Introduction

Capsule endoscopy (CE) is an important non-invasive diagnostic modality for the evaluation of small bowel and colon. However, in patients with gastrointestinal tract anatomy altered by surgical interventions, there can be a higher risk of incomplete examination of small bowel and colon.

Aims & Methods

The aim of our study was to evaluate the rate of complete examination and diagnostic yield of CE, in patients with previous gastrointestinal surgery, as well as the impact of endoscopic placement of CE using the AdvanCE device.
Retrospective, cohort study, including patients submitted to CE of the small bowel or colon, detailing patients with previous gastrointestinal surgeries and with endoscopic placement of CE.

Results

A total of 642 patients was included, 17 with previous gastrointestinal surgery (2.6%), from which 9 with gastric bypass and Y-de-Roux (with 3 having esophagojejunostomy and 6 gastrojejunostomy), 3 patients with Bilroth II, 2 with Bilroth I e 3 patients with sleeve gastrectomy.
Endoscopic placement of CE was performed at the discretion of the responsible gastroenterologist and occurred in 8 patients (1.2%). It was 13.3 times more likely to be performed in patients with previous gastrointestinal surgery (11.8% vs 1.0%, p=0.017).
In patients without endoscopic placement of CE, the rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was comparable between those with and without previous gastrointestinal surgery: 86.7% vs 85.3% (p=1.000), 73.3% vs 78.1% (p=0.751) e 40% vs 38% (p=0.875), respectively.
In patients with gastrointestinal surgery, the rate of complete examination of the gastrointestinal tract was comparable between patients with and without endoscopic placement of CE: 50.0% vs 86.7% (p=0.331). The rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was not influenced by the different types of surgery, considering patients with gastric bypass vs Y-de-Roux vs Bilroth II: 75.0% vs 80.0% vs 66.7% (p=0.915), 50.0% vs 60.0% vs 66.7% (p=0.902) e 25.0% vs 20.0% vs 66.7% (p=0.363), respectively.

Conclusion

CE is effective, even in patients with previous gastrointestinal surgery, with diagnostic yield and rate of complete examination of the gastrointestinal tract similar to other patients, regardless of the type of surgery. Endoscopic placement of CE with AdvanCE device does not seem to improve outcomes in patients with previous gastrointestinal surgery.

Introduction

The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized.

Aims & Methods

Compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for intestinal preparation for SBCE.
A prospective, multicentre, randomized clinical trial including consecutive patients submitted to SBCE was conducted. All patients were instructed to comply with a clear liquid diet and 12-hour fasting before the exam. After ingesting water and 100 mg of simethicone and swallowing the capsule, once it reached the small bowel, patients ingested a booster, randomized into one of three protocols: 1) 1 liter of polyethylene glycol (PEG), 2) 1 liter of PEG and ascorbic acid, 3) 1 liter of water. The patients’ bowel preparation was evaluated with SB-CLEAR. Each patient responded to a questionnaire about their tolerability.

Results

A total of 261 patients were included, 96 patients (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (p=0.655, p=0.193 and p=0.589, respectively). The overall SB-CLEAR score was similar among the protocols (p=0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5±0.1 vs 2: 2.6±0.1 vs 3: 2.3±0.1, p=0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (p=0.850). The patients’ reported tolerability was higher in protocol 3 (protocol 1: 2.8±0.1 vs 2: 3.0±0.2 vs 3: 0.6±0.1, p<0.001).

Conclusion

Using 1 liter of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield versus PEG with or without ascorbic acid.

Introduction

Gastroparesis is common in patients with Diabetes mellitus, especially in those with poor glycemic control. Due to this association, diabetic patients are at risk of prolonged gastric transit time (PGTT) when undergoing small-bowel capsule endoscopy (SBCE).

Aims & Methods

In this investigation we aimed to assess if there was an association between hemoglobin A1c levels and PGTT in diabetic patients undergoing SBCE.
We have conducted a single-center retrospective study including all consecutive diabetic patients undergoing SBCE for two years. Patients without a valid hemoglobin A1c measurement within 3 months from SBCE were excluded. The assessed outcome was PGTT (defined as SBCE remaining in the stomach for >1h, requiring prokinetic administration and/or endoscopically assisted capsule delivery into the duodenum). Possible confounders – age, gender, inpatient status, smoking habits, diagnosis of IBD, thyroid disease, prokinetics or antidepressants regular usage - were also assessed.

Results

Final sample included 77 patients, 40 (51.9%) of them males, with a mean age of 70±10 years. PGTT occurred in 33 (42.9%) individuals. Mean hemoglobin A1c levels were significantly higher in diabetic patients with PGTT (7.4±0.8% vs 6.5±0.8%; p<0.001). In a multivariate analysis including significant confounders, hemoglobin A1c levels were still an independent predictor of PGTT (B=1.35; p<0.001). Single-handedly, hemoglobin A1c levels demonstrated very good acuity in predicting PGTT (AUC=0.80; p<0.001), with an optimal cut-off of HbA1c ≥6.8% (sensitivity 81% and specificity 73%).

Conclusion

Hemoglobin A1c levels significantly influenced the occurrence of PGTT in diabetic patients undergoing SBCE. This may eventually allow the performance of preemptive measurements to avoid PGTT in diabetic patients with poor glycemic control.

Introduction

Small bowel (SB) capsule endoscopy (CE) is a first line procedure for exploring the SB and has numerous indications. Endoscopic GastroIntestinal PlacemenT (EGIPT) of SB CE is sometimes necessary. The experience of EGIPT is large in the pediatric population but limited in adults.

Aims & Methods

We aimed to describe the safety, efficacy and outcomes of EGIPT of SB CE in adult patients.The international CApsule endoscopy REsearch (iCARE) group set up a retrospective multicentric study. Patients over 18 year-old who underwent EGIPT of SB CE before May 2022 were included. Data were collected from medical records and capsule recordings of each participating center. The primary endpoint was the technical success rate of the EGIPT procedures. The secondary endpoints included the adverse events (AE) rate, the duration of EGIPT procedure, the small bowel transit time (SBTT), the completion rate (CR), and the diagnostic yield (DY).

Results

A total of 630 patients were included (mean age 62.5 years old, 55.9% female) from 29 centers. Main indication for SB CE was suspected SB bleeding (70.6%). An impossible oral ingestion (41.8%) and a prolonged lodging of previous CE in the upper GI tract (34.5%) were the two most frequent indications for EGIPT. EGIPT technical success was achieved in 610 procedures (96.8%). Anesthesia was an independent factor of technical success (p<0.0001). AE occurred for 94 patients (14.9%), being severe in three patients. No death occurred. Mean procedure time was 7.2 ± 37.0 minutes. When technically successful, mean SBTT was 278.1 ± 137.9 minutes and EGIPT was associated with a high SB CE CR (84.4%) and with a substantial DY (61.1%). Completion rate was significantly higher when the capsule was delivered in the SB compared to when delivered in the stomach (p<0.0001).

Conclusion

EGIPT of SB CE is highly feasible, safe and comes with high completion rate and diagnostic yield. SBTT seems longer than when CE is orally ingested (220-250 minutes, according to largest series in the literature), most likely related to patient sedation. However, completion rate (84.4%) after SB CE-EGIPT seems similar to that after oral ingestion (83.0% in largest series) whereas DY seems higher (probably for better selected patients).
When indicated, EGIPT should be performed under anesthesia and the capsule should be delivered in the duodenum rather than in the stomach, for better SB examination outcomes.

References

1. Nass KJ, et al. Gastrointest Endosc. 2022;95(6):1078-1085
2. Liao Z, et al. Gastrointest Endosc. 2010;71(2):280-6
3. Cortegoso Valdivia P, et al. Diagnostics (Basel). 2022;12(5):1105.

Disclosure

Lecture fees for Medtronic

Introduction

The timing of performing upper gastrointestinal endoscopy(EGD) in patients with acute upper GI bleeding remains controversial. Different recommendations exist regarding the ideal time interval between the first clinical presentation of acute upper GI bleeding and EGD, assuming no postponement before patient arrival at the hospital. While it is generally agreed that upper gastrointestinal endoscopy should be performed within 24 hours of the first clinical presentation of acute upper GI bleeding, this recommendation poses a significant challenge for medical staff during weekends and healthcare centres with fewer resources than major hospitals.

Aims & Methods

This study was conducted at the Department of Internal Medicine, Gastroenterology Division, at Aleppo University Hospital between July 2018 and June 2020. The study included patients who were admitted due to acute upper gastrointestinal bleeding. The clinical manifestation of upper gastrointestinal bleeding, its duration, and the interval between the first upper gastrointestinal bleeding and the GI endoscopy were determined. Patients were divided into three groups: Group I underwent urgent endoscopy within less than 24 hours of the first bleeding; Group II underwent endoscopy between 24 and 72 hours from the first bleeding; and Group III underwent endoscopy after 72 hours or more of bleeding.

Results

234 patients were included in the study who were admitted to the hospital and underwent upper gastrointestinal endoscopy. Among them, 58.55% were male and 41.45% were female. The average age of the patients was 57.15.
The most common manifestation of acute upper gastrointestinal bleeding was melena, which was observed in 67.59% of cases, followed by hematemesis (52.99%) and epigastric pain (30.34%). The rate of normal esophageal endoscopy findings was 40% in the first group, 54.84% in the second group, and 64.4% in the third group. Hiatal hernia was observed in 30.77% of patients in the first group, 29.03% in the second group, and 28.89% in the third group. Reflux esophagitis was diagnosed in 10.77% of patients in the first group, 10.48% in the second group, and 20% in the third group. Esophageal varices were diagnosed in 10.77% of patients in the first group, 9.68% in the second group, and 13.33% in the third group.
There was no statistically significant difference in the rates of esophageal endoscopy findings among the study groups, except for the presence of blood-filled esophagus, which was significantly more common in the first group (P < 0.05). The highest rate of normal findings in upper gastrointestinal endoscopy was observed in the third group, which was statistically significant (P < 0.05). Blood in the stomach and erosive gastritis were most frequently observed in the first group, with a statistically significant difference in their favor.
The rates of observing gastric ulcers, gastric erosions, hypertensive gastropathy, gastric varices, gastric tumors, portal hypertensive gastropathy, and diffuse mucosal bleeding were similar among the three study groups without a significant statistical difference . The upper gastrointestinal endoscopy was normal in the duodenum in the highest percentage among patients in group three, with a statistically significant difference (P < 0.05). Blood in the duodenum and duodenal edema were observed with the highest rate in patients of the first group with a statistically significant difference compared to the other two groups (P < 0.05). The evaluation of the duodenum among patients of the first group could not be achieved with a higher rate compared to the other two groups, and the statistical difference was significant.
The percentage of observing esophageal ulcers, esophageal biopsies, adherent thrombus, and vascular distortion were similar among the three groups without a significant statistical difference (P > 0.05). The cause of bleeding was identified with certainty by visualizing the bleeding lesion in 32.31% of patients in the first group, 9.68% of patients in the second group, and 4.44% of patients in the third group. There was a statistically significant difference between the groups in favor of the first group.

Conclusion

Our research revealed no significant variance in endoscopic results in patients who underwent endoscopy at distinct time intervals. However, performing early endoscopy, within 24 hours of the first clinical presentation of acute upper GI bleeding, had a higher incidence of detecting the bleeding lesion and identifying the cause of bleeding in comparison to delayed endoscopy. Our study emphasizes the significance of early endoscopy in patients with acute upper GI bleeding to enhance the possibility of identifying the cause of bleeding and administering timely interventions to minimize complications and mortality.

References

1. Acute upper gastrointestinal bleeding: management. London: National Institute for Health and Clinical Excellence: Guidance; 2012.
2. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152(2): 101e13.
3. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy 2015;47(10):a1e46.
4. Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, et al. The role of endoscopy in the management of acute nonvariceal upper GI bleeding. Gastrointest Endosc 2012;75(6):1132e8
5. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107(3):345e60. quiz 61. 6 Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E, et al. Outpatient management of patients with low-risk upper-gastrointestinal hemorrhage: multicenter validation and prospective evaluation. Lancet 2009;373(9657):42e7

Introduction

Delayed bleeding (DB) is a possible adverse event following gastric endoscopic submucosal dissection (ESD). The Bleeding after ESD Trend from Japan (BEST-J) score was created as a risk prediction model for DB following gastric ESD, but is yet to be validated in non-Asiatic populations.

Aims & Methods

We aimed to apply and validate the BEST-J score on a European sample.
We have conducted a longitudinal study of all consecutive patients undergoing gastric ESD on a European Endoscopic Unit. DB was defined as a hemorrhage with clinical symptoms and confirmed by emergency endoscopy from the time of completion of ESD to 28 days after ESD.
BEST-J score (use of vitamin K antagonists +4, direct oral anticoagulants +4, aspirin or P2Y12R antagonists +2; withdrawing antithrombotic drugs -1; chronic kidney disease +3; multiple lesions +1; lesion ≥30mm +1; lesion in lower-third of the stomach +1) was calculated in each patient and confronted with the outcome (DB).

Results

Final sample included 161 patients, 102 (63.4%) male, with a mean age of 68±8 years. From these, 10 (6.2%) presented DB following ESD, with a median time to bleeding of 7 days (IQR 6.8).
According to BEST-J score, bleeding risk was low (0-1 points) in 111 (68.9%), intermediate (2 points) in 29 (18.0%), high (3-4 points) in 16 (9.9%) and very high (≥5 points) in 5 (3.1%) patients.
BEST-J score presented an excellent accuracy predicting DB in our sample, with an AUC=0.907 (95%CI=0.801-1.000; p<0.001). The optimal cut-off value to predict DB was a BEST-J score ≥3, which matches the cut-off value for high-risk of bleeding in the original investigation. This value had a sensitivity of 90% and specificity of 92%.

Conclusion

The BEST-J score still presents excellent accuracy in risk stratification for post-ESD bleeding in European individuals. Thus, this score may help to guide which patients benefit the most from prophylactic therapies following gastric ESD in this setting.

Introduction

Unexplained chronic abdominal pain remains a frequent and often frustrating diagnostic challenge in clinical practice. When initial investigations such as colonoscopy and gastroscopy are inconclusive, small bowel capsule endoscopy (SBCE) provides a non-invasive means to evaluate the small intestine, a part of the gastrointestinal tract that is otherwise difficult to examine. This study explores the effectiveness of SBCE in uncovering underlying causes in patients with unexplained chronic abdominal pain.

Aims & Methods

We aimed to determine the diagnostic yield of SBCE in patients presenting with unexplained chronic abdominal pain and to identify predictive factors for positive findings. This was a retrospective analysis of prospectively collected data from all consecutive patients who underwent SBCE in our tertiary referral center in Greece between March 1, 2003, and April 30, 2025. We included patients who underwent SBCE following negative colonoscopy and gastroscopy. A positive diagnostic yield was defined as the detection of lesions capable of explaining the patient’s symptoms. Predictive factors for positive findings were evaluated using multivariate analysis.

Results

During the study period a total of 11.201 patients were subjected to SBCE and among them 1398(12.4%) patients underwent the test for the investigation of chronic abdominal pain (men/women: 694/704, mean age ± SD: 52.6±27.3 years). Positive findings were detected in 241 patients, leading to a diagnostic yield of 17.2%. The most common findings were inflammatory lesions that were seen in 176 (73.0%) patients[erosions from non-steroidal anti-inflammatory drugs n=75,erosions or ulcers from Crohn’s disease n=97, erosions from radiation enteritis, n =4]while 47 (19.5%) patients had tumor/mass lesions, 9 (3.7%) patients had ischemic colitis, 6 (2.5%) patients had parasites and 3 (1.2%) patients had small bowel strictures. By multivariate analysis, predictive factors for positive findings were elevated C-reactive protein (CRP) (OR=2.73, p<0.0001) and failure to intubate the terminal ileum during colonoscopy (OR=1.40 p=0.03).

Conclusion

The diagnostic yield of SBCE in patients with unexplained chronic abdominal pain is relatively low. Patients with elevated CRP or those in whom the terminal ileum was not examined during colonoscopy are those who will benefit most from the test.