Occult small bowel bleeding - Video capsule first

Transcription

1 Occult small bowel bleeding - Video capsule first Prof. Joseph Sung The Chinese University of Hong Kong Disclosure of Potential Conflict of Interest: Nothing to Disclose

2 Obscure Gastrointestinal Bleeding Definition: Bleeding from the GI tract that persist or recurs without an obvious etiology after EGD, colonoscopy and radiologic evaluation of the small bowel such as small bowel follow-through or enteroclysis Obscure overt bleeding: recurrent passage of visible blood Obscure occult bleeding: recurrent iron-deficiency anemia or positive FOBT results AGA Institute Medical Position Statement. Gastroenterology 2007

3 Capsule Endoscopy versus SM Enteroscopy

4 Most studies showed CE versus DBE have comparable yield Study No. of OGIB CE Yield DBE Yield Matsumoto, % 36% May % 80% Hadithi, % 60% Nakamura % 43% Mehdizadeh % 43% Li, % 53% Ohmiya, % 53% Kameda, % 66% Arakawa, % 64%

5 Meta-Analysis VCE versus DBE Pasha S et al. CGH 2008

6 Capsule Endoscopy is comparable to Doubleballoon Enteroscopy in different pathologies CE DBD IY 95%CI Overall (11 studies) Vascular (10 studies) Inflammatory (9 studies) Tumor (9 studies) 60% 57% 3% -4% to 10% 24% 24% 0% -5% to 6% 18% 16% 0% -5% t0 6% 11% 11% -1% -5% to 4% Pasha SF CGH 2008

7 CE Compared to DBE patients with CE and DBE both anterograde and retrograde approach Yield Total SB K CE 42 (55%) 35 (46%) DBE 46 (61%) 35 (46%) 0.57 DBE CE K Anterograde 30/66 (45%) 38/66 (58%) 0.34 Total DBE 21/35 (60%) 21/35 (60%) 0.76 Fukumoto, 2009

8 CE or DBE? Which test produce a higher yield? Wrong question Which leads to change in management? A better (but still wrong) question Which leads to a better outcome? Right question

9 Yield of CE depends on type of patients Conclusion: CE is an effective diagnostic tool for OGIB

10 Yield of CE depends on type of patient Diagnosis: Positive That explain the bleeding Suspicious Unsure the significance as source of bleeding Negative No significant lesion found Positive Suspicious Negative 47 Pennazio et al Gastroenterol 2004

11 Patients with overt or recent bleeding have higher yield on CE Pennazio et al Gastroenterol 2004

12 CE vs PE as a first-line investigation Cross-over if negative Prospective Randomized Study Dx:50% Dx: 24% PE: 25% CE: 79% Leusse et al. Gastroenterol 2007

13 Using Capsule Endoscopy as first-line investigation is better Leusse et al. Gastroenterol 2007

14 Clinical Outcome is superior in those using CE as first strategy Leusse et al. Gastroenterol 2007

15 How to interpret CE results? Obscure GI Bleeding Capsule Endoscopy Diagnostic Non-diagnostic No significant

16 Outcome after positive CE

17 Outcome after positive CE Neu et al. Am J Gastro 2005

18 What happen after CE? 77 patients with OGIB Capsule endoscopy find clinically significant in 58.4% Follow up for 2 years

19 Outcome depends on pathology Angiodysplasia (after cautery) 50% Tumor (after surgery) 0% Ulcer (after endoscopy) 0% Crohn s disease 0% Endo et al. BMC Gastro 2008

20 Rebleeding after negative CE Obscure GI bleeding: N=49 Lesion found: N=31 (63%) Intervention: N=15(30.6%) Follow up: 19 months

21 Rebleeding after Negative CE

22 Rebleed is rare with Negative CE Lai et al. Am J Gastro 2006

23 Long term follow up after CE- 101 patients Median follow up 50 months (4 years) 1 yr 4 yr Overall rebleeding Overt rebleeding 68.2% 28.6% 30.3% 11.4%

24 Rebleeding: Multivariate Analysis Hazard Ratio P 95% CI Age 65 years old Positive CE Lowest Hb < 8g/dL before CE Usage of H2RA within 30 days before CE

25 Rebleeding in patients with Obscure GIB Log rank P<0.001

26 Recurrent bleeding in patients with Overt Rebleeding Log rank P = 0.027

27 Mortality: Multi-variate Analysis Hazard Ratio P 95% CI Age 65 years old Positive CE Lowest Hb < 8g/dL before CE

28 Mortality of Obscure GIB Log rank P=0.027

29 Rebleeding after Negative CE No. of patients Follow up (months) Total recur bleed (%) Rebleeding after CE- (%) Lorenceau-Savale Redondo-Cerezo N/A Hartmann N/A Kovacs N/A Lai Delvaux Landi N/A MacDonald

30 Why second look CE might work? Lesion missed by first examination as CE propels itself through the small intestine Lesion located in the terminal ileum may not be detectable with low transit time Lesion not actively bleeding in the first examination

31 Proposed Algorithm for OGIB Obscure GI Bleeding Capsule Endoscopy Diagnostic Non-diagnostic No significant

32 Proposed Algorithm for OGIB Obscure GI Bleeding Small bowel tumor Bleeding ulcer Bleeding angiodysplasia Capsule Endoscopy Diagnostic Non-diagnostic No significant Specific Rx Follow up 6-12 months

33 Proposed Algorithm for OGIB Obscure GI Bleeding Capsule Endoscopy Diagnostic Non-bleeding angiodysplasia Small bowel polyps Non-bleeding ulcer Erosions and aphthous ulcers Blood in lumen of small bowel Non-diagnostic Check Hb every 3m Monitor symptom No significant Drop in HB>4g or Hb<8g Change from occult to overt No drop in Hb No overt bleeding 2 nd look CE FU months

34 Proposed Algorithm for OGIB Obscure GI Bleeding Capsule Endoscopy Diagnostic Non-diagnostic No significant Observe id age <65 years and Hb >8g/dl

35 Algorithm for OGIB Obscure GI Bleeding Capsule Endoscopy Diagnostic Specific Rx Non-diagnostic Check Hb every 3m Monitor symptom No significant Observe Follow up 6-12 months Drop in HB>4g or Hb<8g Change from occult to overt 2 nd look CE No drop in Hb No overt bleeding FU months