Introduction

In patients treated with anticoagulant medication, the number of hospital admissions for gastrointestinal bleeding is up to 1.15 for 100 patients per year, with an increased risk for patients treated with DOACs (1).

Aims & Methods

The study aims to evaluate the diagnostic yield of small bowel capsule endoscopy in patients while on antithrombotic therapy for suspected small bowel bleeding. This is a single center, retrospective, observational study conducted from January 2015 to March 2019. We enrolled consecutive patients with suspected small bowel bleeding or iron deficiency anemia undergoing SBCE after bidirectional negative endoscopy. Positive findings were defined according to the P0-P2 classification reported by Saurin et al (3). Bleeding severity was defined according to the "International Society of Thrombosis and Haemostasis" (ISTH) criteria. We considered in anticoagulant therapy: direct oral anticoagulant (DOAC), vitamin K antagonist (VKA), injective anticoagulant (Low-molecular-weight heparin, unfractionated heparin, fondaparinux). We considered in antiplatelet therapy: aspirin, clopidogrel, ticagrelor. A descriptive analysis of the data was performed, with a calculation of the mean, median, proportions, standard deviation and 95% confidence limits depending on data type.

Results

We analyzed and collected data from 369 patients, 95 while on antithrombotic therapy: 40 with DOACs, 35 with VKAs, and 20 with injective anticoagulants. The mean age was, overall, 66.4 years (SD±14.9), 60.1 years (SD±16.2) in the control group, 72.4 (SD±8.8) in the antiplatelet group, 73.3 years (SD±11.49) in the anticoagulant group and 71.3 years (SD±12.2) in the anticoagulant+antiplatelet group. In table 1, there are reported patients’ demographic and clinical characteristics. In the DOAC group we found a statistically significant higher number of patients presenting with active bleeding and without lesion identification (8 patients 20.0% Vs 11 patients 6.0% in the control group, 3 patients 8.6% in AVK group and 3 patients 15.0% in the injective anticoagulant group). The angioectasia is the most frequent lesion detected in patients with antiplatelet + anticoagulant therapy (7 patients 46.7% VS 21 patients 20.2% in the control group, 8 patients 21.1% in the antiplatelet group and 3 patients 8.8% in the anticoagulant alone group; p=0.027).

Conclusion

Our results show that patients with antithrombotic therapy are, usually, elderly and with more comorbidities than the control group. Furthermore, in this specific group, the hemoglobin level was lower and the need for transfusion was higher. Angioectasia is the most frequent positive findings in patients with both antiplatelet and anticoagulant therapy.

References

1. Ray WA, et al. Association of Oral Anticoagulants and Proton Pump Inhibitor Cotherapy With Hospitalization for Upper Gastrointestinal Tract Bleeding. JAMA. 2018;320(21):2221

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

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

Capsule endoscopy (CE) is a valuable, non-invasive diagnostic tool for the evaluation of small bowel disorders, particularly in patients with suspected inflammatory bowel disease (IBD), known Crohn’s disease, or non-responsive celiac disease (NRCD) (1). Its role in identifying mucosal lesions and guiding clinical decision-making continues to expand, especially in the context of complex or unclear gastrointestinal symptoms.

Aims & Methods

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. Indications for CE included suspected IBD (e.g., diarrhea, abdominal pain, elevated fecal calprotectin), follow-up of known ileal Crohn’s disease, and evaluation of NRCD. Demographic and clinical data were collected in a dedicated database. CE was considered positive if at least one of the following findings was present: evidence of recent bleeding, ulcers, or villous atrophy. Multivariate analyses were used to assess risk factors associated with ulcers and villous atrophy. Statistical analyses were conducted using STATA 18.

Results

A total of 351 CE procedures were included: 210 for suspected IBD, 108 for IBD follow-up, and 37 for NRCD. The mean age of the cohort was 45.7 ± 16.0 years, with 47% male patients. The diagnostic yield was 39.3% for suspected IBD, 44.4% for IBD follow-up, and 56.7% for NRCD. The prevalence of recent bleeding was similar across groups (31.1% vs. 27.4% vs. 31.6%, p=0.895), as was the presence of ulcers (65.3% vs. 62.1% vs. 40%, p=0.105). However, villous atrophy was significantly more frequent in NRCD patients (0% in suspected IBD, 2.3% in IBD, and 66.7% in NRCD; p<0.001). No association was found between lesions and age, sex, hemoglobin levels, or comorbidities. CE findings led to therapeutic changes in 37% of IBD cases and in 16% of NRCD cases.

Conclusion

This single-centre cohort study confirms the high diagnostic yield of capsule endoscopy in patients with small bowel disorders and highlights its impact on their clinical management.

References

1. Tamilarasan AG, Tran Y, Paramsothy S, Leong R. The diagnostic yield of pan-enteric capsule endoscopy in inflammatory bowel disease: A systematic review and meta-analysis. Journal of Gastroenterology and Hepatology (Australia). 2022 Dec 1;37(12):2207–16.

Clinical Case Summary

Secondary aortoenteric fistula (AEF) is an abnormal connection between the aorta and gastrointestinal tract (GT) resulting from reconstructive surgery for an abdominal aortic aneurysm (AAA), including open repair surgery and endovascular treatment. Despite the low incidence (1.6 to 4%) [1–4], it is life-threatening and has a high mortality rate (24 to 45.8%) [5–6].
A 79- year-old man reported to the emergency department of our hospital with overt bleeding from the stoma. The patient had a history of open Dacron graft repair for a ruptured AAA eight months previosly, which became complicated on the 5th postoperative day by sigmoid ishemia that required an emergency Hartmann procedure.
His blood pressure was 90/60 mmHg, heart rate 93/minute and hemoglobin level 7.5 g/dL.
The patient was admitted to our department. He underwent upper and lower endoscopy and no bleeding lesions were found. After endoscopy the patient presented another episode of overt bleeding from the stoma and we decided to perform Small-bowel capsule endoscopy (SBCE) which showed activ bleeding within the proximal ileum. The contrast-enhanced CT demostrated an aneurysm sac enlargement, a close proximity of the small bowel loops with the aneurysm sac in the pelvic cavity and a suspected leakage at the distal part of the aneurysm sac.
The patient was therefore admitted to the Surgical Derpatment and underwent an emergency endovascular repair of the leakage caused by distal detachment of the aorto-aortic prosthesis using a bifurcated stant graft. No more bleeding from the stoma occurred and the patient was discharged three days later with a diagnosis of distal aortic anastomosis leakage with aorto-ileal fistula.
The duplex ultrasound of the graft after one, three and six months showed no sign of endoleak.
This case shows that the SBCE may be useful in patients with history of recostructive surgery for AAA who manifest overt bleeding from the GT and no lesions are found in upper and lower endoscopy.

References

1.Wilson WR, Bower TC, Creager MA, Amin-Hanjani S, O’Gara PT, Lockhart PB, Darouiche RO, Ramlawi B, Derdeyn CP, Bolger AF, et al. Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association. Circulation. 2016;134(20): e412–60
2.Champion MC, Sullivan S, Coles J, Goldbach M, Watson WC. Aortoenteric fistula. Incidence, presentation recognition, and management. Ann Surg. 1982;195(3):314–7
3.Hallett JW Jr, Marshall DM, Petterson TM, Gray DT, Bower TC, Cherry KJ Jr, Gloviczki P, Pairolero PC. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg. 1997;25(2):277–84. discussion 285-276
4.Chenu C, Marcheix B, Barcelo C, Rousseau H. Aorto-enteric fistula after endovascular abdominal aortic aneurysm repair: case report and review. Eur J Vasc Endovasc Surg. 2009;37(4):401–6
5.Malik MU, Ucbilek E, Sherwal AS. Critical gastrointestinal bleed due to secondary aortoenteric fistula. J Community Hosp Intern Med Perspect. 2015;5(6):29677
6.Gnus J, Ferenc S, Koscielna M, Paprocka-Borowicz M, Dawidczyk P, Dziewiszek M, Witkiewicz W. Secondary Aortoenteric Fistula After Abdominal Aortic Graft Implementation in Our Own Material. Adv Clin Exp Med. 2016;25(6):1265–71