Capsule Endoscopy in Patients with Obscure Gastrointestinal Bleeding

The diagnosis of the source of bleeding in patients with obscure digestive bleeding has considerably improved, with a significant influence on the outcome for patients, since the introduction of capsule endoscopy - as shown by numerous studies reporting a higher diagnostic yield with capsule endoscopy in comparison with push enteroscopy and by our recent study [1], on which Dalla Valle et al. have commented [2]. The issue of lesions missed during previous endoscopic examinations was been identified even before the introduction of capsule endoscopy, with several studies on push enteroscopy showing that some 25 % of the lesions detected by push enteroscopy were within the range of a routine esophagogastroduodenoscopy [3] [4]. In the lower gastrointestinal tract, retrograde ileoscopy had a low diagnostic yield and was abandoned by most clinical teams, who limited the exploration to the terminal ileum during colonoscopy [5].

The consequences of a delayed diagnosis of cancer in the upper gastrointestinal tract or colon are obvious and have been well demonstrated in clinical studies, as pointed out by Dalla Valle et al. We would agree with them that the recommendation made by the American Gastroenterological Association [6] may further delay the diagnosis, for two practical reasons: firstly, endoscopic examinations carried out after a delay since the bleeding episode have a lower diagnostic yield and may miss the bleeding source in case of spot lesions such as Dieulafoy’s ulcers, including colonic lesions [7]; secondly, patients have frequently undergone several unsuccessful endoscopies before being referred for capsule endoscopy or other intestinal investigations [8]. Indefinitely repeating endoscopies leads to delays in diagnosis and increases in health-care costs. In patients who have undergone multiple previous investigations, we consider that capsule endoscopy should be carried out as a first-line examination, for the following reasons:

It may indicate the location of the bleeding source, as pointed out by Dalla Valle et al., and as we proposed in the algorithm designed on the basis of our results. Further endoscopies can better be targeted and limited, leading to reduced health-care costs. Capsule endoscopy has a high negative predictive value 1, so that other intestinal examinations can be avoided, focusing further endoscopic procedures on the lower or upper gastrointestinal tract.

The issue raised by Dalla Valle et al. also points to the need for a genuine quality-assurance policy in endoscopy. Systematic documentation of endoscopic examinations with endoscopic pictures, as suggested by the European Society for Gastrointestinal Endoscopy [9], would provide more reliable information about the quality of bowel cleansing, which is a major cause of missed lesions in the colon.

In conclusion, we agree with Dalla Valle et al. that further outcome studies are needed in order to validate the approach to patients with obscure bleeding that we proposed on the basis of results previously reported in this journal [1]. We would also plead for improvements in quality-assurance policies used in endoscopy.

References

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