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The role of capsule endoscopy in acute gastrointestinal bleeding Moshe Nadler and Rami Eliakim Therapeutic Advances in Gastroenterology published online 11 September 2013 DOI: 10.1177/1756283X13504727 The online version of this article can be found at: http://tag.sagepub.com/content/early/2013/09/11/1756283X13504727 A more recent version of this article was published on - Jan 27, 2014
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TAG0010.1177/1756283X13504727Therapeutic Advances in GastroenterologyM Nadler and R Eliakim
Therapeutic Advances in Gastroenterology
Review
The role of capsule endoscopy in acute gastrointestinal bleeding
Ther Adv Gastroenterol (2013) 0(0) 1–6 DOI: 10.1177/ 1756283X13504727 © The Author(s), 2013. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Moshe Nadler and Rami Eliakim
Abstract: Acute gastrointestinal (GI) bleeding is a common cause of hospitalization, resulting in about 400,000 hospital admissions annually, with a mortality rate of 5– 10%. It is estimated that 5% of acute GI bleedings are of obscure origin with a normal esophagogastroduodenoscopy and ileocolonoscopy. Capsule endoscopy is the state-of-the-art procedure for inspection of the entire small bowel with a high sensitivity for the detection of causes of bleeding. In recent years, many studies have addressed the sensitivity and outcome of capsule-endoscopy procedures in patients with acute GI bleeding. This review looks at the role of capsule endoscopy in the evaluation of patients with acute GI bleeding from either the upper GI tract or small bowel. Keywords: acute bleeding, capsule endoscopy, overt bleeding
Introduction The introduction of small-bowel capsule endoscopy (SBCE) to the gastrointestinal (GI) arena was a major breakthrough as it provided, for the first time, a user-friendly method that has the ability to investigate the entire small bowel, which was a ‘dark hole’ until that time. Since its introduction in 2000 [Iddan, 2000], SBCE has become a valuable tool in assessing small-bowel pathologies, with a high diagnostic yield and higher sensitivity rate compared with other radiographic and endoscopic procedures [Triester et al. 2005; Marmo et al. 2005; Pennazio et al. 2005]. SBCE is the best means for exploring the entire luminal surface of the small bowel and is considered to be the state of the art for small-bowel endoscopic imaging [Mishkin et al. 2006]. The PillCam SB3 video capsule endoscope (Given Imaging, Yokneam, Israel) is a wireless capsule (11 × 26 mm2) containing a light source, lens, CMOS imager, battery, and wireless transmitter. The battery allows 11 h of operation with the ability to photograph more than 70,000 images throughout the study. Since its introduction in early 2000, the capsule has undergone a few changes and the third-generation capsule will be released shortly (PillCam SB3). Other small-bowel capsules have been
introduced from Japan (EndoCapsule, Olympus, Tokyo, Japan), Korea (MiroCam, IntroMedic, Seoul, Korea), China (OMOM, Jinshan Science and Technology Company, Chongqing, China), and the USA (CapsoCam SV-1, CapsoVision Inc., Saratoga, CA, USA) (Figure 1). When evaluating the diagnostic agreement between the PillCam and MiroCam using a head-to-head comparison in 83 patients, similar efficacy was found [Pioche et al. 2011]. A similar comparison was performed between the MiroCam and the EndoCapsule in 50 patients and no statistical difference was found in their performance [Dolak et al. 2012].
Correspondence to: Rami Eliakim, MD Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, 5265601, Israel Abraham.eliakim@sheba. health.gov.il Moshe Nadler, MD Department of Gastroenterology, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Given Imaging also developed a double-headed esophageal capsule (PillCam Eso3) and a doubleheaded colonic capsule (PillCam Colon 2). The main indications for performing a SBCE examination include: obscure overt/occult GI bleeding, suspected Crohn’s disease, suspected small-bowel tumor, evaluation of patients with nonresponding celiac disease, small-bowel evaluation of patients with inherited polyposis syndromes, evaluation of patients with abnormal small-bowel imaging, and/or evaluation of any suspected small-bowel injury. The contraindications are presented in Table 1 [Eliakim, 2013].
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Figure 1. The capsule endoscopes presently available. Table 1. Relative and absolute contraindications for video capsule endoscopy. Adapted from Ho, K. and Joyce, A. [2007] with permissions from Wolters Kluwer Health. Absolute contraindications Clinical or radiographic evidence of relevant bowel obstruction Extensive and active Crohn’s disease of the small bowel, with or without obstruction Intestinal pseudo-obstruction Young children (< 10 years) Relative contraindications Cardiac pacemakers or other implanted electromedical devices Dysphagia Previous abdominal or pelvic surgery Pregnancy Extensive intestinal diverticulosis
In order to try and shorten the reading time of a capsule-endoscopy examination, two options exist: to use the ‘quick-view’ mode or the nonsingle frame-view mode. The quick-view mode was found to be reliable and accurate in inpatients with obscure GI bleeding (OGIB) as well as in outpatients with occult GI bleeding or suspected Crohn’s disease [Koulaouzidis et al. 2012]. Saurin and colleagues reported that by using the quickview reading mode, reading time was reduced to 11.6 min and 94% of significant lesions were observed [Saurin et al. 2012]. Gunther and
colleagues reported that by using the quadric-view mode as compared with the single-view mode, reading time can be reduced by half (from 22 min to 11 min),with only slightly lower detection rates (one case, a lymphoma-suspect lesion, was overlooked) [Gunther et al. 2012]. The present review summarizes our knowledge regarding the use of capsule endoscopy in the evaluation of acute GI bleeding. Since most of the data involves the original Given Imaging SBCE, we review the data on the PillCam SB capsules.
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M Nadler and R Eliakim Acute gastrointestinal bleeding Hematemesis
Melena or hematochezia
EGD
Nasogastric tube aspiration Fresh blood/ coffee ground EGD
Clear content
Ileocolonoscopy Normal ileocolonoscopy Capsule endoscopy
Figure 2. The approach to a patient with acute gastrointestinal bleeding. EGD, esophagogastroduodenoscopy.
GI bleeding Acute GI bleeding is a serious medical condition and a common cause of hospital admission, resulting in 400,000 worldwide admissions annually and mortality rates that range from 5% to 10% [Gralnek et al. 2008; Loperfido et al. 2009]. When facing a patient with acute GI bleeding, one needs to know if it is upper GI tract bleeding, lower/colonic bleeding, or whether it is OGIB. OGIB is defined as a bleeding from an unknown site after a negative endoscopic evaluation of the GI tract with esophagogastroduodenoscopy (EGD) and ileocolonoscopy [Fisher et al. 2010]. OGIB accounts for approximately 5% of patients presenting with GI bleeding [Zuckerman et al. 2000]. OGIB may be categorized by two important aspects: its characteristics, i.e. overt or occult; its location, i.e. upper, lower, or mid-bowel. Occult bleeding will usually present as anemia or positive occult blood in the stool, while overt bleeding will present as melena or hematochezia.
Acute-overt GI bleeding is traditionally divided into upper GI bleeding and lower GI bleeding with the Treitz ligament serving as the anatomical demarcation border. Today, with improvements in the ability to visualize the small bowel by capsule endoscopy, new endoscopic techniques such as device-assisted enteroscopy, and radiographic techniques, the source of bleeding can even be divided into three parts, i.e. the upper GI tract, lower GI tract, and small bowel. Most OGIB sources are located in the small bowel [Pennazio et al. 2004], and patients with obscureovert bleeding are more likely to suffer from a significant lesion compared with those patients with obscure-occult bleeding [Hartmann et al. 2005]. The approach to patients with GI bleeding is shown in Figure 2. Role of capsule endoscopy in obscure-overt GI bleeding SBCE has been shown to be significantly superior to cross-sectional radiology and push enteroscopy,
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Therapeutic Advances in Gastroenterology 0 (0) and as good as balloon-assisted enteroscopy in evaluating and finding the lesion causing the bleeding [Triester et al. 2005]. Leung and colleagues reported on 60 patients with acute-overt OGIB who were randomized to undergo capsule endoscopy or angiography as their initial examination. The diagnostic yield of capsule endoscopy was significantly higher than angiography (53.3% versus 20%; p = 0.016). In a follow up of up to 5 years, there was no significant difference in the long-term outcomes including further transfusion, hospitalization for rebleeding, and mortality between the two procedures [Leung et al. 2012]. Similar results were described by Laine and colleagues who compared 136 patients who underwent capsule endoscopy or dedicated small-bowel contrast radiography and found improved diagnostic yield of capsule endoscopy, with no difference in outcome [Laine et al. 2010]. Two important questions arise when one decides to perform a capsule endoscopy examination: (a) when is the best time to perform the study?; (b) does the capsule examination influence the clinical course? Most studies have shown that the answer to the first question is that the earlier to the onset of bleeding appearance the capsule study is performed, the greater the diagnostic yield that is achieved. Pennazio and colleagues reported a significantly higher diagnostic yield of capsule endoscopy in patients with ongoing obscure-overt bleeding (92.3%) compared with patients with obscureoccult bleeding (44.2%), or patients with a history of obscure-overt bleeding (12.9%) [Pennazio et al. 2004]. Carey and colleagues reported similar findings, i.e. capsule endoscopies that were performed in patients with ongoing bleeding had a significant higher diagnostic yield compared with those performed in patients with distant overt bleeding (87% versus 56%; p = 0.02) [Carey et al. 2007]. Regarding the second question, Lecleire and colleagues studied 55 patients with severe obscureovert GI bleeding who underwent an emergency capsule-endoscopy examination within 24–48 h of admission, after negative urgent upper and lower endoscopies [Lecleire et al. 2012]. Fresh blood was seen in 75% of patients undergoing the SBCE examination, and relevant lesions were seen in 67% of patients. As a consequence, further procedures were undertaken in 78% of patients: endoscopic (54%), surgical (22%), or radiological (2%). Thus the SBCE results led to various diagnostic and therapeutic procedures. In
a median follow up of 36 months after capsule endoscopy, six patients (11%) experienced rebleeding after treatment. All these patients had multiple small-bowel angiodysplasia. The cause for overt GI bleeding varies according to patient’s age. Duodenal ulcer and hemorrhoid were found to be the main reason for bleeding in patients younger than 40 years, while gastric ulcer was most common in other age groups [Okazaki et al. 2009]. Mujica and Barkin found that the cause of smallbowel bleeding also varies depending on patient’s age [Mujica and Barkin, 1996]: 1. < 40 years: Meckel’s diverticulum Dieulafoy’s lesions Crohn’s disease small-bowel tumors 2. > 40 years: angioectasia nonsteroidal anti-inflammatory druginduced enteropathy
Acute upper GI bleeding In recent years it has been hypothesized that the capsule-endoscopy procedure if performed early enough in the course of bleeding may contribute to the identification of high-risk patients presenting with acute upper GI bleeding. To date, risk stratification is based on clinical judgment, Blatchford and Rockall scores, which are validated, but their use is not widespread, and on nasogastric aspirate, the accuracy of which is questioned [Barkun et al. 2003]. Rubin and colleagues reported on a real-time capsule-endoscopy examination that was performed bed-side on 12 patients within 48 h of admission to the emergency room due to upper GI bleeding [Rubin et al. 2011]. Of the 12 patients, 7 had positive findings on capsule-endoscopy examination, all of which were confirmed by EGD that was performed within 6 h of the capsule examination. Four out of five patients with negative capsuleendoscopy examinations underwent EGD within 24 h and no pathological findings were observed; EGD was not performed on one patient due to comorbidities. A control group (12 patients) underwent EGD within 24 h with no prior capsule examination. When the two groups were compared, time to endoscopy was significantly shorter in the capsule endoscopy-positive group, but the length of hospital stay or blood-transfusion requirements were not significantly different.
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M Nadler and R Eliakim Gralnek and colleagues studied 41 patients who underwent real-time capsule endoscopy up to 6 h from their arrival at the emergency room due to acute upper GI bleeding [Gralnek et al. 2013]. Capsule findings were compared with the prognostic and diagnostic yield of nasogastric aspirate and EGD. Capsule endoscopy revealed blood in the upper GI tract significantly more than the nasogastric aspirate (83.3% versus 33.3%; p = 0.035). There were no significant differences between the pathological findings in the capsule endoscopy examination and EGD findings. The capsule used in this study was a doubleheaded esophageal capsule with a higher frame rate/s and a shorter battery life, and intended for the upper GI tract only. Andrew and colleagues reported on 25 patients who underwent real-time capsule endoscopy at the emergency room due to melena or hematemesis [Andrew et al. 2013]. The capsule results were reviewed by two nongastroenterologist emergencyroom physicians who underwent brief training in capsule-endoscopy interpretation of GI pathologies and by two trained gastroenterologists. There was excellent agreement between the readings of the trained gastroenterologists and the emergencyroom physicians. The capsule was well tolerated in 96% of patients, and showed 88% sensitivity and 64% specificity for detecting fresh blood. Complications The two main complications of capsule endoscopy are retention and aspiration. Frequency of retention was reported according to the capsule-endoscopy indication: 0% in healthy volunteers, 1.4% in patients with suspected Crohn’s disease, 5% in patients with obscure GI bleeding, 8% in patients with known Crohn’s disease, and 21% in patients with suspected small-bowel obstruction [Eliakim, 2006].
studies should be performed in order to assess the practical use of capsule endoscopy in acute GI bleeding and the cost effectiveness of the procedure. Funding This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Conflict of interest statement The authors declare that there is no conflict of interest.
References Andrew, C., Meltzer, M., Aamir, A., Roderick, B., Gayatri, B., Smith, P. et al. (2013) Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med 61: 438–443. Barkun, A., Bardou, M. and Marshall, J. (2003) Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 139: 843–857. Carey, E., Leighton, J., Heigh, R., Shiff, A., Sharma, V., Post, J. et al. (2007) A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 102: 89–95. Dolak, W., Kulnigg-Dabsch, S., Evstatiev, R., Gasche, C., Trauner, M. and Puspok, A. (2012) A randomized head-to-head study of small-bowel imaging comparing MiroCam and EndoCapsule. Endoscopy 44: 1012–1020. Eliakim, R. (2013) Video capsule endoscopy of the small bowel. Curr Opin Gastroenterol 29: 133–139. Eliakim, A. (2006) Video capsule endoscopy of the small bowel (PillCam SB). Curr Opin Gastroenterol 22: 124–127.
Inability to swallow the capsule or rare aspiration of the capsule was reported in 1.5% of capsuleendoscopy procedures [Rodonotti et al. 2005].
Fisher, L., Lee Krinsky, M., Anderson, M., Appalaneni, V., Banerjee, S., Ben-Menachem, T. et al.; ASGE Standards of Practice Committee (2010) The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 72: 471–479.
Summary The above reports show that capsule endoscopy is a feasible, safe examination, easily learned in a relatively short period of time by nongastroenterologist physicians. It has a high sensitivity for detecting fresh blood, and is relatively similar to EGD in visualizing upper GI pathologies. Further
Gralnek, I., Barkun, A. and Bardou, M. (2008) Management of acute bleeding from peptic ulcer. N Engl J Med 359: 928–937. Gralnek, I., Ching, Y., Maza, I., Wu, J., Rainer, T., Israelit, S. et al. (2013) Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. Endoscopy 45: 12–19.
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Therapeutic Advances in Gastroenterology 0 (0) Gunther, U., Daum, S., Zeitz, M. and Bojarski, C. (2012) Capsule endoscopy: comparison of two different reading modes. Int J Colorectal Dis 27: 521–525. Hartmann, D., Schmidt, H., Bolz, G., Schilling, D., Kinzel, F., Eickhoff, A. et al. (2005) A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 61: 826–832. Ho, K. and Joyce, A. (2007) Complications of capsule endoscopy. Gastrointest Endosc Clin N Am 17: 169–178. Iddan, G., Meron, G., Glukhovasky, A. and Swain, P. (2000) Wireless capsule endoscopy. Nature 455: 417–418. Koulaouzidis, A., Smirnidis, A., Douglas, S. and Plevris, J. (2012) Quick-view in small bowel capsule endoscopy is useful in certain clinical settings, but quick-view with blue mode is of no additional benefit. Eur J Gastroenterol Hepatol 24: 1099–1104. Laine, L., Sahota, A. and Shah, A. (2010) Does capsule endoscopy improve outcomes in obscure gastrointestinal bleeding? Randomized trial versus dedicated small bowel radiography. Gastroenterol 138: 1673–1680. Lecleire, I., Iwanicki-Caron, A., Di-Fiore, C., Elie, C., Alhameedi, R., Ramirez, S. et al. (2012) Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding. Endoscopy 44: 337–342. Leung, W., Ho, S., Suen, B., Lai, L., Yu, S., Ng, E. et al. (2012) Capsule endoscopy or angiography in patients with acute overt obscure gastrointestinal bleeding: a prospective randomized study with longterm follow-up. Am J Gastroenterol 107: 1370–1376.
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Mujica, V. and Barkin, J. (1996) Occult gastrointestinal bleeding. General overview and approach. Gastrointest Endosc Clin N Am 6: 833–845. Okazaki, H., Fuiwara, Y., Sugimori, S., Nagami, Y., Kameda, N., Machida, H. et al. (2009) Prevalence of mid-gastrointestinal bleeding in patients with acute overt gastrointestinal bleeding: multi-center experience with 1044 consecutive patients. J Gastroenterol 44: 550–555. Pennazio, M., Eisen, G. and Goldfarb, N. (2005) ICCE consensus for obscure gastro-intestinal bleeding. Endoscopy 37: 1046–1050. Pennazio, M., Santucci, R., Rondonotti, E., Abbiati, C., Beccari, G., Rossini, F. et al. (2004) Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 126: 643–653. Pioche, M., Gaudin, J., Filoche, B., Lamouliatte, H., Lapalus, M., Duburque, C. et al. (2011) Prospective, randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding. Gastrointest Endosc 73: 1181–1188. Rondonotti, E., Herrerias, J., Pennazio, M., Caunedo, A., Mascarenhas-Saraiva, M. and de Franchis, R. (2005) Complications, limitations, and failure of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 62: 712–716. Rubin, M., Hussain, S., Shalomov, A., Cortes, R., Smith, M. and Kim, S. (2011) Live view video capsule endoscopy enables risk stratification of patients with acute upper GI bleeding in the emergency room: a pilot study. Dig Dis Sci 56: 786–791.
Loperfido, S., Baldo, V., Piovesana, E., Bellina, L., Rossi, K., Groppo, M. et al. (2009) Changing trends in acute upper-GI bleeding: a population-based study. Gastrointest Endosc 70: 212–224.
Saurin, J., Lapalus, M., Cholet, F., D’Halluin, P., Filoche, B., Gaudric, M. et al.; French Society of Digestive Endoscopy (SFED). (2012) Can we shorten the small bowel capsule reading time with the ‘quick-view’ image detection system. Dig Liver Dis 44: 477–481.
Marmo, R., Rotondano, G., Piscopo, R., Bianco, M. and Cipolletta, L. (2005) Meta-analysis: capsule enteroscopy versus conventional modalities in diagnosis of small bowel diseases. Aliment Pharmacol Ther 22: 595–604.
Triester, S., Leighton, J., Leontiadis, G., Gurudu, S., Fleischer, D., Hara, A. et al. (2005) A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure GI bleeding. Am J Gastroenterol 100: 2407–2418.
Mishkin, D., Chuttani, R., Croffie, J., Disario, J., Liu, J., Shah, R. et al. (2006) ASGE technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc 63: 539–545.
Zuckerman, G., Prakash, C., Askin, M. and Lewis, B. (2000) AGA technical review on the evaluation and the management of occult and obscure gastrointestinal bleeding. Gastroenterology 118: 201–221.
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The role of capsule endoscopy in acute gastrointestinal bleeding Moshe Nadler and Rami Eliakim Therapeutic Advances in Gastroenterology published online 11 September 2013 DOI: 10.1177/1756283X13504727 The online version of this article can be found at: http://tag.sagepub.com/content/early/2013/09/11/1756283X13504727 A more recent version of this article was published on - Jan 27, 2014
Published by: http://www.sagepublications.com
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Version of Record - Jan 27, 2014 >> OnlineFirst Version of Record - Sep 11, 2013 What is This?
Downloaded from tag.sagepub.com at University of Texas Libraries on June 28, 2014
504727 504727 2013
TAG0010.1177/1756283X13504727Therapeutic Advances in GastroenterologyM Nadler and R Eliakim
Therapeutic Advances in Gastroenterology
Review
The role of capsule endoscopy in acute gastrointestinal bleeding
Ther Adv Gastroenterol (2013) 0(0) 1–6 DOI: 10.1177/ 1756283X13504727 © The Author(s), 2013. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Moshe Nadler and Rami Eliakim
Abstract: Acute gastrointestinal (GI) bleeding is a common cause of hospitalization, resulting in about 400,000 hospital admissions annually, with a mortality rate of 5– 10%. It is estimated that 5% of acute GI bleedings are of obscure origin with a normal esophagogastroduodenoscopy and ileocolonoscopy. Capsule endoscopy is the state-of-the-art procedure for inspection of the entire small bowel with a high sensitivity for the detection of causes of bleeding. In recent years, many studies have addressed the sensitivity and outcome of capsule-endoscopy procedures in patients with acute GI bleeding. This review looks at the role of capsule endoscopy in the evaluation of patients with acute GI bleeding from either the upper GI tract or small bowel. Keywords: acute bleeding, capsule endoscopy, overt bleeding
Introduction The introduction of small-bowel capsule endoscopy (SBCE) to the gastrointestinal (GI) arena was a major breakthrough as it provided, for the first time, a user-friendly method that has the ability to investigate the entire small bowel, which was a ‘dark hole’ until that time. Since its introduction in 2000 [Iddan, 2000], SBCE has become a valuable tool in assessing small-bowel pathologies, with a high diagnostic yield and higher sensitivity rate compared with other radiographic and endoscopic procedures [Triester et al. 2005; Marmo et al. 2005; Pennazio et al. 2005]. SBCE is the best means for exploring the entire luminal surface of the small bowel and is considered to be the state of the art for small-bowel endoscopic imaging [Mishkin et al. 2006]. The PillCam SB3 video capsule endoscope (Given Imaging, Yokneam, Israel) is a wireless capsule (11 × 26 mm2) containing a light source, lens, CMOS imager, battery, and wireless transmitter. The battery allows 11 h of operation with the ability to photograph more than 70,000 images throughout the study. Since its introduction in early 2000, the capsule has undergone a few changes and the third-generation capsule will be released shortly (PillCam SB3). Other small-bowel capsules have been
introduced from Japan (EndoCapsule, Olympus, Tokyo, Japan), Korea (MiroCam, IntroMedic, Seoul, Korea), China (OMOM, Jinshan Science and Technology Company, Chongqing, China), and the USA (CapsoCam SV-1, CapsoVision Inc., Saratoga, CA, USA) (Figure 1). When evaluating the diagnostic agreement between the PillCam and MiroCam using a head-to-head comparison in 83 patients, similar efficacy was found [Pioche et al. 2011]. A similar comparison was performed between the MiroCam and the EndoCapsule in 50 patients and no statistical difference was found in their performance [Dolak et al. 2012].
Correspondence to: Rami Eliakim, MD Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, 5265601, Israel Abraham.eliakim@sheba. health.gov.il Moshe Nadler, MD Department of Gastroenterology, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Given Imaging also developed a double-headed esophageal capsule (PillCam Eso3) and a doubleheaded colonic capsule (PillCam Colon 2). The main indications for performing a SBCE examination include: obscure overt/occult GI bleeding, suspected Crohn’s disease, suspected small-bowel tumor, evaluation of patients with nonresponding celiac disease, small-bowel evaluation of patients with inherited polyposis syndromes, evaluation of patients with abnormal small-bowel imaging, and/or evaluation of any suspected small-bowel injury. The contraindications are presented in Table 1 [Eliakim, 2013].
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Figure 1. The capsule endoscopes presently available. Table 1. Relative and absolute contraindications for video capsule endoscopy. Adapted from Ho, K. and Joyce, A. [2007] with permissions from Wolters Kluwer Health. Absolute contraindications Clinical or radiographic evidence of relevant bowel obstruction Extensive and active Crohn’s disease of the small bowel, with or without obstruction Intestinal pseudo-obstruction Young children (< 10 years) Relative contraindications Cardiac pacemakers or other implanted electromedical devices Dysphagia Previous abdominal or pelvic surgery Pregnancy Extensive intestinal diverticulosis
In order to try and shorten the reading time of a capsule-endoscopy examination, two options exist: to use the ‘quick-view’ mode or the nonsingle frame-view mode. The quick-view mode was found to be reliable and accurate in inpatients with obscure GI bleeding (OGIB) as well as in outpatients with occult GI bleeding or suspected Crohn’s disease [Koulaouzidis et al. 2012]. Saurin and colleagues reported that by using the quickview reading mode, reading time was reduced to 11.6 min and 94% of significant lesions were observed [Saurin et al. 2012]. Gunther and
colleagues reported that by using the quadric-view mode as compared with the single-view mode, reading time can be reduced by half (from 22 min to 11 min),with only slightly lower detection rates (one case, a lymphoma-suspect lesion, was overlooked) [Gunther et al. 2012]. The present review summarizes our knowledge regarding the use of capsule endoscopy in the evaluation of acute GI bleeding. Since most of the data involves the original Given Imaging SBCE, we review the data on the PillCam SB capsules.
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M Nadler and R Eliakim Acute gastrointestinal bleeding Hematemesis
Melena or hematochezia
EGD
Nasogastric tube aspiration Fresh blood/ coffee ground EGD
Clear content
Ileocolonoscopy Normal ileocolonoscopy Capsule endoscopy
Figure 2. The approach to a patient with acute gastrointestinal bleeding. EGD, esophagogastroduodenoscopy.
GI bleeding Acute GI bleeding is a serious medical condition and a common cause of hospital admission, resulting in 400,000 worldwide admissions annually and mortality rates that range from 5% to 10% [Gralnek et al. 2008; Loperfido et al. 2009]. When facing a patient with acute GI bleeding, one needs to know if it is upper GI tract bleeding, lower/colonic bleeding, or whether it is OGIB. OGIB is defined as a bleeding from an unknown site after a negative endoscopic evaluation of the GI tract with esophagogastroduodenoscopy (EGD) and ileocolonoscopy [Fisher et al. 2010]. OGIB accounts for approximately 5% of patients presenting with GI bleeding [Zuckerman et al. 2000]. OGIB may be categorized by two important aspects: its characteristics, i.e. overt or occult; its location, i.e. upper, lower, or mid-bowel. Occult bleeding will usually present as anemia or positive occult blood in the stool, while overt bleeding will present as melena or hematochezia.
Acute-overt GI bleeding is traditionally divided into upper GI bleeding and lower GI bleeding with the Treitz ligament serving as the anatomical demarcation border. Today, with improvements in the ability to visualize the small bowel by capsule endoscopy, new endoscopic techniques such as device-assisted enteroscopy, and radiographic techniques, the source of bleeding can even be divided into three parts, i.e. the upper GI tract, lower GI tract, and small bowel. Most OGIB sources are located in the small bowel [Pennazio et al. 2004], and patients with obscureovert bleeding are more likely to suffer from a significant lesion compared with those patients with obscure-occult bleeding [Hartmann et al. 2005]. The approach to patients with GI bleeding is shown in Figure 2. Role of capsule endoscopy in obscure-overt GI bleeding SBCE has been shown to be significantly superior to cross-sectional radiology and push enteroscopy,
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Therapeutic Advances in Gastroenterology 0 (0) and as good as balloon-assisted enteroscopy in evaluating and finding the lesion causing the bleeding [Triester et al. 2005]. Leung and colleagues reported on 60 patients with acute-overt OGIB who were randomized to undergo capsule endoscopy or angiography as their initial examination. The diagnostic yield of capsule endoscopy was significantly higher than angiography (53.3% versus 20%; p = 0.016). In a follow up of up to 5 years, there was no significant difference in the long-term outcomes including further transfusion, hospitalization for rebleeding, and mortality between the two procedures [Leung et al. 2012]. Similar results were described by Laine and colleagues who compared 136 patients who underwent capsule endoscopy or dedicated small-bowel contrast radiography and found improved diagnostic yield of capsule endoscopy, with no difference in outcome [Laine et al. 2010]. Two important questions arise when one decides to perform a capsule endoscopy examination: (a) when is the best time to perform the study?; (b) does the capsule examination influence the clinical course? Most studies have shown that the answer to the first question is that the earlier to the onset of bleeding appearance the capsule study is performed, the greater the diagnostic yield that is achieved. Pennazio and colleagues reported a significantly higher diagnostic yield of capsule endoscopy in patients with ongoing obscure-overt bleeding (92.3%) compared with patients with obscureoccult bleeding (44.2%), or patients with a history of obscure-overt bleeding (12.9%) [Pennazio et al. 2004]. Carey and colleagues reported similar findings, i.e. capsule endoscopies that were performed in patients with ongoing bleeding had a significant higher diagnostic yield compared with those performed in patients with distant overt bleeding (87% versus 56%; p = 0.02) [Carey et al. 2007]. Regarding the second question, Lecleire and colleagues studied 55 patients with severe obscureovert GI bleeding who underwent an emergency capsule-endoscopy examination within 24–48 h of admission, after negative urgent upper and lower endoscopies [Lecleire et al. 2012]. Fresh blood was seen in 75% of patients undergoing the SBCE examination, and relevant lesions were seen in 67% of patients. As a consequence, further procedures were undertaken in 78% of patients: endoscopic (54%), surgical (22%), or radiological (2%). Thus the SBCE results led to various diagnostic and therapeutic procedures. In
a median follow up of 36 months after capsule endoscopy, six patients (11%) experienced rebleeding after treatment. All these patients had multiple small-bowel angiodysplasia. The cause for overt GI bleeding varies according to patient’s age. Duodenal ulcer and hemorrhoid were found to be the main reason for bleeding in patients younger than 40 years, while gastric ulcer was most common in other age groups [Okazaki et al. 2009]. Mujica and Barkin found that the cause of smallbowel bleeding also varies depending on patient’s age [Mujica and Barkin, 1996]: 1. < 40 years: Meckel’s diverticulum Dieulafoy’s lesions Crohn’s disease small-bowel tumors 2. > 40 years: angioectasia nonsteroidal anti-inflammatory druginduced enteropathy
Acute upper GI bleeding In recent years it has been hypothesized that the capsule-endoscopy procedure if performed early enough in the course of bleeding may contribute to the identification of high-risk patients presenting with acute upper GI bleeding. To date, risk stratification is based on clinical judgment, Blatchford and Rockall scores, which are validated, but their use is not widespread, and on nasogastric aspirate, the accuracy of which is questioned [Barkun et al. 2003]. Rubin and colleagues reported on a real-time capsule-endoscopy examination that was performed bed-side on 12 patients within 48 h of admission to the emergency room due to upper GI bleeding [Rubin et al. 2011]. Of the 12 patients, 7 had positive findings on capsule-endoscopy examination, all of which were confirmed by EGD that was performed within 6 h of the capsule examination. Four out of five patients with negative capsuleendoscopy examinations underwent EGD within 24 h and no pathological findings were observed; EGD was not performed on one patient due to comorbidities. A control group (12 patients) underwent EGD within 24 h with no prior capsule examination. When the two groups were compared, time to endoscopy was significantly shorter in the capsule endoscopy-positive group, but the length of hospital stay or blood-transfusion requirements were not significantly different.
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M Nadler and R Eliakim Gralnek and colleagues studied 41 patients who underwent real-time capsule endoscopy up to 6 h from their arrival at the emergency room due to acute upper GI bleeding [Gralnek et al. 2013]. Capsule findings were compared with the prognostic and diagnostic yield of nasogastric aspirate and EGD. Capsule endoscopy revealed blood in the upper GI tract significantly more than the nasogastric aspirate (83.3% versus 33.3%; p = 0.035). There were no significant differences between the pathological findings in the capsule endoscopy examination and EGD findings. The capsule used in this study was a doubleheaded esophageal capsule with a higher frame rate/s and a shorter battery life, and intended for the upper GI tract only. Andrew and colleagues reported on 25 patients who underwent real-time capsule endoscopy at the emergency room due to melena or hematemesis [Andrew et al. 2013]. The capsule results were reviewed by two nongastroenterologist emergencyroom physicians who underwent brief training in capsule-endoscopy interpretation of GI pathologies and by two trained gastroenterologists. There was excellent agreement between the readings of the trained gastroenterologists and the emergencyroom physicians. The capsule was well tolerated in 96% of patients, and showed 88% sensitivity and 64% specificity for detecting fresh blood. Complications The two main complications of capsule endoscopy are retention and aspiration. Frequency of retention was reported according to the capsule-endoscopy indication: 0% in healthy volunteers, 1.4% in patients with suspected Crohn’s disease, 5% in patients with obscure GI bleeding, 8% in patients with known Crohn’s disease, and 21% in patients with suspected small-bowel obstruction [Eliakim, 2006].
studies should be performed in order to assess the practical use of capsule endoscopy in acute GI bleeding and the cost effectiveness of the procedure. Funding This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Conflict of interest statement The authors declare that there is no conflict of interest.
References Andrew, C., Meltzer, M., Aamir, A., Roderick, B., Gayatri, B., Smith, P. et al. (2013) Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med 61: 438–443. Barkun, A., Bardou, M. and Marshall, J. (2003) Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 139: 843–857. Carey, E., Leighton, J., Heigh, R., Shiff, A., Sharma, V., Post, J. et al. (2007) A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 102: 89–95. Dolak, W., Kulnigg-Dabsch, S., Evstatiev, R., Gasche, C., Trauner, M. and Puspok, A. (2012) A randomized head-to-head study of small-bowel imaging comparing MiroCam and EndoCapsule. Endoscopy 44: 1012–1020. Eliakim, R. (2013) Video capsule endoscopy of the small bowel. Curr Opin Gastroenterol 29: 133–139. Eliakim, A. (2006) Video capsule endoscopy of the small bowel (PillCam SB). Curr Opin Gastroenterol 22: 124–127.
Inability to swallow the capsule or rare aspiration of the capsule was reported in 1.5% of capsuleendoscopy procedures [Rodonotti et al. 2005].
Fisher, L., Lee Krinsky, M., Anderson, M., Appalaneni, V., Banerjee, S., Ben-Menachem, T. et al.; ASGE Standards of Practice Committee (2010) The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 72: 471–479.
Summary The above reports show that capsule endoscopy is a feasible, safe examination, easily learned in a relatively short period of time by nongastroenterologist physicians. It has a high sensitivity for detecting fresh blood, and is relatively similar to EGD in visualizing upper GI pathologies. Further
Gralnek, I., Barkun, A. and Bardou, M. (2008) Management of acute bleeding from peptic ulcer. N Engl J Med 359: 928–937. Gralnek, I., Ching, Y., Maza, I., Wu, J., Rainer, T., Israelit, S. et al. (2013) Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. Endoscopy 45: 12–19.
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Therapeutic Advances in Gastroenterology 0 (0) Gunther, U., Daum, S., Zeitz, M. and Bojarski, C. (2012) Capsule endoscopy: comparison of two different reading modes. Int J Colorectal Dis 27: 521–525. Hartmann, D., Schmidt, H., Bolz, G., Schilling, D., Kinzel, F., Eickhoff, A. et al. (2005) A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 61: 826–832. Ho, K. and Joyce, A. (2007) Complications of capsule endoscopy. Gastrointest Endosc Clin N Am 17: 169–178. Iddan, G., Meron, G., Glukhovasky, A. and Swain, P. (2000) Wireless capsule endoscopy. Nature 455: 417–418. Koulaouzidis, A., Smirnidis, A., Douglas, S. and Plevris, J. (2012) Quick-view in small bowel capsule endoscopy is useful in certain clinical settings, but quick-view with blue mode is of no additional benefit. Eur J Gastroenterol Hepatol 24: 1099–1104. Laine, L., Sahota, A. and Shah, A. (2010) Does capsule endoscopy improve outcomes in obscure gastrointestinal bleeding? Randomized trial versus dedicated small bowel radiography. Gastroenterol 138: 1673–1680. Lecleire, I., Iwanicki-Caron, A., Di-Fiore, C., Elie, C., Alhameedi, R., Ramirez, S. et al. (2012) Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding. Endoscopy 44: 337–342. Leung, W., Ho, S., Suen, B., Lai, L., Yu, S., Ng, E. et al. (2012) Capsule endoscopy or angiography in patients with acute overt obscure gastrointestinal bleeding: a prospective randomized study with longterm follow-up. Am J Gastroenterol 107: 1370–1376.
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Mujica, V. and Barkin, J. (1996) Occult gastrointestinal bleeding. General overview and approach. Gastrointest Endosc Clin N Am 6: 833–845. Okazaki, H., Fuiwara, Y., Sugimori, S., Nagami, Y., Kameda, N., Machida, H. et al. (2009) Prevalence of mid-gastrointestinal bleeding in patients with acute overt gastrointestinal bleeding: multi-center experience with 1044 consecutive patients. J Gastroenterol 44: 550–555. Pennazio, M., Eisen, G. and Goldfarb, N. (2005) ICCE consensus for obscure gastro-intestinal bleeding. Endoscopy 37: 1046–1050. Pennazio, M., Santucci, R., Rondonotti, E., Abbiati, C., Beccari, G., Rossini, F. et al. (2004) Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 126: 643–653. Pioche, M., Gaudin, J., Filoche, B., Lamouliatte, H., Lapalus, M., Duburque, C. et al. (2011) Prospective, randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding. Gastrointest Endosc 73: 1181–1188. Rondonotti, E., Herrerias, J., Pennazio, M., Caunedo, A., Mascarenhas-Saraiva, M. and de Franchis, R. (2005) Complications, limitations, and failure of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 62: 712–716. Rubin, M., Hussain, S., Shalomov, A., Cortes, R., Smith, M. and Kim, S. (2011) Live view video capsule endoscopy enables risk stratification of patients with acute upper GI bleeding in the emergency room: a pilot study. Dig Dis Sci 56: 786–791.
Loperfido, S., Baldo, V., Piovesana, E., Bellina, L., Rossi, K., Groppo, M. et al. (2009) Changing trends in acute upper-GI bleeding: a population-based study. Gastrointest Endosc 70: 212–224.
Saurin, J., Lapalus, M., Cholet, F., D’Halluin, P., Filoche, B., Gaudric, M. et al.; French Society of Digestive Endoscopy (SFED). (2012) Can we shorten the small bowel capsule reading time with the ‘quick-view’ image detection system. Dig Liver Dis 44: 477–481.
Marmo, R., Rotondano, G., Piscopo, R., Bianco, M. and Cipolletta, L. (2005) Meta-analysis: capsule enteroscopy versus conventional modalities in diagnosis of small bowel diseases. Aliment Pharmacol Ther 22: 595–604.
Triester, S., Leighton, J., Leontiadis, G., Gurudu, S., Fleischer, D., Hara, A. et al. (2005) A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure GI bleeding. Am J Gastroenterol 100: 2407–2418.
Mishkin, D., Chuttani, R., Croffie, J., Disario, J., Liu, J., Shah, R. et al. (2006) ASGE technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc 63: 539–545.
Zuckerman, G., Prakash, C., Askin, M. and Lewis, B. (2000) AGA technical review on the evaluation and the management of occult and obscure gastrointestinal bleeding. Gastroenterology 118: 201–221.
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![[Usefulness of capsule endoscopy in obscure gastrointestinal bleeding].](/assets/img/hold.png)
