Prediction models for recurrence in patients with small bowel bleeding

Obscure gastrointestinal bleeding(OGIB)has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy.OGIB can present as overt bleeding or occult bleeding,and small bowel lesions are the most common causes.The small bowel can be evaluated using capsule endoscopy,device-assisted enteroscopy,computed tomography enterography,or magnetic resonance enterography.Once the cause of smallbowel bleeding is identified and targeted therapeutic intervention is completed,the patient can be managed with routine visits.However,diagnostic tests may produce negative results,and some patients with small bowel bleeding,regardless of diagnostic findings,may experience rebleeding.Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans.Several studies have identified different factors associated with rebleeding,and a limited number of studies have attempted to create prediction models for recurrence.This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding.These models may aid clinicians in forming tailored patient management and surveillance.

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding:A systematic review and metaanalysis

AIM To compare the diagnostic accuracy of video capsule endoscopy(VCE) and double-balloon enteroscopy(DBE) in cases of obscure gastrointestinal bleeding(OGIB) of vascular origin.METHODS MEDLINE(via PubMed), LILACS(via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables(sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.RESULTS In the per-patient analysis, 17 studies(1477 lesions) were included. We identified3150 exams(1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864(58.5%) were diagnosed by VCE, and 613(41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84%(95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was92%(95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29(95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20(95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to90%.CONCLUSION The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Massive small bowel bleeding caused by scrub typhus in Korea

A 79-year-old man was diagnosed with scrub typhus based on fever,eschar,skin rash and a markedly elevated serum tsutsugamushi antibody and doxycycline was started.Five days later,hematochezia developed and multiple small bowel ulcerations with hemorrhage were seen on colonoscopy.Despite intensive therapy,the massive hematochezia worsened and the distal small bowel was resected.Multiple ulcerated lesions were identified pathologically as vasculitis caused by scrub typhus.This is the first reported case of pathologically proven small bowel involvement in scrub typhus infection.

Outpatient management of obscure gastrointestinal bleeding:A new perspective in high-risk patients

Mid-gastrointestinal bleeding accounts for approximately 5%-10%of all gastrointestinal bleeding cases,and vascular lesions represent the most frequent cause.The rebleeding rate for these lesions is quite high(about 42%).We hereby recommend that scheduled outpatient management of these patients could reduce the risk of rebleeding episodes.

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding

AIM: To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions. METHODS: In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration(cases) and 60 matched patients with a non-bleeding peptic ulcer(controls) underwent small bowel capsule endoscopy, after a negative colonoscopy(compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowellesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present. Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy.RESULTS: Forty(67%) cases and 18(30%) controls presented small bowel erosions(P = 0.0001), while 22(37%) cases and 4(8%) controls presented small bowel ulcers(P < 0.0001). Among non-steroidal antiinflammatory drug(NSAID) consumers, 39(95%) cases and 17(33%) controls presented small bowel erosions(P < 0.0001), while 22(55%) cases and 4(10%) controls presented small bowel ulcers(P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3(SD = 1.4) g/d L in cases with small bowel ulcerative lesions and 10.5(SD = 1.3) g/dL in those without(P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6(27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective(relative risk 0.13, P = 0.05).CONCLUSION: Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.

Endoscopic band ligation for bleeding lesions in the small bowel

AIM: To investigate the safety and efficacy of endo-scopic band ligation(EBL) for bleeding lesions in the small bowel.METHODS: This is a retrospective study evaluating EBL in six consecutive patients(three males, three fe-males, 46-86 years of age) treated between May 2009 and February 2014: duodenal vascular ectasia; 1, je-junal bleeding diverticulum; 1, ileal Dieulafoy's lesion; 1 and ileal bleeding diverticula; 3. The success of the initial hemostasis was evaluated, and patients were observed for early rebleeding(within 30 d after EBL), and complications such as perforation and abscess for-mation. Follow-up endoscopies were performed in four patients.RESULTS: Initial hemostasis was successfully achieved with EBL in all six patients. Eversion was not sufficient in four diverticular lesions. Early rebleeding occurred three days after EBL in one ileal diverticulum, and arepeat endoscopy revealed dislodgement of the O-band and ulcer formation at the banded site. This rebleeding was managed conservatively. Late rebleeding occurred in this case(13 and 21 mo after initial EBL), and re-EBL was performed. Follow-up endoscopies revealed scar formation and the disappearance of vascular lesions at the banded site in the case with a duodenal bleeding lesion, and unresolved ileal diverticula in three cases. Surgery or transarterial embolization was not required without any complications during the median follow-up period of 45(range, 2-83) mo.CONCLUSION: EBL is a safe and effective endoscopic treatment for hemostasis of bleeding lesions in the small bowel.

Risk factors for small bowel angioectasia:The impact of visceral fat accumulation

AIM: To investigate visceral fat accumulation in association with the risk of small bowel angioectasia.METHODS: We retrospectively investigated 198 consecutive patients who underwent both capsule endoscopy and CT for investigation of obscure gastrointestinal bleeding(OGIB) from January 2009 to September 2013. The visceral fat area(VFA) and subcutaneous fat area were measured by CT, and information on comorbidities, body mass index, and medications was obtained from their medical records.Logistic regression analysis was used to evaluate associations.RESULTS: Capsule endoscopy revealed small bowel angioectasia in 18/198(9.1%) patients with OGIB.Compared to patients without small bowel angioectasia,those with small bowel angioectasia had a significantly higher VFA(96 ± 76.0 cm2 vs 63.4 ±51.5 cm2, P = 0.016) and a higher prevalence of liver cirrhosis(61% vs 22%, P < 0.001). The proportion of patients with chronic renal failure was higher in patients with small bowel angioectasia(22% vs 9%,P = 0.11). There were no significant differences in subcutaneous fat area or waist circumference. The prevalence of small bowel angioectasia progressively increased according to the VFA. Multivariate analysis showed that the VFA [odd ratio(OR) for each 10-cm2 increment = 1.1; [95% confidence interval(CI):1.02-1.19; P = 0.021] and liver cirrhosis(OR = 6.1,95%CI: 2.2-18.5; P < 0.001) were significant risk factors for small bowel angioectasia.CONCLUSION: VFA is positively associated with theprevalence of small bowel angioectasia, for which VFA and liver cirrhosis are independent risk factors in patients with OGIB.

Non-small bowel lesion detection at small bowel capsule endoscopy: A comprehensive literature review

Small bowel capsule endoscopy is a minimally-invasive endoscopic investigation that is often used in clinical practice to investigate overt or occult gastrointestinal(GI) bleeding among other clinical indications. International guidance recommends small bowel capsule endoscopy as a first-line investigation to detect abnormalities in the small bowel, when gastroscopy and colonoscopy fail to identify a cause of GI bleeding. It can diagnose with accuracy abnormalities in the small bowel. However, there has been increasing evidence indicating that small bowel capsule endoscopy may also detect lesions outside the small intestine that are within the reach of conventional endoscopy and have been probably missed during prior endoscopic investigations. Such lesions vary from vascular deformities to malignancy and their detection often alters patient management, leading to further endoscopic and/or surgical interventions. The current study attempts to review all available studies in the literature and summarise their relevant findings.

Small bowel tumors detected and missed during capsule endoscopy: Single center experience

AIM:To characterize small bowel(SB)tumors detected by capsule endoscopy(CE),and identify missed tumors.METHODS:The study included 145 consecutive patients in whom 150 CEs were performed.Following CE,the medical records of the study population were reviewed.Results of double-or single-balloon enteroscopy performed after CE and the results of surgery in all patients operated on were retrieved.The patients were contacted through telephone interviews or postal mail.In addition,the national cancer registry and the polish clinical gastrointestinal stromal tumor(GIST)Registry were searched to identify missed neoplasms.RESULTS:Indications for CE included overt and occult obscure gastrointestinal bleeding(n=81,53.7%),anemia(n=19,12.7%),malabsorption(n=18,12%),abnormal CB follow through(n=9,6%),abdominal pain(n=7,5%),celiac disease(n=5,3%),neuroendocrine tumor(n=3,2%),Crohn’s disease(n=2,<2%),Peutz-Jeghers syndrome(n=2,<2%),other polyposes(n=2,<2%),and diarrhea(n=2,<2%).The capsule reached the colon in 115(76.6%)examinations.In 150 investigations,CE identified 15SB tumors(10%),14 of which were operated on or treated endoscopically.Malignancies included metastatic melanoma(n=1),adenocarcinoma(n=2),and GIST(n=3).Benign neoplasms included dysplastic Peutz-Jeghers polyps(n=4).Non-neoplastic masses included venous malformation(n=1),inflammatory tumors(n=2),and a mass of unknown histology(n=1).During the follow-up period,three additional SB tumors were found(2 GISTs and one mesenteric tumor of undefined nature).The National Cancer Registry and Polish Clinical GIST Registry revealed no additional SB neoplasms in the post-examination period(follow-up:range 4.2-102.5 mo,median 39 mo).The sensitivity of CE for tumor detection was 83.3%,and the negative predictive value was 97.6%.The specificity and positive predictive value were both 100%.CONCLUSION:Neoplasms may be missed by CE,especially in the proximal SB.In overt obscure gastrointestinal bleeding,complementary endoscopic and/or radiologic diagnostic tests are indicated.

Role of double-balloon enteroscopy in malignant small bowel tumors

AIM: To assess the double-balloon enteroscopy(DBE) role in malignant small bowel tumors(MSBT).METHODS: This is a retrospective descriptive study performed in a single center. All consecutive patients who underwent a DBE with final diagnosis of a malignant neoplasm from 2004 to 2014 in our referral center were included. Patient demographic and clinical pathological characteristics were recorded and reviewed. MSBT diagnosis was achieved either by DBE directed biopsy with multiple tissue sampling, endoscopic findings or histological analysis of surgical specimen. We have analyzed double-balloon enteroscopy impact in outcome and clinical course of these patients. RESULTS: Of 627 patients, 28(4.5%)(mean age = 60 ± 17.3 years) underwent 30 procedures(25 anterograde, 5 retrograde) and were diagnosed of a malignant tumor. Patients presented with obscure gastrointestinal bleeding(n = 19, 67.9%), occlusion syndrome(n = 7, 25%) and diarrhea(n = 1, 3.6%). They were diagnosed by DBE biopsy(n = 18, 64.3%), histological analysis of surgical specimen(n = 7, 25%) and unequivocal endoscopic findings(n = 2, 7.1%). Gastrointestinal stromal tumor(n = 8, 28.6%), adenocarcinoma(n = 7, 25%), lymphoma(n = 4, 14.3%), neuroendocrine tumor(n = 4, 14.3%), metastatic(n = 3, 10.7%) and Kaposi sarcoma(n = 1, 3.6%) were identified. DBE modified outcome in 7 cases(25%), delaying or avoiding emergency surgery(n = 3), modifying surgery approach(n = 2) and indicating emergency SB partial resection instead of elective approach(n = 2).CONCLUSION: DBE may be critical in the management of MSBT providing additional information that may be decisive in the clinical course of these patients.

Small bowel diverticulitis with severe anemia and abdominal pain

The current case report is related to a male patient with diabetes, obesity [body mass index(BMI) 33], hypertension and recurrence of anemia associated to melena and deep asthenia. M.P., a 60-year-old obese individual, was referred to our department by the primary care unit(PCU) of our hospital for severe anemia(Hemoglobin 6.5 g/d L) associated to episodes of melena and abdominal pain. In the past 5 mo the patient referred to the local hospital 3 times for episodes of melena(hemoglobin levels showed anemia 9.8 g/d L) but the main gastroenterological exams were completely negative(colonoscopy and gastroscopy). The PCU of our Hospital, after stabilization of the main parameters and blood transfusion for the low levels of hemoglobin, referred the patient to gastroenterologists: the patient was subjected to both colonoscopy and gastroscopy that were negative. Due to the condition of acute severe hemorrhage the patient, during the first 3 h from the access to the PCU, was subjected to arteriography that did not reveal any hemorrhagic foci or vascular alterations. The video capsule for the study of the small bowel showed the presence of blood beginning from the third portion of duodenum but deep gastroscopy did not reveal it. The patient was then subjected to double balloon endoscopy that revealed a severe diverticulosis of the small bowel with blood from the diverticula. The entero-tomografia computerizzata confirmed the diagnosis and revealed an extension of the diverticula for almost the entire small bowel(no diverticula in the colon). The patient was subjected to wide spectrum antibiotic therapy with resolution of the symptoms and stabilization of hemoglobin levels. The surgeon suggests no indication to surgery for the wide area involved from the disease and potential high risk of complication due to the high BMI. At home, the patient started a monthly therapy with rifaximin and probiotics associated to mesalazine. At present, after 12 mo from the last episode of hemorrhage, the patient is in good clinical condition, reduced his body weight of about 7 kg and the hemoglobin levels appear in slow progressive increase(last measurement 13.2 g/d L).

疑似小肠出血患者双气囊小肠镜全小肠对接检查的临床研究

背景:双气囊小肠镜(DBE)全小肠对接检查在疑似小肠出血(SSBB)患者诊治中发挥重要作用。目的:调查SSBB患者DBE全小肠对接检查情况并分析其临床特征。方法:纳入2018年6月—2023年4月安徽省蚌埠市第三人民医院和安徽医科大学第一附属医院需行DBE对接检查的94例SSBB患者,并分析其临床特征。结果:共54例SSBB患者完成DBE全小肠对接检查,对接成功率为57.4%。因发现出血病变而中止对接检查者10例(10.6%),肠腔狭窄而中止对接检查者5例(5.3%),操作中出现进镜困难而中止对接检查者25例(26.5%)。SSBB患者DBE全小肠对接率与不同对接时间、医师既往小肠镜操作例数有关(P<0.05),而与患者性别、年龄、出血表现形式、烟酒嗜好、营养风险、腹部手术史、肛周病变、自身免疫病、术前贫血、术前白蛋白水平、进镜途径均无关(P>0.05)。ROC曲线结果显示,先进镜深度的截断值为385 cm时,评估SSBB患者完成全小肠对接检查的敏感性为72.2%,特异性为77.5%,曲线下面积为0.800(95%CI:0.705~0.875,P<0.001)。结论:SSBB患者DBE全小肠对接率与不同对接时间、医师既往小肠镜操作例数有关。先进镜深度达到385 cm以上,80%的SSBB患者有望实现全小肠对接检查。

双气囊小肠镜在疑似小肠出血中的临床应用:一项单中心回顾性队列研究

目的探讨近10年双气囊小肠镜(double-balloon enteroscopy,DBE)检查疑似小肠出血(suspected small bowel bleeding,SSBB)的适应证、诊断率及不良事件的变化。方法回顾性分析某三级医院第1阶段(较早阶段,2013年9月至2018年8月)和第2阶段(较晚阶段,2018年9月至2023年8月)完成DBE检查患者的临床及内镜资料。结果共纳入451例患者(第1阶段214例,第2阶段237例)。第2阶段中从最后一次出血到DBE检查的时间间隔比第1阶段更短[(5.8±1.3)d vs(6.6±1.8),P<0.001]。第2阶段显性出血比例和全小肠检查率(total enteroscopy rate,TER)均高于第1阶段(89.9%vs 79.9%,P<0.05;88.4%vs 59.0%,P<0.001)。肿瘤(26.4%)、克罗恩病(15.7%)和憩室(12.6%)是SSBB的前三大常见病因。第2阶段血管病变的诊断率和比例高于第1阶段(85.7%vs 66.8%,P<0.01;13.5%vs 3.7%,P<0.05)。两阶段检查相关不良事件发生率差异无统计学意义(2.1%vs 3.7%,P>0.05)。结论DBE诊断SSBB有效、安全。随着时间推移,显性出血作为DBE检查的适应症变得越来越普遍。与第1阶段相比,第2阶段DBE的诊断率有所提高,并发症发生率无显著差异。

双气囊小肠镜对小肠出血的临床诊治价值

目的探讨双气囊小肠镜对小肠出血性疾病的临床诊疗价值。方法回顾性分析汕头市中心医院内镜中心2019年8月至2023年5月因小肠出血行双气囊小肠镜检查87例患者的临床资料,分析双气囊小肠镜对小肠出血病因的诊疗情况。结果87例小肠出血患者共进行117次双气囊小肠镜检查,其中,单侧经口进镜29次,单侧经肛进镜28次,30例患者同时进行经口经肛双侧进镜检查,经口进镜深度大于经肛进镜,且经口进镜检查时间少于经肛进镜检查时间。双气囊小肠镜诊断率为83.91%,病理诊断准确率为83.78%。小肠肿瘤是本研究中导致小肠出血的主要病因,小肠间质瘤是小肠肿瘤中最常见的病理类型,年龄>40岁人群中出现小肠肿瘤的频率要高于年龄≤40岁人群,差异有统计学意义(P<0.05)。克罗恩病发生在回肠的频率高于空肠,年龄≤40岁人群中发生克罗恩病的频率高于年龄>40岁人群,差异均有统计学意义(P<0.05)。共有14例小肠出血患者经双气囊小肠镜行内镜下止血成功,所有患者术中均未出现消化道穿孔、严重出血等并发症。结论双气囊小肠镜对小肠出血性疾病具有较高的诊断价值,必要时可进行内镜下治疗,是一种安全、可靠、实用的诊疗方法。

147例中老年小肠出血患者临床特征和预后分析

目的探讨中老年人群小肠出血的临床特征,为中老年人群小肠出血的诊疗提供依据。方法纳入2015年1月1日至2021年1月1日在郑州大学第一附属医院确诊为小肠出血的中老年患者共147例,对其一般情况、实验室检查、影像学检查、治疗与预后进行回顾性分析。结果147例小肠出血患者中,常见的病因依次为血管性病变(36.1%)、肿瘤性病变(34.7%)及炎症性病变(34.0%);分别以血管畸形(81.1%)、间质瘤(62.7%)、溃疡性病变(46.0%)和糜烂性病变(40.0%)更为多见。血管畸形组、间质瘤组与炎症性病变组三组小肠出血患者的显性出血率、胃肠道反应的发生率及合并腹部手术史的比例均不同[93.0%(40/43)vs 84.4%(27/32)vs 72.0%(36/50)、9.3%(4/43)vs 43.8%(14/32)vs 40.0%(20/50)、20.9%(9/43)vs 12.5%(4/32)vs 46.0%(23/50)],差异有统计学意义(χ^(2)=7.161、13.919、12.659,P均<0.05);Bonferroni法两两比较显示,血管畸形组腹痛的发生率低于间质瘤组及炎症性病变组(P均<0.05);炎症性病变组合并腹部手术史的比例高于血管畸形组和间质瘤组(P均<0.05)。在三组表现为显性出血的患者中,黑便较血便更多见(P均<0.05)。计算机断层扫描对肿瘤的阳性检出率高于血管性病变和炎症性病变(P<0.01);经口小肠镜对中老年小肠出血的总体检出率高于经肛小肠镜(P<0.05)。结论中老年小肠出血的常见病因构成为血管性病变、肿瘤性病变和炎症性病变,不同病因引起的小肠出血有一定的临床特征,可为临床经验性诊断小肠出血提供一定的依据。中老年小肠出血以黑便较为多见,血管畸形组患者更少发生胃肠道反应,炎症性病变组患者常合并有腹部手术史;相比于经肛小肠镜,经口小肠镜在中老年小肠出血患者中有更高的总体检出率。

沙利度胺治疗1例小肠血管畸形致顽固性消化道出血8年的治疗经验和随访

观察报道1例沙利度胺治疗小肠血管畸形所致顽固性消化道出血患者的临床疗效、不良反应。分析其病例临床特点、诊疗方案,并对维持时间进行探讨,患者取得了满意治疗效果。通过学习该病例,提高对该病的认识及诊治水平,以减少消化道出血的机会。

Protons pump inhibitor treatment and lower gastrointestinal bleeding: Balancing risks and benefits

Proton pump inhibitors(PPIs) represent a milestone in the treatment of acid-related diseases, and are the mainstay in preventing upper gastrointestinal bleeding in high-risk patients treated with nonsteroidal antiinflammatory drugs(NSAIDs) or low-dose aspirin. However, this beneficial effect does not extend to the lower gastrointestinal tract. PPIs do not prevent NSAID or aspirin-associated lower gastrointestinal bleeding(LGB). PPIs may increase both small bowel injury related to NSAIDs and low-dose aspirin treatment and the risk of LGB. Recent studies suggested that altering intestinal microbiota by PPIs may be involved in the pathogenesis of NSAID-enteropathy. An increase in LGB hospitalization rates may occur more frequently in older patients with more comorbidities and are associated with high hospital resource utilization, longer hospitalization, and increased mortality. Preventive strategies for NSAID and aspirin-associated gastrointestinal bleeding should be directed toward preventing both upper and lower gastrointestinal damage. Future research should be directed toward identifying patients at low-risk for gastrointestinal events associated with the use of NSAIDs or aspirin to avoid inappropriate PPI prescribing. Alternatively, the efficacy of new pharmacologic strategies should be evaluated in high-risk groups, with the aim of reducing the risk of both upper and lower gastrointestinal bleeding in these patients.

Ileal polypoid lymphangiectasia bleeding diagnosed and treated by double balloon enteroscopy

Intestinal lymphangiectasia is a rare disease characterized by focal or diffuse dilated enteric lymphatics with impaired lymph drainage.It causes protein-losing enteropathy and may lead to gastrointestinal bleeding.Commonly,lymphangiectasia presents as whitish spots or specks.To our knowledge,small bowel bleeding resulting from polypoid intestinal lymphangiectasia has not been reported.Here,we report a rare case of active bleeding from the small bowel caused by polypoid lymphangiectasia with a review of the relevant literature.An 80-year-old woman was hospitalized for melena.Esophagogastroduodenoscopy could not identify the source of bleeding.Subsequent colonoscopy showed fresh bloody material gushing from the small bowel.An abdominal-pelvic contrast-enhanced computed tomography scan did not reveal any abnormal findings.Video capsule endoscopy showed evidence of active and recent bleeding in the ileum.To localize the bleeding site,we performed double balloon enteroscopy by the anal approach.A small,bleeding,polypoid lesion was found in the distal ileum and was successfully removed using endoscopic snare electrocautery.

Outcome in obscure gastrointestinal bleeding after capsule endoscopy

AIM: To investigate the clinical impact of capsule endoscopy(CE) after an obscure gastrointestinal bleeding(OGIB) episode, focusing on diagnostic work-up, followup and predictive factors of rebleeding. METHODS: Patients who were referred to Hospital del Mar(Barcelona, Spain) between 2007 and 2009 for OGIB who underwent a CE were retrospectively analyzed. Demographic data, current treatment with non-steroid antiinflammtory drugs or anticoagulant drugs, hemoglobin levels, transfusion requirements, previous diagnostic tests for the bleeding episode, as well as CE findings(significant or non-significant), work-up and patient out-comes were analyzed from electronic charts. Variables were compared by χ 2 analysis and Student t test. Risk factors of rebleeding were assessed by Log-rank test, Kaplan-Meier curves and Cox regression model. RESULTS: There were 105 patients [45.7% women, median age of 72 years old(interquartile range 56-79)] and a median follow-up of 326 d(interquartile range 123-641) included in this study. The overall diagnostic yield of CE was 58.1%(55.2% and 63.2%, for patients with occult OGIB and overt OGIB, respectively). In 73 patients(69.5%), OGIB was resolved. Multivariate analysis showed that hemoglobin levels lower than 8 g/dL at diagnosis [hazard ratios(HR) = 2.7, 95%CI: 1.9-6.3], patients aged 70 years and above(HR = 2.1, 95%CI: 1.2-6.1) and significant findings in CE(HR = 2.4, 95%CI: 1.1-5.8) were independent predictors of rebleeding. CONCLUSION: One third of the patients presented with rebleeding after CE; risk factors were hemoglobin levels < 8 g/dL, age ≥ 70 years or the presence of significant lesions.

Yield,etiologies and outcomes of capsule endoscopy in Thai patients with obscure gastrointestinal bleeding

AIM:To investigate the yield,etiologies and impact of capsule endoscopy(CE) in Thai patients with obscure gastrointestinal bleeding(OGIB).METHODS:The present study is a retrospective cohort study.All patients with OGIB who underwent CE in Siriraj Hospital,Bangkok,Thailand during 2005-2009 were included in the study.All the patients' medical records and results of the CE videos were reviewed.CE findings were classified as significant,suspicious/equivocal and negative.Sites of the lesions were located to duodenum,jejunum,jejunoileum,ileum and diffuse lesions by the localization device of the CE.Impact of CE on the patients' management was defined by any investigation or treatment given to the patients that was more than an iron supplement or blood transfusion.Patients' outcomes(rebleeding,persistent bleeding,anemia or requirement of blood transfusion) were collected from chart reviews and direct phone interviews with the patients.RESULTS:Overall,there were 103 patients with OGIB included in the study.Mean age of the patients was 64 ± 16 years(range 9-88 years) and 57 patients(55%) were male.Types of OGIB were overt in 80(78%) and occult in 23 patients(22%).The median time interval of CE after onset of OGIB was 10 d(range 1-180 d).The median time of follow-up was 19 mo(range 1-54 mo).Capsules reached caecum in 77 patients(74%) and capsule retention was found in 1 patient(1%).The diagnostic yield of CE revealed significant lesions in 37 patients(36%),suspicious/equivocal lesions in 15 patients(15%) and 51 patients(49%) had negative CE result.Among the significant lesions,the bleeding etiologies were small bowel ulcers in 44%,angiodysplasia in 27%,small bowel tumor in 13%,miscellaneous in 8% and active bleeding without identifiable causes in 8%.Patients with small bowel ulcers were significantly associated with the use of non-steroidal anti-inflammatory drugs(48%,P = 0.034),while patients with small bowel tumors were more commonly female(86%,P = 0.043) compared to the other etiologies.The rate of rebleeding,persistent bleeding or anemia in patients with positive,equivocal and negative CE results were 5%,0% and 18%,respectively(P = 0.078).All the 9 patients with rebleeding after negative CE were subsequently found to be from hematologic disorders(4),colonic diverticulosis(2),colonic Dieulafoy's(1),hemorrhoid(1) and hemosuccus pancreaticus(1).Results of CE had a positive impact on the patients' management in 35% of the patients whose results were positive,but none on the patients whose results were equivocal or negative CE(P < 0.001).CONCLUSION:In Thai OGIB patients,CE had low yield and small bowel ulcer was most common.Positive CE impacted managements and outcomes.Negative CE caused low rebleeding.