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
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
Capsule Endoscopy versus SM Enteroscopy
Most studies showed CE versus DBE have comparable yield Study No. of OGIB CE Yield DBE Yield Matsumoto, 2005 13 55% 36% May 2005 52 73% 80% Hadithi, 2006 35 80% 60% Nakamura 2006 32 59% 43% Mehdizadeh 2006 115 55% 43% Li, 2007 116 65% 53% Ohmiya, 2007 74 50% 53% Kameda, 2008 32 72% 66% Arakawa, 2009 162 54% 64%
Meta-Analysis VCE versus DBE Pasha S et al. CGH 2008
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
CE Compared to DBE 2009 76 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
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
Yield of CE depends on type of patients Conclusion: CE is an effective diagnostic tool for OGIB
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 38 15 Positive Suspicious Negative 47 Pennazio et al Gastroenterol 2004
Patients with overt or recent bleeding have higher yield on CE Pennazio et al Gastroenterol 2004
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
Using Capsule Endoscopy as first-line investigation is better Leusse et al. Gastroenterol 2007
Clinical Outcome is superior in those using CE as first strategy Leusse et al. Gastroenterol 2007
How to interpret CE results? Obscure GI Bleeding Capsule Endoscopy Diagnostic Non-diagnostic No significant
Outcome after positive CE
Outcome after positive CE Neu et al. Am J Gastro 2005
What happen after CE? 77 patients with OGIB Capsule endoscopy find clinically significant in 58.4% Follow up for 2 years
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
Rebleeding after negative CE Obscure GI bleeding: N=49 Lesion found: N=31 (63%) Intervention: N=15(30.6%) Follow up: 19 months
Rebleeding after Negative CE
Rebleed is rare with Negative CE Lai et al. Am J Gastro 2006
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%
Rebleeding: Multivariate Analysis Hazard Ratio P 95% CI Age 65 years old 1.927 0.029 1.070-3.472 Positive CE 2.986 0.002 1.484-6.009 Lowest Hb < 8g/dL before CE 1.963 0.035 1.049-3.673 Usage of H2RA within 30 days before CE 1.652 0.094 0.918-2.973
Rebleeding in patients with Obscure GIB Log rank P<0.001
Recurrent bleeding in patients with Overt Rebleeding Log rank P = 0.027
Mortality: Multi-variate Analysis Hazard Ratio P 95% CI Age 65 years old 4.315 0.009 1.445-12.884 Positive CE 4.867 0.034 1.131-20.942 Lowest Hb < 8g/dL before CE 1.734 0.285 0.633-4.753
Mortality of Obscure GIB Log rank P=0.027
Rebleeding after Negative CE No. of patients Follow up (months) Total recur bleed (%) Rebleeding after CE- (%) Lorenceau-Savale 07 35 12 23 0 Redondo-Cerezo 07 30 12 17 N/A Hartmann 07 47 12 26 N/A Kovacs 06 66 20 18 N/A Lai 06 49 12 33 6 Delvaux 05 44 12 11 0 Landi 02 105 29 31 N/A MacDonald 08 49 17 28 11
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
Proposed Algorithm for OGIB Obscure GI Bleeding Capsule Endoscopy Diagnostic Non-diagnostic No significant
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
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 24-48 months
Proposed Algorithm for OGIB Obscure GI Bleeding Capsule Endoscopy Diagnostic Non-diagnostic No significant Observe id age <65 years and Hb >8g/dl
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 24-48 months