Diagnostic Yield and Clinical Impact of Capsule Endoscopy in Obscure Gastrointestinal Bleeding during Routine Clinical Practice: A Single-Center Experience

Objective: This study assessed the diagnostic yield of capsule endoscopy (CE) and its impact on patients with obscure gastrointestinal bleeding (OGIB). Subjects and Methods: Between May 2007 and May 2009, 63 patients with OGIB (overt bleeding: 25, and occult blood loss with chronic ferropenic anemia: 38) and normal upper and lower endoscopy were studied by CE. Demographic characteristics, prior diagnostic tests, CE findings, therapeutic interventions, medical treatment and clinical outcomes following CE were evaluated. Results: The overall diagnostic yield was 44.44% of patients and included findings of angiectasia in 11 (17.46%) patients, nonsteroidal anti-inflammatory drugs enteropathy in 6 (9.52%) patients, celiac disease in 3 (4.76%) patients, tumors in 2 (3.17%) patients, and a variety of other diagnoses ranging from varices to ulcers (due to congenital afibrinogenemia and amyloidosis). The diagnostic yield was notably higher in overt bleeders (15/25, 60%) compared to occult bleeders (13/38, 34.21%; p = 0.044), and in patients with overt Received: June 11, 2009 Revised: November 9, 2009 Grigoris Chatzimavroudis Department of Endoscopy and Motility Unit Central Hospital, Ethnikis Aminis 41 GR–64635 Thessaloniki (Greece) Tel. +30 231 096 3266, Fax +30 231 099 2563, E-Mail gchatzimav @ yahoo.gr © 2010 S. Karger AG, Basel 1011–7571/11/0201–0060$38.00/0 Accessible online at: www.karger.com/mpp D ow nl oa de d by : 54 .7 0. 40 .1 1 11 /2 3/ 20 17 2 :4 3: 26 A M Clinical Usefulness of Capsule Endoscopy in Obscure GI Bleeding Med Princ Pract 2011;20:60–65 61 bowel follow-through and computed tomography in detecting bleeding lesions in the small intestine. Numerous studies have shown that the diagnostic yield of CE ranges from 45 to 75% [4, 8–13] . Moreover, several calculations have been performed to define the impact of CE on the outcome of patients evaluated for OGIB, with impact percentages ranging from as low as 30% to as high as 77.3% [8–16] . However, most of the studies were performed in tertiary referral centers with large experience in CE. Therefore, there is limited experience [14, 17] on the diagnostic yield and clinical impact of CE in patients with OGIB during routine clinical practice. The aim of this study was to evaluate the diagnostic yield of CE and its effect on the management of patients with OGIB in routine clinical practice. Subjects and Methods Between May 2007 and May 2009, a total of 63 patients with OGIB were referred to the Department of Endoscopy and Motility Unit of ‘G. Gennimatas’ General Hospital, Thessaloniki, Greece, where they underwent CE. The small intestine was examined in all patients as the capsule reached the cecum successfully at the end of its battery life. There were 30 males and 33 females, with a mean age of 54.17 8 15.4 years (range: 17–86 years) ( table 1 ). Our department is a tertiary referral center in Northern Greece, highly specialized in interventional endoscopy. Obscure gastrointestinal bleeding was defined according to the recently published American Gastroenterological Association (AGA) position statement [18] . Patients were defined as having occult digestive bleeding when they presented with chronic iron deficiency anemia without any clinically evident bleeding episode, no evidence of inadequate iron intake, no excessive gynecological bleeding or evidence of malabsorption. Patients were defined as having overt digestive bleeding when they had a bleeding episode marked by melena, hematochezia or hematemesis. All patients had undergone nondiagnostic upper and lower endoscopy. Exclusion criteria were: pregnancy, symptoms/signs of bowel obstruction, presence of implanted pacemaker, use of narcotics, and swallowing disorders. Written informed consent was obtained from all patients before CE, after verbal and written explanation about the advantages and possible complications of the examination. Patients remained fasted for 12 h before swallowing the capsule. An oral purge (with 3 liters of polyethylene glycol solution in the evening and 1 liter in the morning) was given before capsule ingestion. A total of 4 liters instead of 2 liters of oral purge was preferred in order to improve the visibility of the small intestines and thus increase the validity and reliability of the test. CE was performed using the Olympus Capsule Endoscopy (Olympus, Tokyo, Japan). Once the system had been set up and the capsule was swallowed, patients were observed for 8 h in the hospital before the system was removed. The recorder was connected to a computer workstation, in which the images were processed and then viewed on a monitor using a specifically designed software package, allowing images to be viewed at various speeds, with facilities for pausing and rewinding. Capsule images were reviewed by an experienced endoscopist (PK). The reviewer, who was not blinded to the indication of OGIB, interpreted and characterized the lesions at the time of reading in a similar fashion to the CE structured terminology (CEST) previously described and reported in 2005 [19] . A plain abdominal radiograph was performed if the capsule was not expelled 72 h after ingestion. The findings were considered clinically significant if they could be the cause of GI bleeding or iron malabsorption. These included angiectasia, large ulcerations, tumors, varices, multiple erosions and changes suggestive of celiac disease [19] . Findings that were considered not to have bleeding potential included red spots, small isolated erosions, nonbleeding diverticula and nodules without mucosal breaks [19] . All findings on CE were communicated to the referring physicians, and the patients’ subsequent management was carried out at the discretion of the referring physician, the patient’s decision and our ability to perform specialized endoscopic interventions (single balloon enteroscopy). Clinical and laboratory data collected regarding CE included age, gender, duration of OGIB, type of GI bleeding (obscure-overt vs. obscure-occult), prior endoscopic evaluation, prior radiographic examination (small bowel follow-through, abdominal CT and MRI) or other diagnostic modalities (angiography, 99m Tc-pertechnate scan), hematological and biochemical profile, antigliandin, antiendomysial and antitransglutaminase antibodies and history of nonsteroidal anti-inflammatory drugs (NSAIDs) or antiplatelet use. Follow-up information was obtained from a review of the inpatient and outpatient charts and by telephone contact with the referring physicians, patients or their families in order to assess the current medical status of the patients and to determine whether medical treatment, or endoscopic or surgical intervention occurred at another hospital. Specific medical therapy included long-acting somatostatin for nonresectable or unsuccessful endoscopically cauterized angiectasia and gluten-free diet. Endoscopic therapy included cauterization of angiectasia. Surgeons performed segmental small bowel resection in patients with a tumor and intractable angiectasia. A positive outcome was determined by the improvement in hemoglobin levels (decreased need or interruption of blood transfusions or iron supplements). The study was approved by the Central Hospital Institutional Review Board. Statistical Analysis The statistical analysis was performed using the Statistical Package for Social Sciences (SPSS, version 13.0, Chicago, Ill., USA). The differences in diagnostic yields of CE between the study subgroups were analyzed with 2 and Fisher’s exact tests as appropriate. p ! 0.05 was considered statistically significant.