding and subsequent investigations, management and outcome of these patients. Results From a total of 1949 CE studies (1082 PillCamTM/867 MiroCamTM), SB neoplasia was diagnosed in 7 patients (0.36%; 2 F/5 M; median age 50, range 34–67). Two had lymphoma, 2 gastrointestinal stromal tumours (GIST), 2 duodenal adenocarcinomas, 1 jejunal metastasis from a sarcomatoid lung tumour. In these patients, CE was performed for: iron-deficiency anaemia (IDA) (n = 5), diarrhoea (n = 1) & suspicion of SB lymphoma (n = 1). 6/7 patients had prior negative bidirectional GI endoscopies; 1 had a normal gastroscopy. Prior to CE, two patients had abdominal USS, 4 had CT scan, 2 had SB follow-through and 1 had a bone marrow aspirate. Two patients had capsule retention; one was removed with a gastroscope, the other with push enteroscopy. All 7 patients had further investigations after CE. Six had a chest, abdomen & pelvis CT scan for staging. Two patients had push enteroscopy, both of whom were diagnosed with duodenal adenocarcinoma. One had double balloon enteroscopy (DBE), two had colonoscopy, two had UGIE; there was one abdominal USS and one bone marrow aspirate. Four pts underwent SB resection. Following resection, 1 patient with GIST had imatinib chemotherapy. Of the two individuals with duodenal adenocarcinoma, one underwent gastroenterostomy and the other had an elective Whipple procedure. Four patients passed away. Two remain under follow up with oncology and one with the GI team. Conclusion SB cancers are rare and our experience is in agreement with other studies. The median age of 50 indicates that SB malignancy is more common in relatively younger patients. Unexplained iron deficiency anaemia was the main presenting complaint in our patients which triggered further investigation despite negative bidirectional endoscopies. CE is effective in picking up SB neoplasia where other imaging modalities have failed. References 1 Schottenfeld D, Beebe-Dimmer JL, Vigneau FD. The epidemiology and pathogenesis of neoplasia in the small intestine. Ann Epidemiol 2009;19:58–69. 2 Pennazio M, Rondonotti E, de Franchis R. Capsule endoscopy in neoplastic diseases. World J Gastroenterol 2008;14:5245–53. 3 Pennazio M, Spada C, Eliakim R, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2015;47:352–86. 4 Rondonotti E, Pennazio M, Toth E, et al. Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study. Endoscopy 2008;40:488–95. Disclosure of Interest C. Johnston: None Declared, D. Yung: None Declared, A. Koulaouzidis Grant/research support from: ESGE- Given®Imaging Research grant 2011, J. Plevris: None Declared

Efficacy and implications of a 48-h cutoff for video capsule endoscopy application in overt obscure gastrointestinal bleeding.

Background and study aims: Early video capsule endoscopy (VCE) may provide a high diagnostic yield and improve clinical outcomes in patients with overt obscure gastrointestinal bleeding (OGIB); however, there is no practical recommendation for the ideal timing of VCE application in overt OGIB. Therefore, this study investigated the diagnostic yield and efficacy of VCE to assess overt OGIB with respect to the timing of application. Patients and methods: We retrospectively enrolled patients who had undergone VCE for overt OGIB between April 2004 and February 2014 at a tertiary referral academic center. We included hemodynamically stable patients who underwent VCE for overt OGIB after negative bidirectional endoscopy. We analyzed the diagnostic yield of VCE, therapeutic intervention rate, and length of hospital stay. Results: A total of 94 patients underwent VCE to assess overt OGIB. The diagnostic yields in the groups that underwent VCE < 48 h and > 48 h from the last overt OGIB were 66.7 % and 40.6 %, respectively (P = 0.019). Therapeutic intervention was performed in 26.7 % and 9.4 % of patients in the < 48-h and > 48-h groups, respectively (P = 0.028). The mean lengths of hospital stay in the < 48-h and > 48-h groups were 5 days (95 % confidence interval [CI], 4.8 – 7.7) and 7 days (95 %CI, 6.9 – 10.1), respectively (P = 0.039). Conclusions: Performing VCE within 2 days from the last overt OGIB results in a higher diagnostic yield, higher therapeutic intervention rate, and shorter hospital stay. Therefore, VCE application with a 48-h cutoff could improve the outcome of patients with overt OGIB.

The Utility of Capsule Endoscopy in Patients under 50 Years of Age with Recurrent Iron Deficiency Anaemia: Is the Juice Worth the Squeeze?

Background and Aims. The role of capsule endoscopy (CE) in the <50 years of age patients with iron deficiency anaemia (IDA) remains unclear. We aim to assess its utility in this cohort. Methods. All patients referred for CE for recurrent IDA were included retrospectively. Patients were divided into Group 1 (<50 years) and Group 2 (≥50 years). Results. There were 971 patients with recurrent IDA and 28% belonged to Group 1. The mean age was 40 years in this group with a DY of 28% (n = 76). Significant diagnoses included erosions and ulcers (26%; n = 71), small bowel (SB) angioectasia (AE) (10%; n = 27), SB tumours (3%; n = 7), Crohn's disease (3%; n = 7), SB bowel strictures (1%; n = 3), and SB varices (1%; n = 2). On logistic regression, the presence of diabetes (P = 0.02) and the use of warfarin (P = 0.049) was associated with increased DY. The DY in Group 2 was 38% which was significantly higher than in Group 1 (P = 0.02). While SB tumours were equally common in both groups, AE was commoner in Group 2 (P < 0.001). Conclusion. A significant proportion of patients <50 years are referred for CE. Although the DY is lower compared to those ≥50 years, significant pathology is found in this age group. CE is advisable in patients <50 years old with recurrent IDA and negative bidirectional endoscopies.

The role of capsule endoscopy in the evaluation and treatment of obscure-overt gastrointestinal bleeding during daily clinical practice: a prospective multicenter study

Objective. Capsule endoscopy (CE) is most commonly performed to evaluate obscure gastrointestinal bleeding (GIB). However, at present the role of CE in patients with obscure-overt GIB especially during daily clinical practice is unknown. The aim of the present study was to investigate the diagnostic yield and the impact of CE on the management of patients with obscure-overt GIB. Material and methods. Between January 2007 and December 2011 we prospectively included all patients with obscure-overt GIB who underwent CE after negative bidirectional endoscopy. CE findings revealing the cause of bleeding, type of therapeutic intervention and clinical variables associated with positive CE and recurrence of GIB were evaluated. Results. One hundred and eighteen patients with a median age of 66 years (range 8–89 years) were enrolled in the final analysis. The overall diagnostic yield of the CE was 66.9%. The most common findings were angiodysplasias (33.1%), followed by ulcer (23.7%), and tumors (6.8%). Age (p = 0.001) and cardiovascular disease (p = 0.007) were significant clinical variables predicting the higher incidence of angiodysplasias. Specific therapeutic interventions were undertaken in 54 patients with positive CE (68.4%). Recurrence of GIB was observed in one patient with negative CE (2.6%) and 16 patients with positive CE (20.3%). Univariate and multivariate analysis showed high age and no therapeutic intervention as significant factors associated with recurrent bleeding. Conclusions. CE represents a promising diagnostic method in the investigation of obscure-overt GIB, with significant impact on its clinical management in daily clinical practice.

Evaluation and outcomes of patients with obscure gastrointestinal bleeding.

Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding or presence of iron deficiency anaemia after evaluation with a negative bidirectional endoscopy. OGIB accounts for 5% of gastrointestinal bleeding and presents a diagnostic challenge. Current modalities available for the investigation of OGIB include capsule endoscopy, balloon assisted enteroscopy, spiral enteroscopy and computed tomography enterography. These modalities overcome the limitations of previous techniques. Following a negative bidirectional endoscopy, capsule endoscopy and double balloon enteroscopy remain the cornerstone of investigation in OGIB given their high diagnostic yield. Long-term outcome data in patients with OGIB is limited, but is most promising for capsule endoscopy. This article reviews the current literature and provides an overview of the clinical evaluation of patients with OGIB, available diagnostic and therapeutic modalities and long-term clinical outcomes.

PTH-040 What is the Utility of Capsule Endoscopy in Patients with Obscure Gastrointestinal Bleeding and Chronic Renal Failure?

IntroductionAnaemia is a common complication of chronic renal failure (CRF). The cause of the anaemia is often multifactorial including erythropoietin deficiency, uraemic platelet dysfunction, absolute iron deficiency anaemia (IDA) and...

PWE-203 Capsule endoscopy: a district general hospital experience in a multiethnic community

IntroductionCapsule endoscopy (CE) is a useful tool to assess the small bowel (SB). The 2008 British Society of Gastroenterology (BSG) guidelines detailed the use of CE in occult gastrointestinal bleeding...

Small Bowel Evaluation in Asymptomatic Fecal Immunochemical Test-Positive Patients with a Negative Colonoscopy: Is It Necessary?

Screening for colorectal cancer (CRC) and its precursors by fecal occult blood test (FOBT) is widely recommended and is being applied more than ever [1–3]. Although annual or biennial guaiac fecal occult blood test (gFOBT) screening has been proved to reduce the mortality of CRC [4], the gFOBT has been faulted for its low sensitivity [5, 6]. More recently, the fecal immunochemical test (FIT) has been introduced as an alternative to the gFOBT. The FIT is currently preferred over the gFOBT due to its higher sensitivity and improved detection rate for advanced neoplasia [5, 7–10]. Besides its diagnostic performance, the FIT has several advantages over the gFOBT including no need for dietary restriction, easier stool collection method, and automated analysis [11]. Furthermore, quantitative FIT allows for the adjustment of the cutoff value for an abnormal result based on population characteristics and available colonoscopy resources. Due to these characteristics, quantitative FIT is more favored as a screening tool than qualitative FIT [11]. The FIT selectively reacts with the globin moiety of human hemoglobin [12]. Because globin is rapidly degraded by proteases in the upper gastrointestinal (GI) tract, the FIT dose not detect small amounts of blood in the upper GI tract and selectively recognizes occult bleeding of colorectal origin [12]. With regard to small bowel lesions, although there is a possibility that some small bowel occult bleeding could be identified by FIT, no data are currently available regarding this issue. In the current issue of Digestive Diseases and Sciences, Chiba et al. [13] present the results of their prospective study on small bowel evaluation in asymptomatic FIT-positive subjects with a negative colonoscopy. In this, the first study to evaluate the small bowel with capsule endoscopy (CE) in asymptomatic FIT-positive patients with a negative colonoscopy, 53 asymptomatic patients with FIT-positivity and a negative total colonoscopy and esophagogastroduodenoscopy underwent CE. The CE findings were classified into three categories: P0, no abnormalities or findings without potential for bleeding; P1, findings with uncertain potential for bleeding; and P2, findings with high potential for bleeding. The cecal completion rate was 92.5%. There were no cases of P2, 19 cases of P1, and 34 cases of P0. Moreover, no abnormalities were identified in five patients who underwent additional diagnostic evaluations that were considered necessary based on the individual clinical results. No clinically significant small bowel lesions were found in the asymptomatic FIT-positive patients with negative bidirectional endoscopy. Although FIT has been widely accepted as a CRC screening tool, 40–60% of subjects with a positive FIT are found to have no lesions in their colon or rectum to explain their positive status [5, 14, 15]. How then do we explain the discrepancy between the results of FIT and colonoscopy? There are several possible explanations for this discrepancy. First, this may reflect true false-positive results of FIT for advanced neoplasia. Quantitative FIT results are subjected to predetermined cut-off values for fecal hemoglobin; this methodology could inevitably yield some true false positives. Additionally, medications that can increase the likelihood of GI bleeding may cause false-positive FIT J. J. Park Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, Seoul, Korea

Fecal calprotectin: A selection tool for small bowel capsule endoscopy in suspected IBD with prior negative bi-directional endoscopy

Background and aim. Fecal calprotectin (FC) is a non-invasive marker of gastrointestinal inflammation with advocated diagnostic precision in distinguishing inflammatory bowel disease (IBD) from non-IBD diagnoses. FC correlates with abnormalities seen on small bowel barium radiology, but little data exist in relation with small bowel capsule endoscopy (SBCE). To investigate the value of FC as a selection tool for further investigation of the small bowel with SBCE, in a cohort of patients who had negative bi-directional endoscopies, but with continuing clinical suspicion of Crohn's disease (CD). Methods. We retrospectively correlated the findings of SBCE with FC levels in patients referred with clinical suspicion of CD and negative bi-directional endoscopies. Only patients with FC results prior to the SBCE test were included; in cases of multiple FC determinations, the value closest to the SBCE date was selected. Medications history including usage of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) was made available for all patients. SBCE findings were analyzed against final diagnosis and FC values. Results. Seventy adult patients were studied (53 females, 17 males). Three cases were excluded, due to capsule retention in the stomach. Median time from FC measurement to SBCE was 62 days. Twenty-three patients had normal FC (≤50 μg/g) and in all those the SBCE was normal. Forty-four patients had FC >50 μg/g; in this group, nine patients had FC between 51 and 100 μg/g and all had a normal SBCE. Thirty-five patients had FC levels >100 μg/g; of those, 15 (42.85%) had SBCE findings compatible with CD and mean FC levels 326 μg/g (range 116–1430 μg/g). A definitive clinical diagnosis of CD, based on subsequent follow-up, was made in 10/35 (28.5%) of patients. These 10 patients were within the subgroup of 15 patients with positive SBCE findings and had median FC levels 368 μg/g (range 235–1430 μg/g). Conclusions. Measurement of FC levels prior to referral for SBCE is a useful tool to select patients with possible small bowel CD. A FC >100 μg/g is good predictor of positive SBCE findings, while FC >200 μg/g was associated with higher SBCE yield (65%) and confirmed CD in 50% of cases. Patients with FC between 50 and 100 μg/g had normal SBCE, despite symptoms suggestive of IBD. In all patients with clinical suspicion of CD and negative bi-directional endoscopies, FC assessment should be carried out prior to their referral for SBCE. Where FC is <100 μg/g (NPV 1.0), SBCE is not indicated.

Exploration d’une anémie ferriprive

Only one third of anemias diagnosed in patients older than 65 years are iron-deficiency anemias. In these iron-deficiency anemias after 65 years, bidirectional endoscopy diagnoses a cause in up to 90% of cases. In case of negative bidirectional endoscopy, capsule endoscopy is clearly the best approach. After a negative capsule, a new bidirectional endoscopy for the detection of previously missed lesions is the recommended option. In young women with anemia is much more often an iron-deficiency anemia. The causes of this anemia can be multiple: low iron-intake, gynaecologic, and finally digestive. A step-by-step approach is thus of utmost importance to avoid unjustified examinations. In case of digestive symptoms, an upper (or in rare cases lower) endoscopy can be justified, major diagnoses being Helicobacter Pylor gastritis and celiac disease. The clinical relevance of capsule endoscopy is poorly evaluated in this group of patients, and seems of minimal impact.

PTH-088 A faecal calprotectin level of &gt;100 μg/g in patients with negative bi-directional endoscopies is associated with high yield of pathology detection by capsule endoscopy

<h3>Introduction</h3> Faecal calprotectin (FC) is a non-invasive marker of gastrointestinal inflammation with diagnostic precision in distinguishing inflammatory bowel disease (IBD) from non-IBD diagnoses; the higher precision is reported at a cut-off level of 100 μg/g. FC correlates with abnormalities seen on radiology of the small bowel, but little data exist in relation with capsule Endoscopy (SBCE). <h3>Aims</h3> We aim to correlate the findings of SBCE with FC values in patients with clinical suspicion of Crohn9s disease and negative bi-directional endoscopies. <h3>Methods</h3> Patients who underwent SBCE due to suspicion of small bowel Crohn9s were identified from the Rapid database. FC status was established for all review patients. Only patients with FC measured any time prior to the SBCE were included in the final review; in cases of multiple FC measurements, the value closest to the SBCE date was selected. Patients with prior known Crohn9s or NSAIDs use were excluded. <h3>Results</h3> A total of 45 patients were identified (32 females and 13 males). Two were excluded from further analysis as the capsules were retained in the upper GI tract. The remaining 43 cases, exhibited one or more of the following indications: Abdominal pain: 34, Loss of weight: 7, Diarrhoea: 21, High inflammation indices: 8 and anaemia/blood loss: 7. 18 patients had normal FC and 25 abnormal FC results. All those with FC&lt;50 μg/g (normal reference range &lt;50) and 7 patients who had FC between 50 and 100 μg/g, had normal SBCE. 18 patients had a FC &gt;100 μg/g; of those 8 (44.5%) had findings suggestive of Crohn9s disease. The patients (n=8) with SBCE indicative of Crohn9s, had a mean FC levels of 367.12, range 115–1430 μg/g. <h3>Conclusion</h3> FC&gt;100 μg/g is a useful predictor of small bowel Crohn9s findings by SBCE. FC levels &lt;100 μg/g seem to have an excellent NPV. FC is a useful tool in prioritising patients with suspected Crohn9s and increases the diagnostic yield of SBCE.

PTH-074 Small bowel capsule endoscopy in the investigation of iron deficiency anaemia: referral patterns and clinical outcomes

Introduction Small Bowel capsule endoscopy (SBCE) is a useful diagnostic modality in the investigation of patients with Obscure Gastrointestinal bleed (OGIB)/Iron deficiency anaemia (IDA) when prior bi-directional endoscopies are negative. Methods We retrospectively analysed data from patients referred to our tertiary centre for investigation of unexplained IDA, after negative bidirectional endoscopies. We aimed to establish referral patterns and clinical outcomes following SBCE. Results Over a 5-year period (2004–2009), 133 patients (51 males, 82 females/mean age: 59.7) with unexplained IDA were referred to our service. Of those, 18 were referred from District General Hospitals (DGH) of South East Scotland, 106 from the Medical/Surgical Gastrointestinal (GI) service of our centre, 8 from the regional Haemophilia/Coagulation Medicine Centre (HCMC) and 1 from Renal medicine. One hundred and thirteen (n: 113/84.9%) patients were ≥40 years of age; in this group, small bowel angioectasias was the prevailing diagnosis (33/113, 29.2%), followed by Crohn9s (9/113, 7.9%), while portal hypertension GAVE/PHG (9/113, 7.9%) and undiagnosed caecal angiodysplasias (5/113, 4.42%) formed an appreciable group (12.3%). One case of coeliac and one of lymphoma were also diagnosed, together with three cases of NSAID9s-related enteropathy. SBCE was normal in 58 cases (51.3%). In the group of those Interestingly, the percentage of normal investigations was around 50%, irrespective of the source of referral (DGH 50%, HCMC 50%, and GI 51%). Small bowel angioectasias was the prevailing pathology irrespective of referral source (DGH 22%, HCMC 25%, GI 30.2%). Conclusion In our cohort (patients with prior negative bidirectional tests), small bowel angioectasias are the prevailing cause of unexplained IDA irrespective of referral source. The referral source does not seem to impact on the percentage of normal SBCE. A significant proportion of those ≥40 years (12.3%), had pathologies missed by endoscopies. We recommend repeating bi-directional endoscopies in this age group, while on the waiting list for SBCE.

Five years' experience with capsule endoscopy in a single center.

Capsule endoscopy (CE) is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding (OGIB) has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases. Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn's disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.