EDITORIAL
Emergency video capsule endoscopy: A game-changing strategy? Toward a better use of endoscopic resources Appropriate assessment and management of upper GI bleeding (UGIB) have been shown to improve outcomes. Endoscopy proved to be an effective and reliable diagnostic and therapeutic tool in UGIB and is associated with a reduction in blood transfusions and length of hospital stay and, in some settings, can be used to assess the need for hospital admission.1 Although most GI bleeds can be located by using standard EGD or colonoscopy, the etiology of the bleeding remains unknown after upper and lower endoscopic examination in approximately 10% to 20% of cases. Nearly 5% of overall GI bleeds recur or persist and originate between the ligament of Treitz and the ileocecal valve; this poses a diagnostic challenge.2 Obscure GI bleeding (OGIB) is classified as occult or overt. The latter is characterized by the recurrent passage of visible blood with melena or hematochezia of unknown origin after negative initial upper and lower endoscopic evaluation. OGIB is potentially the most frequent accepted indication for video capsule endoscopy (VCE) examination once EGD and colonoscopy have failed to identify the bleeding source.3 The VCE diagnostic yield increases as much as 92% in patients with acute overt OGIB when it is performed as close as possible to the bleeding event. This results in a higher rate of therapeutic interventions and a potential reduction in costs and length of hospital stay.4,5 In this issue of Gastrointestinal Endoscopy, Schlag and colleagues6 report the results of a prospective study in which they performed emergency VCE on patients with acute severe GI bleeding within 24 hours of presentation, after an initial negative result on EGD. Their findings are consistent with those of other reports,7,8 which indicate that emergency VCE is a feasible and safe procedure that can detect recent or active UGIB in the emergency department. VCE can identify the source of bleeding in as many as 75% of cases with an initial negative result on EGD. The authors showed that emergency VCE can affect decision making; it enables a better selection and use of resources and therapeutic procedures during acute severe GI bleeding.
Major limitations of the study include a small sample size, a nonrandomized experimental design, and short patient follow-up evaluations (which made it difficult to determine the rate of recurrent bleeding and whether the therapeutic maneuvers were successful or sufficient). In addition, the potential widespread applicability of this study is limited; for the approach to be successful, live-view equipment is required to detect acute bleeding and to proceed accordingly, even before VCE recording time ends. Despite the limitations and weaknesses, these results are comparable to those of a similar study9 of 55 patients
Thus far, the Schlag et al study and available evidence strongly suggest that video capsule endoscopy is more productive when performed closest to the bleeding onset because a higher diagnostic yield is achieved (87%92%) in patients with ongoing obscure-overt bleeding compared with patients with obscure-occult or distant overt bleeding (12%-56%).
Copyright ª 2015 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.12.035
with severe overt OGIB in which emergency VCE identified bleeding lesions in 67% of patients when performed 24 to 48 hours after negative findings on EGD and colonoscopy. The report of Schlag et al is interesting because it could potentially indicate the possibility of revising current guidelines if such results could be validated in future randomized, controlled trials. Current American Society for Gastrointestinal Endoscopy guidelines on the role of endoscopy in the management of acute nonvariceal and OGIB1,10 suggest consideration of colonoscopy after negative findings on the initial EGD. If the findings of both examinations were negative, then obscure GI bleeding is diagnosed, and repeating EGD/colonoscopy or performing enteroscopy or VCE should be considered, depending on whether the bleeding was overt or occult. By using their proposed approach, Schlag et al avoided approximately 11 colonoscopies and 5 second-look EGDs after VCE detected 11 patients with bleeding from the
896 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org
Peláez-Luna
Editorial
mid gut. The need for a colonoscopy was avoided in these patients; this directly resulted in enteroscopy (n Z 10) and surgery (n Z 1). In 4 patients, VCE suggested a colon source, and the colonoscopy that followed detected and treated bleeding in 3 patients, and a repeat EGD was needed in only 1 patient. Only 5 patients had negative findings on VCE; in these patients, a colonoscopy successfully treated 3 patients, and findings of the colonoscopy and second EGD were negative in the remaining 2 patients. The latter finding not only indicates that performing an emergency VCE after negative findings on the initial EGD affects the diagnostic and therapeutic approach, but it also suggests a potential decrease in the incidence of obscure GI bleeding to 2% compared with previously reported higher rates. Following the current guidelines, a colonoscopy should be performed after negative findings on the initial EGD; considering that this would have detected active bleeding in all of the sites within its reach, 14 of the initial 88 patients (16%) still would have been classified as having OGIB and would have undergone repeat EGD and colonoscopy and, subsequently, VCE. Theoretically, the rate of OGIB could be higher if the colonoscopies showed negative results, considering that most GI bleedings are self-limiting in nearly 80% of cases within 24 to 48 hours after presentation. However, these figures are mere speculation drawn from the results of a study that analyzed a highly select population. The Schlag et al study did not intend to assess the OGIB rate, which should be assessed in properly designed trials. Now the question is this: Is this approach cost-effective? According to recent reports,11,12 emergency VCE, compared with repeat EGD and colonoscopy, appears to be the more advantageous method in low- and moderate-risk patients presenting with acute UGIB to the emergency department. Thus far, the Schlag et al study and available evidence strongly suggest that VCE is more productive when performed closest to the bleeding onset because a higher diagnostic yield is achieved (87%-92%) in patients with ongoing obscure-overt bleeding compared with patients with obscure-occult or distant overt bleeding (12%– 56%).5,13 Furthermore, in this highly select population with a high suspicion of acute UGIB, emergency VCE after negative findings on EGD enabled the physicians to modify management and to aid in the selection of the most appropriate therapeutic procedures. Interestingly, although it was not a primary outcome, the question of whether emergency VCE decreases the frequency of OGIB remains to be assessed. Although these results might not be enough to make us consider modifying the current approach to GI bleeding, these findings represent a call for larger, randomized, and comparative studies that could place VCE in a completely different position, one that could increase its diagnostic yield, avoid repeating unnecessary EGDs and
1. ASGE Standards of Practice Committee; Hwang JH, Fisher DA, BenMenachem T, et al. The role of endoscopy in the management of acute nonvariceal upper GI bleeding. Gastrointest Endosc 2012;75:1132-8. 2. Rondonotti E, Marmo R, Petracchini M, et al. The American Society for Gastrointestinal Endoscopy (ASGE) diagnostic algorithm for obscure gastrointestinal bleeding: eight burning questions from everyday clinical practice. Dig Dis Liv 2013;45:179-85. 3. ASGE Standards of Practice Committee; Early DS, Ben-Menachem T, Decker GA, et al. Appropriate use of GI endoscopy. Gastrointest Endosc 2012;75:1127-31. 4. Singh A, Marshall C, Biswashree C, et al. Timing of video capsule endoscopy relative to overt obscure GI bleeding: implications from a retrospective study. Gastrointest Endosc 2013;77:761-6. 5. Carey E, Leighton J, Heigh R, et al. A single center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 2007;102:89-95. 6. Schlag C, Menzel C, Nennstiel S, et al. Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results. Gastrointest Endosc 2015;81:889-95. 7. Meltzer AC, Amir MA, Kresiberg RB, et al. Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med 2013;61:438-43. 8. Gralnek IM, Ching JY, Maza I, et al. Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. Endoscopy 2013;45:12-9. 9. Lecleire S, Iwanicki-Caron I, Di-Fiore A, et al. Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding. Endoscopy 2012;44:337-42. 10. ASGE Standards of Practice Committee; Fisher L, Lee Krinsky M, Anderson MA, et al. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 2010;72:471-9. 11. Meltzer AC, Ward MJ, Gralnek IM, et al. The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the emergency department. Am J Emerg Med 2014;32:823-32. 12. Gilbert D, O’Malley S, Selby W. Are repeat upper gastrointestinal endoscopy and colonoscopy necessary within six months of capsule endoscopy in patients with obscure gastrointestinal bleeding? J Gastroenterol Hepatol 2008;23:1806-9. 13. Penazzio M, Gaudin J, Filoche B, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126:643-53.
www.giejournal.org
Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 897
colonoscopies, and allow a better use of diagnostic and therapeutic tools. DISCLOSURE The author disclosed no financial relationships relevant to this article. Mario Peláez-Luna, MD Research Division, School of Medicine, UNAM Gastroenterology Department Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán México City, México Abbreviations: OGIB, obscure GI bleeding; UGIB, upper GI bleeding; VCE, video capsule endoscopy.
REFERENCES
Emergency video capsule endoscopy: A game-changing strategy? Toward a better use of endoscopic resources Appropriate assessment and management of upper GI bleeding (UGIB) have been shown to improve outcomes. Endoscopy proved to be an effective and reliable diagnostic and therapeutic tool in UGIB and is associated with a reduction in blood transfusions and length of hospital stay and, in some settings, can be used to assess the need for hospital admission.1 Although most GI bleeds can be located by using standard EGD or colonoscopy, the etiology of the bleeding remains unknown after upper and lower endoscopic examination in approximately 10% to 20% of cases. Nearly 5% of overall GI bleeds recur or persist and originate between the ligament of Treitz and the ileocecal valve; this poses a diagnostic challenge.2 Obscure GI bleeding (OGIB) is classified as occult or overt. The latter is characterized by the recurrent passage of visible blood with melena or hematochezia of unknown origin after negative initial upper and lower endoscopic evaluation. OGIB is potentially the most frequent accepted indication for video capsule endoscopy (VCE) examination once EGD and colonoscopy have failed to identify the bleeding source.3 The VCE diagnostic yield increases as much as 92% in patients with acute overt OGIB when it is performed as close as possible to the bleeding event. This results in a higher rate of therapeutic interventions and a potential reduction in costs and length of hospital stay.4,5 In this issue of Gastrointestinal Endoscopy, Schlag and colleagues6 report the results of a prospective study in which they performed emergency VCE on patients with acute severe GI bleeding within 24 hours of presentation, after an initial negative result on EGD. Their findings are consistent with those of other reports,7,8 which indicate that emergency VCE is a feasible and safe procedure that can detect recent or active UGIB in the emergency department. VCE can identify the source of bleeding in as many as 75% of cases with an initial negative result on EGD. The authors showed that emergency VCE can affect decision making; it enables a better selection and use of resources and therapeutic procedures during acute severe GI bleeding.
Major limitations of the study include a small sample size, a nonrandomized experimental design, and short patient follow-up evaluations (which made it difficult to determine the rate of recurrent bleeding and whether the therapeutic maneuvers were successful or sufficient). In addition, the potential widespread applicability of this study is limited; for the approach to be successful, live-view equipment is required to detect acute bleeding and to proceed accordingly, even before VCE recording time ends. Despite the limitations and weaknesses, these results are comparable to those of a similar study9 of 55 patients
Thus far, the Schlag et al study and available evidence strongly suggest that video capsule endoscopy is more productive when performed closest to the bleeding onset because a higher diagnostic yield is achieved (87%92%) in patients with ongoing obscure-overt bleeding compared with patients with obscure-occult or distant overt bleeding (12%-56%).
Copyright ª 2015 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.12.035
with severe overt OGIB in which emergency VCE identified bleeding lesions in 67% of patients when performed 24 to 48 hours after negative findings on EGD and colonoscopy. The report of Schlag et al is interesting because it could potentially indicate the possibility of revising current guidelines if such results could be validated in future randomized, controlled trials. Current American Society for Gastrointestinal Endoscopy guidelines on the role of endoscopy in the management of acute nonvariceal and OGIB1,10 suggest consideration of colonoscopy after negative findings on the initial EGD. If the findings of both examinations were negative, then obscure GI bleeding is diagnosed, and repeating EGD/colonoscopy or performing enteroscopy or VCE should be considered, depending on whether the bleeding was overt or occult. By using their proposed approach, Schlag et al avoided approximately 11 colonoscopies and 5 second-look EGDs after VCE detected 11 patients with bleeding from the
896 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org
Peláez-Luna
Editorial
mid gut. The need for a colonoscopy was avoided in these patients; this directly resulted in enteroscopy (n Z 10) and surgery (n Z 1). In 4 patients, VCE suggested a colon source, and the colonoscopy that followed detected and treated bleeding in 3 patients, and a repeat EGD was needed in only 1 patient. Only 5 patients had negative findings on VCE; in these patients, a colonoscopy successfully treated 3 patients, and findings of the colonoscopy and second EGD were negative in the remaining 2 patients. The latter finding not only indicates that performing an emergency VCE after negative findings on the initial EGD affects the diagnostic and therapeutic approach, but it also suggests a potential decrease in the incidence of obscure GI bleeding to 2% compared with previously reported higher rates. Following the current guidelines, a colonoscopy should be performed after negative findings on the initial EGD; considering that this would have detected active bleeding in all of the sites within its reach, 14 of the initial 88 patients (16%) still would have been classified as having OGIB and would have undergone repeat EGD and colonoscopy and, subsequently, VCE. Theoretically, the rate of OGIB could be higher if the colonoscopies showed negative results, considering that most GI bleedings are self-limiting in nearly 80% of cases within 24 to 48 hours after presentation. However, these figures are mere speculation drawn from the results of a study that analyzed a highly select population. The Schlag et al study did not intend to assess the OGIB rate, which should be assessed in properly designed trials. Now the question is this: Is this approach cost-effective? According to recent reports,11,12 emergency VCE, compared with repeat EGD and colonoscopy, appears to be the more advantageous method in low- and moderate-risk patients presenting with acute UGIB to the emergency department. Thus far, the Schlag et al study and available evidence strongly suggest that VCE is more productive when performed closest to the bleeding onset because a higher diagnostic yield is achieved (87%-92%) in patients with ongoing obscure-overt bleeding compared with patients with obscure-occult or distant overt bleeding (12%– 56%).5,13 Furthermore, in this highly select population with a high suspicion of acute UGIB, emergency VCE after negative findings on EGD enabled the physicians to modify management and to aid in the selection of the most appropriate therapeutic procedures. Interestingly, although it was not a primary outcome, the question of whether emergency VCE decreases the frequency of OGIB remains to be assessed. Although these results might not be enough to make us consider modifying the current approach to GI bleeding, these findings represent a call for larger, randomized, and comparative studies that could place VCE in a completely different position, one that could increase its diagnostic yield, avoid repeating unnecessary EGDs and
1. ASGE Standards of Practice Committee; Hwang JH, Fisher DA, BenMenachem T, et al. The role of endoscopy in the management of acute nonvariceal upper GI bleeding. Gastrointest Endosc 2012;75:1132-8. 2. Rondonotti E, Marmo R, Petracchini M, et al. The American Society for Gastrointestinal Endoscopy (ASGE) diagnostic algorithm for obscure gastrointestinal bleeding: eight burning questions from everyday clinical practice. Dig Dis Liv 2013;45:179-85. 3. ASGE Standards of Practice Committee; Early DS, Ben-Menachem T, Decker GA, et al. Appropriate use of GI endoscopy. Gastrointest Endosc 2012;75:1127-31. 4. Singh A, Marshall C, Biswashree C, et al. Timing of video capsule endoscopy relative to overt obscure GI bleeding: implications from a retrospective study. Gastrointest Endosc 2013;77:761-6. 5. Carey E, Leighton J, Heigh R, et al. A single center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 2007;102:89-95. 6. Schlag C, Menzel C, Nennstiel S, et al. Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results. Gastrointest Endosc 2015;81:889-95. 7. Meltzer AC, Amir MA, Kresiberg RB, et al. Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med 2013;61:438-43. 8. Gralnek IM, Ching JY, Maza I, et al. Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. Endoscopy 2013;45:12-9. 9. Lecleire S, Iwanicki-Caron I, Di-Fiore A, et al. Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding. Endoscopy 2012;44:337-42. 10. ASGE Standards of Practice Committee; Fisher L, Lee Krinsky M, Anderson MA, et al. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 2010;72:471-9. 11. Meltzer AC, Ward MJ, Gralnek IM, et al. The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the emergency department. Am J Emerg Med 2014;32:823-32. 12. Gilbert D, O’Malley S, Selby W. Are repeat upper gastrointestinal endoscopy and colonoscopy necessary within six months of capsule endoscopy in patients with obscure gastrointestinal bleeding? J Gastroenterol Hepatol 2008;23:1806-9. 13. Penazzio M, Gaudin J, Filoche B, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126:643-53.
www.giejournal.org
Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 897
colonoscopies, and allow a better use of diagnostic and therapeutic tools. DISCLOSURE The author disclosed no financial relationships relevant to this article. Mario Peláez-Luna, MD Research Division, School of Medicine, UNAM Gastroenterology Department Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán México City, México Abbreviations: OGIB, obscure GI bleeding; UGIB, upper GI bleeding; VCE, video capsule endoscopy.
REFERENCES
