Small Bowel Video Capsule Endoscopy Research Articles

Fecal calprotectin diagnostic level gradient along the small bowel in patients with Crohn's disease.

Fecal calprotectin (FC) is known to be a sensitive biomarker of colonic inflammation but to a lesser degree of small bowel (SB) inflammation. Moreover, data on FC's diagnostic levels in different SB segments are scarce. We aimed to examine FC's diagnostic levels along the SB-axis in CD. This was a post-hoc aggregated analysis of five prospective studies of adult CD patients, who underwent FC testing and SB video capsule endoscopy (VCE). Lewis score (LS) inflammation in different SB segments was tested for correlation with FC level after exclusion of colonic disease. The diagnostic levels of FC for SB inflammatory topographical-gradient were assessed using a receiver operating characteristic. 214 patients were included (age:30 [24-43] year-old, males-57%). For a similar SB inflammatory-activity (LS≥135), FC levels incrementally increased from proximal to distal SB segments (63 [30-121] versus 190 [78-549], p=0.005) and from distal SB segment to the colon (190 [78-549] versus 542 [185-1000], p=0.010). The best FC cutoffs to identify isolated mild proximal/distal SB-inflammation (LS≥135) were 77μgg and 123μgg, respectively. A cutoff of 234μgg was best to detect more significant proximal inflammation (LS≥350) when only mild distal SB-inflammation was present. In sensitivity analyses, this proximal-to-distal FC gradient was maintained when LS≥350 and LS≥790 were used as the inflammatory reference-values. Unlike FC, the magnitude of CRP elevation was unrelated to the topography of inflammation along the SB-axis. FC may serve as a topographical biomarker of CD-activity, with its sensitivity to identify mucosal inflammation increases from proximal to distal SB segments.

Diagnostic Yield of Small Bowel Videocapsule Endoscopy in Patients with Iron Deficiency Anemia. A Systematic Review and meta-analysis.

Gastrointestinal (GI) bleeding or malabsorption represents the most frequent aetiologies of iron deficiency anemia (IDA). The cause of IDA remains undetermined in ~10% to 20% of patients undergoing upper and lower GI endoscopies. In this scenario, a small bowel examination with videocapsule endoscopy (VCE) is recommended. We performed a systematic review with meta-analysis to evaluate the diagnostic yield of VCE in patients with IDA without overt bleeding, assessing the prevalence of either any lesion or lesions at high potential of bleeding. A computerized literature search was performed using relevant keywords to identify all the pertinent articles published until March 2023. Twelve studies with a total of 1703 IDA patients (Males: 47%; age range: 19-92y) were included in this systematic review. The diagnostic yield of VCE for overall lesions in the small bowel was 61% (95% CI=44-77; 95 CI=97.2-98.1; I2=97.7%). When analyzing only small bowel lesions likely responsible of IDA, the diagnostic yield was 40% (95% CI=27-53; 95% CI=95.3-97; I2=96.3%). VCE plays a relevant role in the diagnostic work-up of patients with IDA without overt bleeding with a satisfactory diagnostic yield.

Use of Simethicone After Capsule Ingestion and Its Impact on the Quality of Small Bowel Video Capsule Endoscopy: A Pilot Study.

Background Small bowel capsule endoscopy is a tool to visualize the small bowel (SB) for conditions such as obscure bleeding. Various studies have been performed to compare various bowel preparation regimens in terms of small bowel transit time (SBTT), small bowel visualization quality (SBVQ), and diagnostic yield (DY). Literature suggests that using polyethylene glycol (PEG) prep is significantly better compared to clear liquid and overnight fast in terms of SBVQ and DY. Other investigators have tried to assess the efficacy of adding simethicone to the bowel preparation regimen which seems to improve SBVQ. However, no studies have been done to assess the results of simethicone ingestion after capsule swallowing. We intend to give patients simethicone one hour after capsule ingestion for two consecutive hours and compare results for SBVQ pre-and post-ingestion groups. The objective of this study is to compare the effect of simethicone on SBVQ in pre- andpost-capsule ingestion groups. Methodology This prospective, randomized controlled trial included patients who were scheduled for outpatient capsule endoscopy at Albany Medical Center (AMC) Endoscopy Suite. Patients were divided into the control group, group 1, and the treatment group (group 2). The control group followed the standard AMC pre-capsule protocol that included PEG238 g the evening prior. Group 1 included patients who received 3 mL of simethicone (20 mg/0.3 mL) 20 minutes prior to ingesting the capsule. The treatment group (group 2) included patients who ingested simethicone 3 mL 20 minutes prior to capsule swallowing, 3 mL after one hour, and 1.5 mL after another hour, totaling 7.5 mL of simethicone. Data regarding SBVQ for every patient were evaluated as an individual zone score from 1-3 points, each in proximal, middle, and distal SB based on the SBTT. A cumulative score of 3-9 was given after adding the three zones. These scores were derived using the Boston Bowel Preparation Scale. Data analysis was done using Microsoft Excel software. Results There were six patients in the control group, eight in group 1, and eight in the treatment group (group 2). Proximal, middle, and distal SB did not show any significant difference between their SBVQ scores. Moreover, the total combined score also showed no statistical difference in the SBVQ score. Conclusions There were no statistically significant differences in the SBVQ neither while looking at the cumulative score nor individual segmental score of the entire SB. However, this is only a pilot project with a small number of subjects and results may differ in future studies with increased power.

Machine learning based small bowel video capsule endoscopy analysis: Challenges and opportunities

Video capsule endoscopy (VCE) is a revolutionary technology for the early diagnosis of gastric disorders. However, owing to the high redundancy and subtle manifestation of anomalies among thousands of frames, the manual construal of VCE videos requires considerable patience, focus, and time. The automatic analysis of these videos using computational methods is a challenge as the capsule is untamed in motion and captures frames inaptly. Several machine learning (ML) methods, including recent deep convolutional neural networks approaches, have been adopted after evaluating their potential of improving the VCE analysis. However, the clinical impact of these methods is yet to be investigated. This survey aimed to highlight the gaps between existing ML-based research methodologies and clinically significant rules recently established by gastroenterologists based on VCE. A framework for interpreting raw frames into contextually relevant frame-level findings and subsequently merging these findings with meta-data to obtain a disease-level diagnosis was formulated. Frame-level findings can be more intelligible for discriminative learning when organized in a taxonomical hierarchy. The proposed taxonomical hierarchy, which is formulated based on pathological and visual similarities, may yield better classification metrics by setting inference classes at a higher level than training classes. Mapping from the frame level to the disease level was structured in the form of a graph based on clinical relevance inspired by the recent international consensus developed by domain experts. Furthermore, existing methods for VCE summarization, classification, segmentation, detection, and localization were critically evaluated and compared based on aspects deemed significant by clinicians. Numerous studies pertain to single anomaly detection instead of a pragmatic approach in a clinical setting. The challenges and opportunities associated with VCE analysis were delineated. A focus on maximizing the discriminative power of features corresponding to various subtle lesions and anomalies may help cope with the diverse and mimicking nature of different VCE frames. Large multicenter datasets must be created to cope with data sparsity, bias, and class imbalance. Explainability, reliability, traceability, and transparency are important for an ML-based diagnostics system in a VCE. Existing ethical and legal bindings narrow the scope of possibilities where ML can potentially be leveraged in healthcare. Despite these limitations, ML based video capsule endoscopy will revolutionize clinical practice, aiding clinicians in rapid and accurate diagnosis.

Laparoscopic resection of a pediatric intestinal leiomyosarcoma

Intestinal leiomyosarcomas represent an exceptionally rare tumour in children. We report a 15-year-old female who presented with a long history of symptomatic iron deficiency anemia. Multiple investigations failed to lead to a diagnosis, however, a small bowel video capsule endoscopy demonstrated an ileal polyp. She proceeded to surgery where an ileo-ileal intussusception was found and underwent a small bowel resection. Histopathology confirmed a well-differentiated leiomyosarcoma that stained positive for smooth muscle actin and negative for c-kit, differentiating it from a gastrointestinal stromal tumour (GIST). This case becomes only the fourth reported case in the 21st century. The authors explore the current literature on this tumour in the pediatric population and how in the last two decades the discovery of specific immunohistochemistry staining resulted in most intestinal leiomyosarcoma being classified correctly as GISTs.

Efficacy-safety profile of the video capsule endoscopy in the study of the small bowel: experience over 100 consecutive procedures.

Video capsule endoscopy (VCE) is currently considered the first-line study in the evaluation of the small bowel (SB). Retrospective study including consecutive patients from 2010 to 2021 in two referral endoscopic centers in Peru, who underwent VCE. Inclusion criteria were patients with middle gastrointestinal bleeding, chronic diarrhea and unexplained chronic abdominal pain (endoscopic studies prior to VCE: normal). We mainly used Pillcam SB VCE (Given Imaging, Israel) SB2 and SB3 generations.

Hemosuccus pancreaticus due to a small arterial pseudoaneurysm detected by CE-EUS and successfully treated with angiographic coiling (with video).

In hemosuccus pancreaticus,[1] potentially life-threatening bleeding into the pancreatic duct is usually caused by a large arterial pseudoaneurysm (average size of 52 mm) in chronic pancreatitis.[2] Bleeding from the papilla can be seen by endoscopy, and pseudoaneurysm can be detected by standard cross-sectional imaging. In this case report, a small pseudoaneurysm of the splenic artery with a fistula to the pancreatic duct could only be discovered by contrast-enhanced EUS (CE-EUS). A 54-year-old man with nonsteroidal anti-inflammatory drug intake and history of chronic alcohol pancreatitis was admitted for tarry stools. A cause for bleeding could not be identified by gastroscopy, ileocolonoscopy, abdominal ultrasound, and computed tomography [Figure 1]. However, the gastrointestinal bleeding continued. Small bowel video capsule endoscopy was performed and showed traces of blood in the duodenum. Repeated duodenoscopy presented a slight hemobilia from the papilla [Figure 2]. Therefore, hemosuccus pancreaticus was assumed, and CE-EUS indeed detected an arterial fistula to the pancreatic duct [Figure 3 and Video 1]. In the following, angiography showed a small pseudoaneurysm of the splenic artery [Figure 4], which was successfully treated by angiographic coiling [Figure 5] according to common guidelines.[3] Bleeding stopped after transfusion of summed up 9 units of blood. In some cases, EUS combined with Doppler ultrasound might be sufficient for the detection of the fistula[4] but failed in this patient. The useful application of CE-EUS in hemosuccus pancreaticus was previously shown in only one case report, in which the feeding vessel of a large pseudoaneurysm (42 mm) could not have been detected by angiography.[5] In conclusion, CE-EUS might be useful to detect hemosuccus pancreaticus due to small arterial pseudoaneurysms in patients with occult gastrointestinal bleeding.Figure 1: Computed tomography of the abdomen showing chronic pancreatitis with calcifications but cannot identify the source of gastrointestinal bleedingFigure 2: Slight hemobilia from the papilla is shown in repeated duodenoscopyFigure 3: Selected image from Video 1 showing the fistula from the arterial pseudoaneurysm to the pancreatic ductFigure 4: Selective angiography showing a small pseudoaneurysm (<20 mm) of the splenic artery. Fistula from the pseudoaneurysm to the pancreatic duct is not demonstratedFigure 5: Successfully treated pseudoaneurysm of the splenic artery by angiographic coiling. Direct application of the coils into the pseudoaneurysm had to be avoidedBRIEF DESCRIPTION CE-EUS was helpful to detect hemosuccus pancreaticus due to a small arterial pseudoaneurysm of the splenic artery in a patient with chronic pancreatitis and on-going occult gastrointestinal bleeding. Hemosuccus pancreaticus was successfully treated by angiographic coiling. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

S2121 Overt Small Bowel Bleeding From a Jejunal GIST

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are rare causes of gastrointestinal malignancies. Herein we describe a cause of upper GI bleeding from a jejunal GIST. CASE DESCRIPTION/METHODS: A 58-year-old male with history of chronic hepatitis B, hypertension and hyperlipidemia presented to the hospital with melena and lightheadedness. The patient was hemodynamically stable with an elevated BUN/creatinine ratio and initial hemoglobin of 11.5 g/dL. His repeat CBC twelve hours later revealed down trend of hemoglobin to 8.5 g/dL. Review of the patient’s past admission and outpatient history revealed the patient was admitted two years prior for GI bleed requiring multiple blood transfusions. At that time, upper endoscopy, colonoscopy and CT scan of the abdomen/pelvis were unrevealing as was a 99 Technetium bleeding scan. He was discharged and scheduled for outpatient small bowel video capsule but was lost to follow up. He returned to the clinic one year later and repeat upper endoscopy and colonoscopy were performed. Upper endoscopy revealed mild gastritis and colonoscopy revealed medium sized hemorrhoids but he had a poor colon bowel prep. Small bowel video capsule endoscopy revealed AVM's in the proximal small bowel but the study was also poor due to bile obscuring most of the small bowel mucosa. Due to concern for possible small bowel AVM bleed, we opted to perform upper endoscopy with push enteroscopy. A large ulcerated friable nodular mass with stigamata of recent bleeding was identified in the proximal jejunum. Bite on bite biopsies were obtained to evaluate the mass and a tattoo was placed for identification purposes. Despite the deep biopsies, pathology later returned as normal small bowel mucosa. A CT enterography was obtained revealing a 3.5 × 3.6 × 3.5 cm hyperenhancing mass arising from the proximal jejunum with adjacent wall thickening. Surgical consultation was obtained and the patient underwent laparoscopic resection of the mass. Pathology demonstrated low grade spindle-cell type gastrointestinal stromal tumor. DISCUSSION: Although an uncommon cause for GI bleeding overall, GISTs are a common cause of small bowel bleeding. Obtaining a thorough history and evaluation of the patient’s prior outpatient records proved useful in identifying the cause of bleeding in this case even though it was different from what was suspected.Figure 1Figure 2

S1311 CNN Analysis of Video Capsule Endoscopy Frames Reduces Miss Rate of Relevant Lesions

INTRODUCTION: Human reads of small bowel video capsule endoscopy (VCE) have a surprisingly high miss-rate for known lesions.1 We previously reported development of a convolutional neural networks (CNN) with very high sensitivity and specificity for detection of lesions on VCE images.2 We aimed to determine if this CNN can detect relevant lesions missed by human readers of VCE. METHODS: A total of 146 VCE studies (not previously exposed to CNN) were evaluated for this retrospective study. Each video was de-identified and analyzed by the CNN to select frames predicted to contain abnormalities. The frames saved by the original reader (‘OR’) were verified to include examples of all relevant lesions mentioned in the de-identified report. Abnormalities identified in ‘OR’ frames and CNN frames were reviewed and classified by 3 experts as clinically relevant, possibly relevant, or innocent. Each abnormality found by ‘OR’ and CNN were aligned by timestamp to determine if found by CNN only, ‘OR’ only, or by both CNN and reader. RESULTS: From these 146 VCEs, there were a total of 542 abnormal findings (17% were relevant, 47% were possibly relevant and 36% were innocent (Table 1). Of the definitely relevant findings, 68% were found by both the ‘OR’ and the CNN, 1% was found by only the ‘OR’ (missed by CNN), and 31% were found by only the CNN (missed by ‘OR’). Of the possibly relevant findings 36% were found by both, 5% were found by only the ‘OR’, and 36% were found by only the CNN. Of the innocent findings 55% were found by both, 19% were found by only the ‘OR’, and 58% were found by only the CNN. Broken down by lesion type, miss rates of definitely relevant lesions by ‘OR’ vs CNN are shown in Table 2. Of the 94,000 mean number of frames analyzed per video, the CNN generated a mean of 200 frames with abnormalities, of which, a mean of 31 were confirmed to have abnormalities (Table 3). CONCLUSION: This retrospective comparison of lesion detection by original reader vs CNN in 146 VCE studies suggests that use of CNN may significantly reduce miss rate of clinically relevant lesions, especially AVMs, bulges, and polypoid lesions.Table 1.: Relevance of abnormalities found reader vs CNNTable 2.: Miss rates among "Definitely Relevant" lesionsTable 3.: Total frames generated by VCE and CNN compared to frames with abnormalities

Indications and diagnostic yield of small-bowel capsule endoscopy in a real-world setting

BackgroundIndications and diagnostic yield of small-bowel video capsule endoscopy (SB-VCE) are communicated in recent clinical academic guidelines. However, guidelines are based mainly on relatively few, small, selection-biased studies at experienced centers, and thus we lack information on indications and diagnostic yield of SB-VCE in the real-world community setting. The aim of the study was to evaluate indications and diagnostic yield of SB-VCE in the real-world community setting.MethodsOur local VCE clinical database was used to identify patients undergoing SB-VCE procedures over a 7-year period (2011–2018). Patients were broadly referred and underwent SB-VCE using PillCam™ SB 2 and SB 3 capsule systems. Procedures were reviewed by local endoscopists, who had undergone similar formal SB-VCE review training. Medical reports of the procedures were composed as such. We retrospectively reviewed all reports and gathered data regarding indications and findings. Diagnostic yield was considered positive if SB-VCE visualized any type of clinically significant pathological finding.Results536 SB-VCE procedures in 516 patients were included in final assessment. Patient mean (± SD) age was 50 ± 20 years with approximately even female/male ratio (275:241). The overall proportion of positive findings was 42% (225/536). The two main indications were obscure gastrointestinal bleeding (occult/anemia or overt/active, OGIB) of 46% (246/536) and definite/suspected Crohn’s disease (CD) of 39% (210/536). Positive SB-VCE findings were obtained in 44% (108/246) of procedures with indication of OGIB and in 50% (104/210) of procedures with indication of CD.ConclusionsThe indications for SB-VCE are largely consistent with guidelines but with an apparently relatively low diagnostic yield in our real-world community setting.

592 Comparison of Endoscopic Placement versus Oral Ingestion of Small Bowel Video Capsule for Evaluation of Inpatients With Small Intestinal Bleeding

INTRODUCTION: Wireless small bowel video capsule endoscopy (VCE) is used to evaluate small intestinal bleeding after upper endoscopy and colonoscopy fail to identify a source of bleeding. The majority of patients swallow the capsule but endoscopic placement in the duodenum is an option. Limited data suggests higher rate of gastric retention of capsule in inpatients due to a variety of reasons, resulting in an incomplete exam. Hypothetically, endoscopic placement should increase likelihood of complete small bowel evaluation but there is little data comparing the two approaches. We aimed to compare completion rates and outcomes of capsule studies via endoscopic placement (CS-EP) versus oral ingestion (CS-OI) in inpatients undergoing VCE. METHODS: Patients who had VCE studies performed inpatient for gastrointestinal bleeding at Rhode Island Hospital between April 2015 and July 2016 were identified retrospectively. Baseline patient demographics, time intervals between reported bleed, date of admission and date of discharge, capsule study, indications for capsule study, completion rates and detection of small bowel bleeding were collected. Statistical tests were done using student's t-test and chi square test. RESULTS: Data was available for 83 patients between April 2015 and July 2016. The most common indications were for obscure bleed (92%) followed by anemia (86%). 29 (35%) patients had small bowel capsule studies that were endoscopically placed. Majority of patients underwent endoscopic placement due to provider preference. CS-EP had a higher proportion of men than CS-OI (66% vs. 44%, P = .06). The mean duration from bleeding episode to capsule study was 8.4 days for both groups. Small bowel bleeding was more likely to be detected by CS-EP than CS-OI (34% vs. 13%, P = 0.02), however completion rates were similar between both studies (69% vs. 76%, P = 0.5). CS-EP had a longer time from study to discharge (days: 7.1 vs. 3.7, P = 0.1) and longer length of stay at the hospital (days: 11.45 vs. 7.47, P = 0.1) compared to CS-OI. CONCLUSION: Based on this single center study, although endoscopic placement of VCE was more likely to detect small bowel bleeding compared to oral ingestion, there was no difference in study completion rates and CS-EP group in fact had a longer length of stay. Investigation into potential causes of longer length of stay and cost of care associated with endoscopic placement are ongoing. Additional data is also being collected for capsule studies performed over several more years.

Evaluating the clinical and economic consequences of using video capsule endoscopy to monitor Crohn's disease.

BackgroundTo assess the cost and patient impact of using small bowel and colon video capsule endoscopy (SBC) for scheduled monitoring of Crohn’s disease (CD).MethodsAn individual-patient, decision-analytic model of the CD care pathway was developed given current practice and expert input. A literature review informed clinical endpoints with data from peer-reviewed literature. Four thousand simulated CD patients were extrapolated from summary patient data from the Project Sonar Database. Two monitoring scenarios were assessed in this population. The first scenario represented common monitoring practice (CMP) for CD (ileocolonoscopy plus imaging), while in the second scenario patients were converted to disease monitoring using SBC. The cost-effectiveness of using SBC was assessed over 20 years. The cost of switching 50% of patients to SBC was assessed over 5 years for a health-plan including 12,000 patients with CD. Uncertainty of results was assessed using probabilistic sensitivity analysis.ResultsAll patient groups showed increased quality of life with SBC versus CMP, with the highest gain in active symptomatic patients. Over 20 years, SBC reduced costs ($313,367 versus $320,015), increased life expectancy (18.15 versus 17.9 years) and increased quality of life (8.7 versus 8.0 QALY), making it a cost-effective option. SBC was cost-effective in 71% of individuals and 78% of populations including 50 patients. A payer implementing SBC in 50% of patients over 5 years could expect a decreased cost of monitoring (–$469 mean per patient) and surgery (–$698), but increased costs for active treatments (+$717). The discounted mean annual cost of care using CMP was $22,681 per patient over 5 years. The annual savings were $1135 per SBC-patient. The total savings for the payer over 5 years were $36.5 million.ConclusionSBC is likely to be a cost-effective and cost-saving strategy for monitoring CD in the US.

Use of Simethicone After Capsule Ingestion and Its Impact on Quality of Small Bowel Video Capsule Endoscopy: A Pilot Study

2891 Figure 1. Shows comparison in means of variance with 95% confidence interval in SBVQ at proximal, middle, distal and cumulative small bowel within three research arms: control, sham and treatment.Introduction: Small bowel capsule endoscopy is a tool to visualize the small bowel (SB) for things like obscure bleeding. Studies suggest that using Polyethylene glycol (PEG) prep is significantly better compared to clear liquid and overnight fast in terms of small bowel visualization quality (SBVQ). No studies have been done where simethicone is ingested after capsule swallowing.We intend to give patients simethicone 1 hour after capsule ingestion for two consecutive hours and compare results for SBVQ pre-and post-ingestion groups. We hypothesize post capsule simethicone ingestion group will have significant improvement in SBVQ. Methods: Patient in outpatient setting were divided in control, sham and treatment group. Control group followed the standard hospital pre-capsule protocol that included PEG 238 gram the evening prior. Sham included group that received 3ml of simethicone (20mg/0.3ml) 20 minutes prior to swallowing of the capsule. Treatment group contained patients that had simethicone 3ml 20 minutes prior to capsule swallowing and then 3ml after 1 hours and then 1.5 ml after another 1 hour totaling 7.5ml simethicone. Data concerning SBVQ for every patient was evaluated as an individual zone score from 1-3 points, each in proximal, middle and distal SB and then get a cumulative number 1-9 after adding the three zones together. These points were derived using the Boston bowel prep score. Results: We had 5 patients in control, 4 in sham and 6 in treatment group. Proximal SB: The sham group had a statistically significant higher SBVQ compared to control. The SBVQ of treatment group was higher than control though wasn't statistically significant. Middle SB: No difference was seen in SBVQ. Distal SB: SBVQ mean dropped in treatment group but there wasn't any statistically different. Cumulative SB: Score from all three group zones when added together showed no difference in SBVQ between the three research arms (figure 1). Conclusion: There was no statistically significant difference in the SBVQ when looking at the cumulative score of the entire small bowel. However, there was statistically significant improvement in SBVQ at the proximal segment of SB between sham and the control group suggesting simethicone may be helpful in increasing visualization early on in the SB and not so much as capsule reaches more distally. This is only a pilot project and results may vary when the power of our study increases.

Antithrombotic Treatment Is Associated with Small-Bowel Video Capsule Endoscopy Positive Findings in Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

The impact of antithrombotic treatment on the findings of small-bowel capsule endoscopy for patients with obscure gastrointestinal bleeding remains contentious. We aimed to determine the effect of these agents on small-bowel video capsule endoscopy positive findings. MEDLINE, Cochrane Library, and Google Scholar were searched for studies reporting on patients receiving concurrent antithrombotic treatment, while undergoing capsule endoscopy for obscure gastrointestinal bleeding (OGIB). Outcomes were the effect of antithrombotic therapy-overall and per type of antithrombotic agent-on the examination's positive findings and re-bleeding risk. The effect size of study outcomes is presented as odds ratio (OR) with 95% confidence interval (CI). Fourteen studies with 1023 patients were included. We detected significant heterogeneity with no evidence of publication bias. Compared to antithrombotic drug nonusers, antithrombotic treatment was associated with an increased prevalence of positive findings [OR 1.98 (95% CI 1.34-2.93); P = 0.0006]. This effect did not differ between antiplatelet and anticoagulant treatments [OR 2.22 (95% CI 1.28-3.84); P = 0.005 and 2.53 (95% CI 1.66-3.87); P < 0.0001, respectively]. Antithrombotic use over no use was not associated either with overt [OR 1.17 (95% CI 0.51-2.66); P = 0.71] or with occult [OR 0.86 (95% CI 0.38-1.95); P = 0.71] bleeding pattern. However, concurrent antithrombotic treatment was associated with higher odds for re-bleeding compared to no treatment [OR 2.53 (95% CI 1.46-4.37); P = 0.0009]. Antithrombotic treatment is associated with more positive findings in small-bowel video capsule endoscopy in OGIB as well as higher odds of re-bleeding.

Video capsule endoscopy is safe and effective in suspected small bowel bleeding among left ventricular assist device recipients.

Suspected small bowel bleeding is frequently encountered in left ventricular assist device recipients and the identification of the culprit lesion may be challenging. Data regarding the safety and yield of small bowel capsule in the investigation of suspected small bowel bleeding are limited. We aimed to evaluate the safety and efficacy of small bowel video capsule endoscopy for the investigation of suspected small bowel bleeding among left ventricular assist device recipients. Patients with left ventricular assist device who underwent video capsule endoscopy for the investigation of suspected small bowel bleeding were identified. Suspected small bowel bleeding was defined as the presence of overt bleeding at least 30 days following left ventricular assist device implantation with no identifiable cause in upper and lower endoscopy. A total of 10 patients with left ventricular assist device associated suspected small bowel bleeding performed 12 small bowel capsule endoscopies between January 2008 and December 2015 at our tertiary medical care facility. There were no cases of capsule retention or any other serious adverse events during the exams. A significant finding was identified in 8 out of 10 patients, including 3 cases of small bowel angioectasia, 2 cases of small bowel ulcers, 1 case of cecal polyp, and 2 cases of active bleeding with no apparent bleeding source. Small bowel enteroscopy identified and treated bleeding angioectasia in the latter two cases. Small bowel capsule endoscopy is safe and effective in the investigation of left ventricular assist device associated suspected small bowel bleeding.

High Concordance between Trained Nurses and Gastroenterologists in Evaluating Recordings of Small Bowel Video Capsule Endoscopy (VCE)

Background &amp; Aims: The video capsule endoscopy (VCE) is an accurate and validated tool to investigate the entire small bowel mucosa, but VCE recordings interpretation by the gastroenterologist is time-consuming.A pre-reading of VCE recordings by an expert nurse could be accurate and cost saving. We assessed the concordance between nurses and gastroenterologists in detecting lesions on VCE examinations.Methods: This was a prospective study enrolling consecutive patients who had undergone VCE in clinical practice. Two trained nurses and two expert gastroenterologists participated in the study. At VCE pre-reading the nurses selected any abnormalities, saved them as “thumbnails” and classified the detected lesions as a vascular abnormality, ulcerative lesion, polyp, tumor mass, and unclassified lesion. Then, the gastroenterologist evaluated and interpreted the selected lesions and, successively, reviewed the entire video for potential missed lesions. The time for VCE evaluation was recorded.Results: A total of 95 VCE procedures performed on consecutive patients (M/F: 47/48; mean age: 63 ± 12years, range: 27−86 years) were evaluated. Overall, the nurses detected at least one lesion in 54 (56.8%) patients.There was total agreement between nurses and gastroenterologists, no missing lesions being discovered at a second look of the entire VCE recording by the physician. The pre-reading procedure by nurse allowed a time reduction of medical evaluation from 49 (33-69) to 10 (8-16) minutes (difference: -79.6%).Conclusions: Our data suggest that trained nurses can accurately identify and select relevant lesions in thumbnails that subsequently were faster reviewed by the gastroenterologist for a final diagnosis. This could significantly reduce the cost of VCE procedure.

High concordance between trained nurses and gastroenterologists in evaluating recordings of small bowel video capsule endoscopy (VCE).

. The video capsule endoscopy (VCE) is an accurate and validated tool to investigate the entire small bowel mucosa, but VCE recordings interpretation by the gastroenterologist is time-consuming. A pre-reading of VCE recordings by an expert nurse could be accurate and cost saving. We assessed the concordance between nurses and gastroenterologists in detecting lesions on VCE examinations. This was a prospective study enrolling consecutive patients who had undergone VCE in clinical practice. Two trained nurses and two expert gastroenterologists participated in the study. At VCE pre-reading the nurses selected any abnormalities, saved them as "thumbnails" and classified the detected lesions as a vascular abnormality, ulcerative lesion, polyp, tumor mass, and unclassified lesion. Then, the gastroenterologist evaluated and interpreted the selected lesions and, successively, reviewed the entire video for potential missed lesions. The time for VCE evaluation was recorded. A total of 95 VCE procedures performed on consecutive patients (M/F: 47/48; mean age: 63 +/- 12 years, range: 27-86 years) were evaluated. Overall, the nurses detected at least one lesion in 54 (56.8%) patients. There was total agreement between nurses and gastroenterologists, no missing lesions being discovered at a second look of the entire VCE recording by the physician. The pre-reading procedure by nurse allowed a time reduction of medical evaluation from 49 (33-69) to 10 (8-16) minutes (difference: -79.6%). Our data suggest that trained nurses can accurately identify and select relevant lesions in thumbnails that subsequently were faster reviewed by the gastroenterologist for a final diagnosis. This could significantly reduce the cost of VCE procedure.

Meta-analysis of randomized controlled trials challenging the usefulness of purgative preparation before small-bowel video capsule endoscopy.

The usefulness of purgative preparation before small-bowel video capsule endoscopy is controversial. We aimed to examine the effect of purgative preparation on small-bowel video capsule endoscopy outcomes. We performed literature searches in MEDLINE and the Cochrane library for randomized controlled trials evaluating the effect of purgative preparation (polyethylene glycol, sodium phosphate, others) vs. clear-liquid diet/fasting in patients undergoing small-bowel capsule endoscopy. Meta-analysis outcomes included the examination's diagnostic yield, small-bowel mucosal visualization quality, the examination's completion rate, and gastric and small-bowel transit times. The effect size on study outcomes was calculated using a fixed- or random-effect model, as appropriate, and is shown as the risk ratio (RR) with 95 % confidence interval (CI). We identified 12 eligible trials with 17 sets of data including 1221 subjects. Significant heterogeneity was detected with no evidence of publication bias. As compared with clear-liquid diet, purgative bowel preparation did not increase capsule endoscopy diagnostic yield (RR 1.17 [95 %CI 0.97 to 1.40]; P = 0.11). Neither the small-bowel mucosal visualization quality (RR 1.14 [95 %CI 0.96 to 1.35]; P = 0.15) nor completion rate for the examination (RR 0.99 [95 %CI 0.95 to 1.04]; P = 0.76) significantly improved after purgative preparation. Purgatives also had no effect on video capsule endoscopy gastric and small-bowel transit times. Our analysis challenges the usefulness of purgative preparation for improving the diagnostic yield of small-bowel video capsule endoscopy and the quality of small-bowel mucosal visualization.

P476 Using small bowel and colon video capsule endoscopy to optimise Crohn’s disease therapy may improve patient quality of life

Video capsule endoscopy (VCE) is a widely accepted technology that has application for monitoring of patients diagnosed with Crohn’s disease (CD). Due to the chronic nature of CD, using endoscopic monitoring to optimise treatment may have a considerable impact on both care costs and patient’s quality of life (QoL). This study aims to identify patient subgroups who may benefit from the use of pan-intestinal VCE. Extended analysis of patient outcomes of a previously published, patient-level, care pathway model that is specific to CD. In the model, treatment and monitoring can influence the onset, progression, or remission of CD flares, fistula, abscess, bowel resection, and death. The model compares outcomes with VCE to the current common monitoring practice of colonoscopy ± MRE or CTE. Data for VCE were derived from PillCam (Medtronic Inc.), which can assess both the small-bowel and colon in a single procedure. Outcomes for 40,000 simulated patients over 20 years were assessed. Cost of care and patient QoL were compared between monitoring options and stratified by patient subgroup. Subgroups based on the patient’s initial health state in the model were: remission, non-active symptomatic, active symptomatic, active non-symptomatic, treatment, treatment failure, surgery, or post-surgery. All subgroups were mutually exclusive. Differences between groups were quantified by the Wilcoxon-signed rank and the odds ratio (OR) with significance at the 95% level (p < 0.05). Overall, patients had significantly lower costs (p < 0.001) and higher QoL (p < 0.001) with use of VCE compared with common monitoring practice. Even patients in remission, the state with the least benefit from VCE, saw QoL improvement in 68% of cases. Patients in an active symptomatic or post-surgical state were the most likely to experience QoL improvement (both 79%). All groups displayed a significantly higher chance of QoL improvement over patients in remission (Figure 1). The likelihood of cost-savings was significantly higher during treatment (OR: 1.11, 1.03–1.19) or surgery (OR: 1.27, 1.13–1.41) when compared with remission. Odds ratio of a positive QoL/Costs difference compared with starting the simulation in remission. Error bars represent the 95% confidence interval. Assessing the extent of active CD with small bowel and colon VCE is likely beneficial for patient QoL and may also help reduce care costs. Targeting certain subgroups may amplify the advantages of VCE. Patients in need of more frequent follow-up, such as those on biological treatment, post-surgery, or with active symptoms, may be especially benefited by pan-intestinal VCE.

The impact of panenteric capsule endoscopy on the management of Crohn's disease.

Crohn's disease (CD) is a chronic inflammatory disease, in most patients involving the small and large bowel. In recent years, with the use of small bowel video capsule endoscopy (SBCE), it has become clear that in 50% or more of adults with established CD there is not only distal but also proximal small bowel involvement that suggests poor prognosis. A great deal of effort has been put into early diagnosis and stratification of patients into low versus high risk, thus directing treatment from step-up, or accelerated step-up, to top-down therapies. SBCE has been used for assessment of small bowel pathologies for over 15 years, mainly for occult gastrointestinal bleeding and suspected CD. In recent years, a colonic capsule, with cameras on both sides and a wider angle of view, has been developed and is used by some to survey both small and large bowel. Recently the same capsule, with adjustments, has been released in Europe, concentrating (with specialized software) on inflammatory bowel disease. In this review I summarize the new data regarding the use of SBCE as well as the small bowel colon (SBC) versions of capsule endoscopy in established CD and the ways these could alter the management of such patients.