Reply to Dr. Jimenez-Saenz et al.

It is a pleasure to acknowledge the agreement of other colleagues regarding the use of capsule endoscopy in evaluation of the small bowel as a possible origin of bleeding in patients with hereditary hemorrhagic telangiectasia (HHT).

Capsule endoscopy is a useful tool in the case of HHT patients who develop chronic anemia with occult bleeding, with absence of epistaxis. The data of our study show, for the first time in a consecutive and prospective series of HHT patients, a high prevalence of small-bowel telangiectases (56 %). This increases the probability, with increasing age, of occult bleeding from the intestine.

Capsule endoscopy is a safe and noninvasive method for assessment of the small bowel, but is quite an expensive procedure at present. According to our data, patients with gastric telangiectases without bleeding from the stomach can present with other locations and potential sources of bleeding in the small bowel. Capsule endoscopy is useful in identifying this subgroup of HHT patients.

However, as alluring as it seems, we need to keep in mind the cost-effectiveness of this strategy.

The routine use of a procedure that is safe, but currently expensive, should be supported by data showing convincing advantages in diagnosis and therapeutic strategies, to avoid unnecessary costs. Our personal opinion is that when larger convincing studies are available, and the cost of capsule endoscopy decreases, its systematic use in HHT patients could be extended.