Introduction

In the European Society of Gastrointestinal Endoscopy guidelines (updated 2022), obscure gastrointestinal bleeding (OGIB) should be reserved for patients not found to have a source of bleeding by small-bowel evaluation. Herein, OGIB was defined as P0 (no bleeding potential) or P1 (less likely to bleed), based on the P classification using small-bowel capsule endoscopy (CE). We aimed to clarify the long-term outcomes of patients with OGIB.

Aims & Methods

We retrospectively examined 796 consecutive patients with OGIB who underwent CE at the Hiroshima University Hospital between March 2014 and October 2021. Of the eligible patients, 302 were excluded because of small-bowel bleeding (148 patients), incomplete observation of the small-bowel (85 patients), a bleeding source located outside the small-bowel (67 patients), or equipment failure (2 patients). Therefore, a total of 494 patients with OGIB and negative CE findings were included in this study. Of these, 33 could not be followed up for more than 1 year. Thus, a final total of 461 patients were enrolled in this study (257 males, median age: 70 years, median observation period: 654 days, and median hemoglobin value: 8.4 g/dL). These were classified into P0 and P1 groups according to CE findings, and we examined rebleeding rates and predictive factors.

Results

Of the 461 patients, 224 (49%) had P0 and 237 (51%) had P1 findings. There were no significant differences between the two groups in terms of sex, age, observation period, hemoglobin value, and bleeding pattern. Nor were there any significant differences in the use of antiplatelet agents, anticoagulants. In terms of comorbidities, the incidences of liver cirrhosis (15% vs. 33%, P < 0.001) and diabetes mellitus (16% vs. 28%, P = 0.002) were significantly higher among patients in the P1 group than those among patients in the P0 group. Rebleeding was observed after CE in 57 of the 461 patients (12.4%), specifically, 20 of the 224 patients (8.9%) in the P0 group and 37 of the 237 patients (15.6%) in the P1 group. Two patients in the P0 group and 15 patients in the P1 group were rebleeding from small-bowel. The rate of rebleeding from the small-bowel was significantly lower in the P0 group than that in the P1 group (0.9% vs. 6.6%, P = 0.002), as was the cumulative rebleeding rate (P = 0.005). According to the multivariate analysis, post-endoscopic treatment of small-bowel lesions (hazard ratio (HR) = 13.028, 95% confidence interval (CI):4.448–38.160, P < 0.001) and P1 CE findings (HR = 10.000, 95% CI:2.154-46.438, P = 0.003) were independent predictive factors for rebleeding from the small-bowel.

Conclusion

Rebleeding may occur in patients with OGIB. Patients with P1 CE findings or post-endoscopic treatment of small-bowel lesions may experience rebleeding from the small-bowel, suggesting the need for careful follow-up.

Introduction

Use of antithrombotics including antiplatelet agents and anticoagulants is associated with upper and lower GI bleeding, thus a higher rate of positive findings is reasonable to be expected when patients receiving these drugs undergo SBCE for the investigation of SBB. However, the results of published studies concerning the impact of antithrombotics on the SBCE diagnostic yield remain conflicting. Furthermore, the clinical outcome of patients under antithrombotics who undergo SBCE for the investigation of SBB is not currently known.

Aims & Methods

We aimed to determine the diagnostic yield and outcome of patients receiving antithrombotic drug therapy subjected to small bowel capsule endoscopy (SBCE) for the investigation of small bowel bleeding (SBB). Multicenter retrospective analysis of collected data from all patients undergoing SBCE for the investigation of SBB from March 2003 to June 2023. The diagnostic yield of SBCE was defined as the detection of positive findings that could explain the cause of the patient’s bleeding. Rebleeding was defined as evidence of bleeding within 1 year after the index episode.

Results

During the study period, 8401 patients underwent SBCE for SBB investigation. Bleeding lesions were detected in 1103/2535 (43.5%) patients receiving antithrombotics, compared to 1113/5866 (18.9%) not receiving these drugs (p<0.00001). Following capsule endoscopy, a therapeutic intervention was possible in 390/2216 (17.5%) patients with a bleeding lesion. Rebleeding occured in 927 (36.5%) of patients receiving antithrombotics (36.5%), compared to 795 (13.5%) not receiving these drugs (13.5%, p<0.00001).

Conclusion

Both the diagnostic yield of SBCE and the rebleeding rate were higher in patients with SBB receiving antithrombotics. Therapeutic intervention was possible in a real world setting only in a minority of patients with positive findings.

References

1. Sherwood MW, Nessel CC, Hellkamp AS, et al. Gastrointestinal bleeding in patients with atrial fibrillation treated with rivaroxaban or warfarin: ROCKET AF trial. J Am Coll Cardiol 2015; 66: 2271–2281.
2. Abraham NS, Hlatky MA, Antman EM, et al. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of PPI and thienopyridines: focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Am J Gastroenterol 2010; 105:2533–2549.
3. Maiden L, Thjodleifsson B, Seigal A, et al. Long-term effects of nonsteroidal anti-infammatory drugs and cyclooxygenase-2 selective agents on the small bowel: a cross-sectional capsule enteroscopy study. Clin Gastroenterol Hepatol. 2007;5:1040–1045.
4. Nagata N, Niikura R, Yamada A, et al. Acute middle gastrointestinal bleeding risk associated with NSAIDs, antithrombotic drugs, and PPIs: a multicenter case-control study. PLoS ONE. 2016;11:e0151332.
5. Lepileur L, Dray X, Antonietti M, et al. Factors associated with diagnosis of obscure gastrointestinal bleeding by video capsule enteroscopy. Clin Gastroenterol Hepatol. 2012;10:1376–1380.
6. Shiotani A, Honda K, Murao T, et al. Combination of low-dose aspirin and thienopyridine exacerbates small bowel injury. Scand J Gastroenterol. 2011;46:281–286.

Introduction

Small bowel bleeding remains challenging to diagnose due to limited access with conventional endoscopy. Capsule endoscopy (CE) is increasingly used both in emergency settings following overt bleeding and in the evaluation of chronic, unexplained anemia (1-2). Better risk stratification for small bowel lesions may refine the need for CE.

Aims & Methods

Our primary aim was to assess the diagnostic yield of CE in suspected small bowel bleeding, while secondarily identifying predictive factors for angiodysplasia, recent bleeding, and ulcers. This observational single-centre retrospective study included all CE procedures performed at the Department of Gastroenterology of the Azienda Ospedaliera–Università di Padova between January 1, 2018, and December 31, 2024, for indications of overt or occult gastrointestinal bleeding. Demographic and clinical data were collected in a dedicated database. CE was considered positive if at least one of the following lesions was identified: angiodysplasia, signs of recent bleeding, polyps, ulcers, red spots, or villous atrophy. Multivariate analyses were conducted to assess the risk factors associated with angiodysplasia, recent bleeding, and ulcers. Statistical analyses were performed using STATA 18.

Results

A total of 1,057 CE procedures were performed for the indication of gastrointestinal bleeding, including 310 for overt bleeding and 747 for occult bleeding. The mean age of the cohort was 71 ± 13 years, and 55.6% were male, with no significant differences in age or sex between the two groups. The overall diagnostic yield was comparable between patients with overt and occult bleeding (77.1% vs. 75.2%, p=0.520). The prevalence of angiodysplasia was similar in both groups (80.4% vs. 78.1%, p=0.501), as was the detection of recent bleeding (57.1% vs. 50.2%, p=0.150). However, small bowel ulcers were significantly more frequent in patients with overt bleeding (45.9% vs. 34.2%, p=0.023).
In the multivariate analysis, the risk of detecting angiodysplasia was lower in patients receiving antiplatelet (OR 0.60; 95% CI: 0.66–0.99) or anticoagulant therapy (OR 0.40; 95% CI: 0.26–0.66), but significantly higher in older age groups compared to those aged 18–45 years: 46–60 years (OR 6.02; 95% CI: 2.2–16.7), 61–80 years (OR 8.80; 95% CI: 3.4–22.7), and >80 years (OR 13.62; 95% CI: 4.9–37.3). Increased risk was also associated with lower hemoglobin levels: 7–10 g/dL (OR 2.90; 95% CI: 1.5–5.5) and <7 g/dL (OR 2.17; 95% CI: 1.2–3.9). Similar predictors were found for recent bleeding. Conversely, the risk of ulcers was lower in patients with occult bleeding (OR 0.60; 95% CI: 0.4–0.9), and higher in those who received blood transfusions (OR 1.70; 95% CI: 1.0–2.7) and those with hemoglobin <10 g/dL (OR 2.40; 95% CI: 1.2–5.0 for Hb 7–10 g/dL and OR 2.60; 95% CI: 1.3–5.2 for Hb <7 g/dL).

Conclusion

This large single-centre cohort study confirms the high diagnostic yield of capsule endoscopy in patients with both overt and occult gastrointestinal bleeding. Older age and severe anemia are strong predictors for angiodysplasia and signs of recent bleeding, while overt bleeding and low hemoglobin levels are significantly associated with the presence of small bowel ulcers.

References

1. Iddan G, Meron G, Glukhovsky A et al. Wireless capsule endoscopy. Nature 2000; 405(6785): 417.
2. Pennazio M, Rondonotti E, Despott EJ, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy. 2023 Jan;55(1):58-95.

Introduction

Double-headed capsules enable the non-invasive one-step endoscopic evaluation of both the small bowel and colon (pan-intestinal capsule endoscopy, PCE).

Aims & Methods

We aim to evaluate the diagnostic accuracy and safety of PCE vs. the current standard of care (conventional colonoscopy) as the first-line examination in patients with iron deficiency anaemia (IDA) and/or overt bleeding after a non-diagnostic upper endoscopy (suspected mid or lower gastrointestinal bleeding, MLGIB).
We conducted a prospective, single-centre, single-blinded cohort study including consecutive patients with suspected MLGIB. All patients were submitted to PCE, followed by same-day colonoscopy under deep sedation. The physicians performing PCE and conventional colonoscopies were independent and blinded to each other’s observations. The diagnostic yield for potentially haemorrhagic lesions (PHL) was compared for efficacy analysis, and adverse events were assessed for both examinations. The gold standard diagnosis was defined by consensus panel. This trial has been registered in ClinicalTrials.gov (ID NCT04782986).

Results

We included 100 consecutive patients with suspected MLGIB, mean age 66.5 (18-92) years, 65% female gender, presenting with IDA (81%) or overt bleeding (19%). Mean haemoglobin level was 8.4 (4.1-12.8) g/dL and 40% were inpatients. For PCE, the PillCam Crohn’s® capsule was used in 88 patients, and PillCam COLON® 2 in the remaining. Patients with overt bleeding performed PCE within 2 weeks in 70% of cases, 15% in the first 72h after the bleeding episode. PCE was complete in 76% of cases, vs. colonoscopy 95% (p<0.01). The quality of bowel preparation was adequate in 72% of PCE vs. 85% of colonoscopies (p=0.012). Overall, PHL were diagnosed, based on the combination of PCE + colonoscopy, in 46% of patients, corresponding to small bowel and/or colon angioectasias in more than two-thirds (69.6%) of cases. PHL were detected by both examinations in 13/46 (28.3%), only by colonoscopy in 3/46 (6.5%), and only by PCE in 30/46 (65.2%) of cases (p<0.01). Overall, colonoscopy detected PHL in 23% of the entire cohort, which means 50% (23/46) of all patients with PHL according to the consensus panel, while for PCE the overall diagnostic yield was 44%, meaning 95.7% (44/46) of all PHL (p<0.01). Considering the gold standard diagnosis for PHL, colonoscopy had a sensitivity of 23/46=50%, specificity 54/54=100%, positive predictive value (PPV) 23/23=100% and negative predictive value (NPV) 54/77=70,1%, while for PCE the sensitivity was 44/46=95.7%, specificity 54/54=100%, PPV 44/44=100% and NPV 54/56=96.4%. Thirty-one percent of patients had PHL accessible to ileocolonoscopy; in those cases, the PCE was able to make the diagnosis in 29/31 (93.5%) vs. conventional colonoscopy in 23/31 (74.2%) of cases, p<0.01. Regarding safety, no significant adverse events occurred with PCE, vs. 2% (cardiopulmonary) with conventional colonoscopy.

Conclusion

PCE is safe and more effective than conventional colonoscopy in identifying PHL both in the small bowel and the colon, and could be considered as a first-line examination in patients with IDA or overt bleeding after a non-diagnostic upper endoscopy. In more than half of patients with suspected MLGIB, PCE does not detect any PHL either in the small bowel or the colon, dismissing any further invasive endoscopic investigations.

Disclosure

Medtronic provided financial support to the acquisition of some of the capsules which were used in the trial

Introduction

A double-balloon enteroscope was introduced in 2001, enabling comprehensive endoscopic examination of the entire small bowel and significantly enhancing the diagnostic utility for small bowel lesions. The advent of technologies such as double-balloon enteroscopy (DBE) and capsule endoscopy has represented a major advancement over recent decades. The novel double-balloon enteroscope EN-840T is equipped with image-enhanced endoscopy (IEE) technologies, including blue laser imaging (BLI) and linked color imaging (LCI). In clinical practice, BLI and LCI are frequently used for esophagogastroduodenoscopy and colonoscopy. However, because conventional double-balloon enteroscopes lack IEE functionality, the efficacy of IEE for detecting small bowel lesions, apart from those in the duodenum, has not yet been reported. In this study, we aimed to evaluate the efficacy of a novel double-balloon enteroscope for enhancing the visibility of small bowel lesions.

Aims & Methods

This single-center retrospective study was conducted at Hiroshima University Hospital and included 49 patients (30 men and 19 women; median age, 55 years; range, 15–89 years) who underwent DBE using EN-840T between March and July 2024. The DBE insertion was performed antegrade in 20 patients, retrograde in 20, and via both routes in nine patients. Lesion visibility and color differences were compared among BLI, LCI, and white light imaging (WLI). The primary and secondary outcomes were the visibility of small bowel lesions on IEE and color differences in these lesions, respectively. Lesion visibility was assessed by five endoscopists, who assigned visibility scores. Additionally, color differences in each IEE and WLI image between normal mucosa and the small reddish lesions, defined as patchy reddish lesions <5 mm in diameter, including angioectasia and erythema, were quantified using the CIE Lab* color space system.

Results

Lesions were classified as inflammatory (n=71 [ulcerations, n=29; erythema, n=25; erosions, n=17]), tumorous (n=39), and vascular (n=10). Notably, LCI did not yield any lesions with decreased visibility compared to WLI. The visibility score improved for most lesions with LCI , including vascular lesions (80%), erythema (80%), erosions (76%), tumorous lesions (72%), and ulcerations (69%). In contrast, BLI demonstrated visibility scores equivalent to those of WLI for the majority of lesions, including vascular lesions (80%), erythema (76%), ulcerations (72%), tumorous lesions (72%), and erosions (65%).
Given the high visibility of vascular lesions and erythema in LCI, we further examined the color differences in small reddish lesions (N=33 [angioectasia, n=8; erythema, n=25]). For angioectasia, the color difference in LCI was significantly higher than that in WLI (25.2 ± 1.83 vs. 20.6 ± 2.14, P < 0.001). Similarly, for erythema, the color difference in LCI was significantly higher than that observed in WLI (25.3 ± 2.25 vs. 19.8 ± 1.82, P < 0.001). Overall, the color difference for all reddish lesions was significantly higher with LCI than with WLI (25.3 ± 2.07 vs. 20.1 ± 1.91, P < 0.001). In contrast, no significant difference in color difference was observed between BLI and WLI.

Conclusion

IEE using a novel EN-840T enteroscope enhanced the visibility of small bowel lesions. Specifically, LCI improved lesion visibility and may contribute to the detection of small lesions.

Disclosure

We have no conflicts of interests.

Clinical Case Summary

Small bowel bleeding can pose a diagnostic and therapeutic challenge.
We present an interesting case involving the use of different endoscopic modalities in jejunal diverticular bleeding. A 66-year-old male with gout and intermittent Naproxen use presented to the Emergency Department with melena. Oesophagogastroduodenoscopy (OGD) and colonoscopy did not reveal any source of bleeding. A Computed Tomography Mesenteric Angiography scan showed evidence of recent hemorrhage within the small bowel loops without active blush seen. Subsequent video capsule endoscopy (VCE) revealed blood pooling in the distal small bowel. He underwent a retrograde double balloon enteroscopy showing only coffee-ground stains in the distal jejunum. Further review of VCE images showed another small ‘dark spot’ in the proximal jejunum. Thus, he underwent an antegrade motorised spiral enteroscopy (MSE) which showed fresh blood clots in the proximal jejunum with multiple large diverticula. Active bleeding was identified from one of the diverticula but difficulty was encountered in manoeuvring the MSE into the jejunal diverticulum. The MSE was switched to a cap-fitted paediatric colonoscope which made it easier to advance into the proximal jejunal diverticulum to address the pulsating vessel. Hemostasis was achieved with adrenaline injection and application of hemostatic clips.
MSE can locate pathology that lies coaxial to the axis of the scope but it can be difficult to reach the culprit lesion due to its off axis location and acute angulation within the diverticulum. Push enteroscopy or balloon-assisted enteroscopy (BAE) maintains its benefit of having a more flexible shaft/tip and can safely enter a jejunal diverticulum for hemostasis even if located off axis compared to MSE. Although MSE represents an innovation, conventional push enteroscopy or BAE still remains an important tool in the endoscopic armamentarium.

References

Illustrative material

1. VCE image with ‘dark spot’
2. Endoscopic image of large diverticulum
3. Hemostasis was achieved with adrenaline injection and application of hemostatic clips