Suspected Small Bowel Bleeding Research Articles

Could Capsule Endoscopy Be Useful in Detection of Suspected Small Bowel Bleeding and IBD-10 Years of Single Center Experience.

A retrospective study in patients who underwent video capsule endoscopy (VCE) between 2006 and 2016 was conducted in the Clinic for gastroenterology and Hepatology, University Clinical Center of Serbia. A total of 245 patients underwent VCE. In 198 patients the indication was obscure gastrointestinal bleeding (OGIB), with 92 patients having overt and the other 106 occult bleeding. The remaining 47 patients underwent VCE due to suspected small bowel (SB) disease (i.e., Von Hippel-Lindau syndrome, familial adenomatous polyposis, Peutz Jeghers syndrome, Crohn's disease, prolonged diarrhea, abdominal pain, congenital lymphangiectasia, protein-losing enteropathy, tumors, refractory celiac disease, etc.). VCE identified a source of bleeding in 38.9% of patients (in the obscure overt group in 48.9% of patients, and in the obscure occult group in 30.2% of patients). The most common findings were angiodysplasias, tumors, Meckel's diverticulum and Crohn's disease. In the smaller group of patients with an indication other than OGIB, 38.3% of patients had positive VCE findings. The most common indication is OGIB, and the best candidates are patients with overt bleeding; patients with IBD should be evaluated in this setting.

The professional background of a referring physician predicts the diagnostic yield of small bowel capsule endoscopy in suspected small bowel bleeding.

Background and study aims The diagnostic yield of small-bowel capsule endoscopy (SBCE) in suspected small bowel bleeding (SSBB) is highly variable. Different reimbursement systems and equipment costs also limit SBCE use in clinical practice. Thus, minimizing non-diagnostic procedures is advisable. This study aimed to assess the SBCE diagnostic yield and identify factors predicting diagnostic findings in a cohort of patients with SSBB. Patients and methods In this retrospective cohort study, we analyzed the medical records of patients who consecutively underwent SBCE for SSBB over 9 years. By logistic regression, we identified covariates predicting diagnostic findings at SBCE. Finally, we performed a post-hoc cost analysis based on previous gastroenterologist or endoscopist consultations versus direct SBCE ordering by other specialists. Results The final analysis included 584 patients. Most SBCEs were ordered by a gastroenterologist or endoscopist (74%). The number of SBCEs without any finding was significantly lower in the gastroenterologist/endoscopist group P <0.001). The SBCE diagnostic yield ordered by a gastroenterologist or endoscopist was significantly higher than that by other specialists (63% vs 52%, odds ratio [OR] 1.57; 95% confidence interval [CI] 1.07-2.26, P =0.019). At multivariate analysis, older age (OR 1.7, 95%CI 1.2-2.4, P =0.005), anemia (OR 4.9, 95%CI 1.9-12, P =0.001), small bowel transit time (OR 1, 95%CI 1-1.02, P =0.039), and referring physician (OR 1.8, 95%CI 1.1-2.7, P =0.003) independently predicted diagnostic findings. Implementing prior gastroenterologist or endoscopist referral vs direct SBCE ordering would reduce medical expenditures by 16%. Conclusions The professional background of referring physicians significantly improves the diagnostic yield of SBCE and contributes to controlling public health costs.

S834 Clinical Efficacy of Video Capsule Endoscopy and Balloon-Assisted in Suspected Small Bowel Bleeding: A Single Center Cohort Study

S834 Clinical Efficacy of Video Capsule Endoscopy and Balloon-Assisted in Suspected Small Bowel Bleeding: A Single Center Cohort Study

S829 Urgent Balloon Assisted Enteroscopy in Acute Overt Suspected Small Bowel Bleeding Is Associated With Decreased Rehospitalization Rate and Increased Bleeding Free Survival

S829 Urgent Balloon Assisted Enteroscopy in Acute Overt Suspected Small Bowel Bleeding Is Associated With Decreased Rehospitalization Rate and Increased Bleeding Free Survival

Capsule Endoscopy for the Diagnosis of Suspected Small Bowel Bleeding

This review discusses the role of capsule endoscopy in diagnosing suspected small bowel bleeding and compares guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), the American College of Gastroenterology (ACG), the American Society for Gastrointestinal Endoscopy (ASGE), the Canadian Association of Gastroenterology (CAG), and the consensus document of 4 Japanese medical societies. European and North American experts recommend capsule endoscopy as a first-line diagnostic modality for suspected small bowel bleeding without life-threatening signs in adult patients when ileocolonoscopy and esophagogastroduodenoscopy failed to be informative. Japanese experts, on the contrary, prefer cross-sectional imaging “from the chest to the pelvis” and consider capsule endoscopy as an alternative.

Where does capsule endoscopy fit in the diagnostic algorithm of small bowel intussusception?

IntroductionThe investigation of small bowel (SB) intussusception is variable, reflecting the lack of existing standards. The aim of this study was to understand the role of small bowel capsule endoscopy (SBCE) to investigate this pathology. MethodologyThis was a retrospective multi-centre study. Patients with intussusception on SBCE and those where SBCE was carried out due to findings of intussusception on radiological investigations were included. Relevant information was collected. ResultsNinety-five patients (median age 39+/-SD19.1 years, IQR 30) were included. Radiological investigations were carried out in 71 patients (74.7%) prior to SBCE with intussusception being present in 60 patients on radiological investigations (84.5%). Thirty patients (42.2%) had intussusception on radiological investigations followed by a normal SBCE. Ten patients (14.1%) had findings of intussusception on radiological investigations, a normal SBCE and repeat radiological investigations that were also normal. Abnormal findings were noted on SBCE that could explain intussusception on imaging in (16 patients) 22.5% of patients.Five patients (5.3%) underwent radiological investigations and SBCE to investigate coeliac disease and intussusception. None had associated malignancy. Four patients (4.2%) underwent SBCE to investigate familial polyposis syndromes and went on to SB enteroscopy and surgery accordingly.Most patients (n = 14; 14.8%) with intussusception on initial SBCE (without prior radiological imaging) had suspected SB bleeding (n = 10, 10.5%). Four patients (4.2%) had additional findings of a mass on CT scan and went on to have surgery. ConclusionSBCE should be used to complement radiology when investigating intussusception. It is a safe non-invasive test that will minimise unnecessary surgery. Additional radiological investigations following a negative SBCE in cases of intussusception noted on initial radiological investigations are unlikely to yield positive findings. Radiological investigations following intussusception noted on SBCE in case of patients presenting with obscure gastrointestinal bleeding, may yield additional findings.

Single or double headed capsules for the investigation of suspected small bowel bleeding: Are two heads better than one

BackgroundCapsule endoscopy is now the accepted first line investigation for suspected small bowel (SB) bleeding. Recent evidence suggests the diagnostic yield for SB pathology may be higher for tailored double headed (DH) SB capsules. Whether other forms of bidirectional capsules offer a similar advantage is less clear.AimTo compare the efficacy of single headed versus bidirectional capsules in detecting pathology in patients with suspected small bowel bleeding.MethodsA single centre prospective comparison study was conducted over an 8 month period in a tertiary care hospital. Patients referred with overt or suspected SB bleeding were assigned to either SB3 Medtronic SB capsule (SH) during the initial four months or PillCam Colon 2 Medtronic capsule (DH) during the subsequent four months. Studies were analysed by trained Capsule Endoscopists and approved by our institutions capsule review board. Findings were compared between SH and DH capsules using a chi2 or t-test as appropriate. A p value of &amp;lt;0.05 was considered significant.Results201 subjects were included, mean age 61.8 years, 90 (45%) male. Majority referred with occult bleeding, 153 (76%). DH and SH capsule used in 100 and 101 cases, respectively. 90% (n=181) capsules were complete and overall diagnostic yield was 57% (n=114). Diagnostic yield was similar between both groups - DH 53% (n=53), SH 60% (n=61). Positive finding in overt bleeding; SH 85% (n=22) versus DH 50% (n=11), p&amp;lt;0.02. SH capsules more frequently detected SB inflammation, 27 (27%) versus 9 (9%), p&amp;lt;0.002. More patients had another diagnosis in the DH (19) than the SH (9), p&amp;lt;0.04, the majority were type 1a vascular lesions, “red spots” or diminutive colonic polyps.ConclusionSingle head and double head capsules perform similary in terms of diagnostic yield overall. This supports the continued use of standard small bowel capsules for investigation of the small bowel.

Very High Yield of Urgent Small-Bowel Capsule Endoscopy for Ongoing Overt Suspected Small-Bowel Bleeding Irrespective of the Usual Predictive Factors.

Evidence for an urgent approach to ongoing overt suspected small-bowel bleeding (SSBB) is scarce. We aimed to analyze our series of urgent small-bowel capsule endoscopies (SBCEs) for ongoing overt SSBB and to identify factors associated with positive findings and outcomes. A retrospective study of all SBCEs performed in the first 48 h after admission for overt SSBB between January 2006 and February 2022 was performed. Descriptive and inferential analyses (univariate and multivariable) were performed. Eighty-three urgent SBCEs were performed for overt SSBB. Patients were mostly men (69.2%, median age 68) and were followed for a median of 58.2 months (range 5-176). The diagnostic yield was 80.7%; in 60.2%, blood was detected in the small bowel (SB), while in 50.6%, a bleeding lesion was identified, mostly angioectasia. Patients with diabetes mellitus or taking NSAIDs were more prone to present SB findings, yet the explanatory power was low. Endoscopic or surgical treatments were performed in 28.9% and 19.3%, respectively, with the "non-conservative" therapeutic yield being 56.6%. Rebleeding occurred in 20.5% and was associated in the multivariable analysis with the female gender and anticoagulants use. This cohort of urgent SBCE, the largest from a European center, reinforces the usefulness of SBCE for ongoing overt SSBB management. This prompt performance of this procedure is highly effective, regardless of patients' features.

Effect of Different Modalities of Purgative Preparation on the Diagnostic Yield of Small Bowel Capsule for the Exploration of Suspected Small Bowel Bleeding: A Multicenter Randomized Controlled Trial.

The aim of our study was to compare clear liquid diet with 2 different polyethylene glycol (PEG)-based bowel preparation methods regarding diagnostic yield of small bowel capsule endoscopy (SBCE) in patients with suspected small bowel bleeding (SBB). In this prospective multicenter randomized controlled trial, consecutive patients undergoing SBCE for suspected SBB between September 2010 and February 2016 were considered. Patients were randomly assigned to standard regimen, that is, clear fluids only (prep 1), standard regimen plus 500 mL PEG after SBCE ingestion (prep 2), or standard regimen plus 2 L PEG plus 500 mL PEG after SBCE ingestion (prep 3). The primary outcome was the detection of at least one clinically significant lesion in the small bowel. The quality of small bowel cleansing was assessed. A questionnaire on the clinical tolerance was filled by the patients. We analyzed 834 patients. No significant difference was observed for detection of P1 or P2 small bowel lesions between prep1 group (40.5%), prep 2 group (40.2%), and prep 3 group (38.5%). Small bowel cleansing was improved in prep 2 and 3 groups compared with that in prep 1 group. Compliance to the preparation and tolerance was better in prep 2 group than in prep 3 group. Small bowel purgative before SBCE allowed better quality of cleansing. However, it did not improve diagnostic yield of SBCE for suspected SBB.

S3299 The Effect of Small Bowel Transit Time on the Accuracy of VCE in Evaluation of Suspected Small Bowel Bleeding: A Retrospective Analysis at Einstein Medical Center

S3299 The Effect of Small Bowel Transit Time on the Accuracy of VCE in Evaluation of Suspected Small Bowel Bleeding: A Retrospective Analysis at Einstein Medical Center

Iron Deficiency and the Small bowel​.

This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options. Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.

Diagnosis of Suspected Small Bowel Bleeding by Capsule Endoscopy in Patients with COVID-19.

The current study evaluated the application of small-bowel capsule endoscopy (SBCE) in SARS-CoV-2-infected patients with suspected small bowel bleeding. We analyzed the clinical characteristics, SBCE procedures, examination results, and treatment for cases of suspected small bowel bleeding in two patients with critical COVID-19. SBCE showed active spotting bleeding in the jejunum and ileum with no identifiable lesions in case 1, while multiple small bowel ulcers were detected in case 2. Two patients had relevant changes in their management plans and received specific treatment based on SBCE findings. In summary, SBCE proved to be a non-invasive diagnostic tool for critical COVID-19 patients with suspected small bowel bleeding.

Diagnosis and therapy using double-balloon endoscopy for small bowel disease: experience from a Chinese tertiary hospital.

ObjectiveTo evaluate the clinical efficacy of double-balloon endoscopy (DBE) for small bowel disease (SBD).MethodsThe clinical and endoscopic data of patients who underwent DBE in a Chinese tertiary hospital from January 2006 to December 2019 were retrospectively reviewed. The patients were divided into three groups by age: the young group (<45 years), middle-aged group (45–65 years), and older group (>65 years).ResultsIn total, 1177 patients who underwent 2134 DBE procedures were included. The anterograde and retrograde route was used in 1111 and 1023 procedures, respectively. The most common reason for performing DBE was suspected small bowel bleeding (SSBB) (53.1%), and the most common SBD was Crohn's disease (CD) (18.1%). Hemostasis was the predominant endoscopic therapy (54.3%). The total complication rate was 0.8%. The incidence of CD was highest in the young group, and the incidence of tumors was highest in the older group; these findings were consistent both among the overall patient population and among patients with SSBB.ConclusionsDBE is effective and safe for the diagnosis and treatment of SBD and is considered to have great potential as a first-line method for diagnosing SBD.

S1298 Identification and Treatment of Gastrointestinal Angiodysplasia With Stigmata of Recent Hemorrhage May Reduce Rebleeding in Patients Admitted for Suspected Small Bowel Bleeding

S1298 Identification and Treatment of Gastrointestinal Angiodysplasia With Stigmata of Recent Hemorrhage May Reduce Rebleeding in Patients Admitted for Suspected Small Bowel Bleeding

Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding

BackgroundIn stable patients, video capsule endoscopy (VCE) is the recommended first test for patients presenting with suspected small bowel bleeding (SSB). The aim of this study is to develop a scoring system to aid clinicians in deciding which patients with SSB would benefit from VCE. A multicenter database of patients who underwent VCE for SSB was created. MethodsA multivariable logistic regression analysis was utilized on a developmental cohort to determine independent predictors of a positive diagnosis on VCE and develop the scoring system. Receiver operating characteristic analysis compared the performance of the scoring system between the developmental cohort and the validation cohort. ResultsThree hundred fourteen patients underwent VCE for SSB. Multivariable analysis revealed 3 variables—age less than 54 years old (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.11-0.58), inpatient status with overt bleeding (OR 2.38, 95% CI 1.05-5.39), and hemoglobin less than 6.4 g/dL (OR 2.68, 95% CI 1.11-6.48) as independent predictors of a diagnosis on VCE. The performance of the scoring system in the developmental cohort (C-statistic 0.70; 95% CI 0.62-0.77) and the validation cohort (C-statistic 0.69; 95% CI 0.61-0.75) was not significantly different (P = 0.91). ConclusionsFor patients with suspected small bowel bleeding, age older than 54 years, hemoglobin <6.4 g/dL, and inpatient status with overt bleeding are significant predictors for identifying a diagnosis on capsule endoscopy. A scoring system composed of these variables was successfully validated. The scoring system is potentially very useful in limiting the use of VCE in low-risk patients.

Small Bowel Angioectasias Rebleeding and the Identification of Higher Risk Patients.

Small bowel capsule endoscopy (SBCE) is the gold standard for suspected small bowel bleeding (SBB). Angioectasias are the most common vascular anomalies in the gastrointestinal tract and have been reported as the source of SBB in up to 80% of patients. Considering their frequency, their usual intermittent bleeding nature, and their risk of rebleeding, the aim of this study was to identify some features and possible predictors of rebleeding in the presence of these lesions. This is a retrospective study, which included consecutive SBCE with angioectasias between April 2008 and December 2017 with a minimum follow-up of 12months. Rebleeding was defined as a drop of hemoglobin ≥ 2g/dl and/or in the presence of hematochezia or melenas with negative esophagogastroduodenoscopy and ileocolonoscopy. Data were collected from medical records, and angioectasias were classified by number, location, size, and type. Univariate and multivariable statistical analysis was performed to identify possible predictors of rebleeding. From a total of 630 patients submitted to SBCE for suspected SBB, 129 with angioectasias were included; 59.7% were female, with a median age of 72 (19-91) years old and a mean follow-up of 44.0 ± 31.9months. In 32.6% (n = 42) of the patients, at least one episode of rebleeding was documented. The presence of heart failure (OR 3.41; IC95% 1.18-9.89; p = 0.024), the size of the angioectasias (OR 5.41; IC95% 2.15-13.6; p < 0.001), and smoking status (OR 3.15; IC95% 1.07-9.27; p = 0.038) were independent predictor factors of rebleeding. Heart failure, smoking status, and angioectasias with a size superior to 5mm are independent predictor factors of rebleeding in a population with angioectasias diagnosed by SBCE.

Emergent Double Balloon Enteroscopy in Overt Suspected Small Bowel Bleeding: Diagnosis and Therapy.

BackgroundDouble balloon enteroscopy (DBE) is a diagnosis and therapy method for suspected small bowel bleeding (SSBB). The data for emergent DBE is limited in overt SSBB cases. The aim of this study was to investigate the role of diagnosis and therapy of emergent DBE in patients with overt SSBB.Material/MethodsThe clinical and endoscopic data for patients with overt SSBB undergoing DBE in a single center from January 2010 to December 2017 were collected and analyzed. Emergent DBE was defined as DBE performed less than 3 days of last bleeding onset.ResultsA total of 265 DBEs in 265 patients with overt SSBB were enrolled (mean age, 44.7±17.3 years; 66.8% males). The patients were divided into 3 groups according to the timing of DBE: less than 3 days (n=32), more than 3 days and less than 7 days (n=146), and more than 7 days (n=87) (first group was the emergent group, the latter 2 groups were the non-emergent groups). The diagnosis yield for the emergent group was significantly higher than the non-emergent groups (84.4% versus 65.1% or 59.8%, respectively, P<0.05), but was not different between the 2 non-emergent groups (P>0.05). The top 3 diagnoses were angioectasias (19.6%), diverticulum (16.2%), and tumor (12.1%). For therapy yield, there was a remarkable reducing trend in the emergent group (<3 days), and the 2 non-emergent groups (3 to 7 days group and >7 days group: 78.1%, 58.2% and 39.1%, respectively, P<0.05. The top 3 endoscopic treatments were hemostatic clips (21.9%), argon plasma coagulation (15.8%), and epinephrine injection (14.0%).ConclusionsThe emergent DBE had the highest yields for diagnosis and therapy. The study finding showed a pivotal role of emergent DBE in overt SSBB.

1899 Bronchial Aspiration of Capsule Endoscopy: A Rare but Potentially Fatal Complication

INTRODUCTION: Video capsule endoscopy (VCE) is increasingly being used in the diagnosis of small bowel disorders and the evaluation of suspected small bowel bleeding in adults. VCE is considered a safe procedure with no attributable deaths. Clinically significant complications include symptomatic capsule retention and aspiration that occur in less than 2% of examinations. CASE DESCRIPTION/METHODS: A 67-year-old male with history of developmental delay and with no history of swallowing disorder or stroke was initially admitted to the hospital with severe symptomatic anemia. His hemoglobin was 7.1g/dl. Anemia work up revealed serum iron level of &lt;10g/dl and a ferritin level of 4.30. He underwent upper GI endoscopy and colonoscopy with findings of a short segment Barrett’s esophagus and small non-bleeding hemorrhoids. He was then scheduled an outpatient VCE. He was given the capsule and asked to swallow it. He initially had some difficulty in swallowing it but then took a big gulp and apparently swallowed it. Immediately upon swallowing, he started experiencing difficulty breathing. Nursing staff present immediately checked his oxygen saturation and noted a transient drop which corrected with minimal oxygen supplementation. An X-ray was immediately ordered and the monitor activated. Images suggested ingestion into the bronchus and a chest X-ray confirmed presence of a pill camera overlying the right main stem bronchus. He underwent an emergent flexible bronchoscopy with successful extraction of the capsule. This was followed by endoscopy assisted capsule insertion into his duodenum.He tolerated the procedure well. DISCUSSION: VCE is increasingly being used to provide diagnostic imaging of the small intestines, an anatomic site that is peculiarly difficult to visualize. Suspected small bowel bleeding and tumors of the small bowel are some of the common indications of VCE.Capsule aspiration although a rare complication with VCE can be life threatening. Early detection with emergent timely retrieval of the capsule is recommended. In order to prevent such complications and to be able to intervene expeditiously, it is recommended that VCE should be administered in an office with oxygen and where other resuscitative facilities are available. In conclusion, though rare, capsule aspiration is a serious complication of VCE and physicians should pay attention to patients who have any delay in capsule ingestion and if possible confirm passage of the capsule endoscope into the stomach before the patient leaves the clinic.

Continuing Medical Education Questions: April 2019.

Article Title: The Clinician's Guide to Suspected Small Bowel Bleeding.

The Clinician's Guide to Suspected Small Bowel Bleeding.

Small bowel bleeding accounts for 5-10% of gastrointestinal bleeding. With the advent of capsule endoscopy, device-assisted enteroscopy, and multiphase CT scanning, a small bowel source can now be found in many instances of what has previously been described as obscure gastrointestinal bleeding. We present a practical review on the evaluation and management of small bowel bleeding for the practicing clinician.