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Relevance of capsule endoscopy in patients with obscure gastrointestinal bleeding - a comprehensive real-world study
M Vetter1,2, S Gebhardt1,2, G Kessler1,2
1Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nurnberg and Universitatsklinikum, Erlangen, Germany.
Insights
Capsule endoscopy (CE) is effective for diagnosing obscure gastrointestinal bleeding, especially in patients with melena. Early and complete CE improves detection rates and guides further management, including double-balloon enteroscopy (DBE).
Area of Science:
- Gastroenterology
- Medical Diagnostics
- Endoscopy
Background:
- Gastrointestinal bleeding is a common issue, with 5% of cases remaining undiagnosed after standard gastroscopy and colonoscopy.
- Obscure gastrointestinal bleeding (OGIB) necessitates advanced diagnostic tools to identify the bleeding source.
- Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are key technologies for investigating OGIB.
Purpose of the Study:
- To evaluate the diagnostic yield of capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding.
- To determine factors influencing CE detection rates for gastrointestinal bleeding.
- To assess the impact of CE findings on subsequent patient management, including the use of DBE.
Main Methods:
- Retrospective analysis of 305 patients who underwent CE for suspected OGIB at two German centers.
- All patients had prior negative gastroscopy and colonoscopy.
- PillCam SB was used for CE; data on bleeding detection, patient symptoms, red blood cell (RBC) transfusion needs, INR levels, and subsequent DBE procedures were analyzed.
Main Results:
- CE identified a bleeding source in 63.9% of patients, with higher detection rates in cases of melena only (72.4%).
- Early (day 1) and complete CE procedures were associated with significantly higher detection rates.
- CE findings influenced the decision for DBE, increasing its utilization and the likelihood of detecting a bleeding source with DBE; however, DBE did not significantly alter hospitalization length or RBC transfusion requirements.
Conclusions:
- Capsule endoscopy is a valuable tool for diagnosing obscure gastrointestinal bleeding, particularly in patients presenting with melena.
- Performing CE early and ensuring its completeness can maximize diagnostic yield.
- CE findings guide the use of further investigations like DBE, potentially improving diagnostic success in complex cases.
Abstract:
Gastrointestinal bleeding is a common clinical problem. In 5% of these cases, no source of bleeding can be found by gastroscopy or colonoscopy. The aim of this study was to investigate which of these patients benefit from capsule endoscopy (CE) and how it affects subsequent management. 305 patients who underwent CE for suspected obscure gastrointestinal bleeding at two German gastroenterological centers were analysed retrospectively. All patients had previously undergone gastroscopy and colonoscopy without evidence of a sufficient source of bleeding. The PillCam SB (Medtronic) was used for CE. A source of bleeding was identified in 63.9% (195/305) of cases with CE. A source of bleeding tented to be detected more frequently by CE in patients with melena only (72.4%, p=0.002) compared to patients with hematochezia with or without melena (55.6% and 45.9%). Furthermore, early CE (day 1: 73.3%, day 2: 61.5%, day 3: 53.8%; p=0.378) and complete CE (71.1% vs. 38.8%, p=2.56*10-6) were associated with a higher detection rate. Blood was detected in 31.5% (96/305) of all CEs. However, this tended to be observed more often in patients with a high need for red blood concentrates (0 RBC: 21.4%, 1-2 RBC: 34.9%, 3-4 RBC: 38.3%, ≥5 RBC: 45.7%; p=0.026), a derailed INR (<1.15: 32.6%, 1.16-2.0: 19.5%, 2.0-3.0: 32.0%, >3: 60.0%; p=0.023) and early CE (day 1: 46.7% (7/15), day 2: 41.0% (16/39), day 3: 25.0% (13/52); p=0.244). In 12.5% of the patients a double-ballon enteroscopy (DBE) was conducted. The detection of blood during CE increased the probability for a DBE (25.0% vs. 6.7%; OR: 4.61; p=2.061*10-5). Detection of a source of hemorrhage with CE increased the likelihood of detecting a source of hemorrhage with DBE (48.1% vs. 9.1%; OR: 8.83; p=0.030). Performing a DBE did not affect the length of hospitalisation (without DBE 10d, with DBE 9.1d, p=0.81) or the number of RBCs transfused after CE (without DBE 1.9 RBC, with DBE 2.4 RBC, p=0.67). In particular, patients with melena and an increased need for RBCs could benefit from an early and complete capsule endoscopy. If a source of bleeding was detected by CE, the probability of a finding in DBE could be increased.
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