Video Capsule Endoscopy for Investigation of Obscure Gastrointestinal Bleeding: Feasibility, Results, and Interobserver Agreement

Background and Study Aims: The aim of the study was to assess the feasibility, diagnostic yield, and interobserver agreement of capsule endoscopy in the investigation of patients with obscure or occult gastrointestinal bleeding.
Patients and Methods: A total of 64 consecutive patients with occult bleeding (31 %) or overt bleeding (69 %) were assessed using capsule endoscopy after negative upper and lower endoscopy and small-bowel radiology. The quality of visualization of the small-bowel mucosa was scored from 1 (poor) to 4 (excellent). Thirty video capsule recordings with normal or abnormal findings were blindly assessed by four independent endoscopists. Interobserver agreement was evaluated using the kappa index.
Results: The small bowel was completely visualized in 57/64 patients (89 %). Incomplete small-bowel transit was most commonly due to prolonged gastric retention (five patients). The mucosa visualization scores (means) for the proximal, middle, and distal thirds of the small bowel were 3.7, 3.3, and 2.2 respectively. Visualization of the distal ileum was good (≥ 3) in 38 % and a bleeding site was found in 45 % of patients. Push-enteroscopy was also performed in 56 patients. The results of the two techniques were similar in 37 patients, capsule endoscopy was superior in 12 patients, and push-enteroscopy was superior in seven patients. Interobserver agreement was good for bleeding and for angiodysplasia, but poor for ulcers and tumors. Mean interobserver agreement was better among experienced endoscopists than among junior endoscopists.
Conclusions: Capsule endoscopy allowed the whole small intestine to be explored in 89 % of patients, with good visualization of the mucosa, except distally. Interobserver agreement was better among the experienced endoscopists and was better for red-colored abnormalities (bleeding and angiodysplasia) than for ulcers and tumors.

References

• 1 Bouhnik Y, Nahon S, Landi B. Synopsis: diagnosis and treatment of occult digestive tract bleeding.  Gastroenterol Clin Biol. 2000;  24 317-323
• 2 Waye J D. Small-intestinal endoscopy.  Endoscopy. 2001;  33 24-30
• 3 Barkin J S, Lewis B S, Reiner D K. et al . Diagnostic and therapeutic jejunoscopy with a new, longer enteroscope.  Gastrointest Endosc. 1992;  38 55-58
• 4 Barkin J S, Chong J, Reiner D K. First-generation video enteroscope: fourth-generation push-type small bowel enteroscopy utilizing an overtube.  Gastrointest Endosc. 1994;  40 743-747
• 5 Berner J S, Mauer K, Lewis B S. Push and sonde enteroscopy for the diagnosis of obscure gastrointestinal bleeding.  Am J Gastroenterol. 1994;  89 2139-2142
• 6 Chong J, Tagle M, Barkin J S, Reiner D K. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology.  Am J Gastroenterol. 1994;  89 2143-2146
• 7 Landi B, Tkoub M, Gaudric M. et al . Diagnostic yield of push-type enteroscopy in relation to indication.  Gut. 1998;  42 421-425
• 8 Ell C, Remke S, May A. et al . The first prospective controlled trial comparing wireless capsule endoscopy with push-enteroscopy in chronic gastrointestinal bleeding.  Endoscopy. 2002;  34 685-689
• 9 Saurin J C, Delvaux M, Gaudin J L. et al . Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy.  Endoscopy. 2003;  35 576-584
• 10 Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push-enteroscopy in patients with gastroscopy- and colonoscopy-negative gastrointestinal bleeding.  Gut. 2003;  52 1122-1126
• 11 Lewis B S, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study.  Gastrointest Endosc. 2002;  56 349-353
• 12 Hartmann D, Schilling D, Bolz G. et al . Capsule endoscopy versus push-enteroscopy in patients with occult gastrointestinal bleeding.  Z Gastroenterol. 2003;  413 77-82
• 13 Fleiss J L. The measurement of interrater agreement.  In: Statistical methods for rates and proportions. New York; Wiley & Sons Inc 1981: 212-236
• 14 Grant J M. The fetal heart rate trace is normal, isn’t it?.  Lancet. 1991;  337 215-218
• 15 Costamagna G, Shah S K, Riccioni M E. et al . A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease.  Gastroenterology. 2002;  123 999-1005
• 16 Pennazio M, Santucci R, Rondonotti E. et al . Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases.  Gastroenterology. 2004;  126 643-653
• 17 Fireman Z, Paz D. Capsule endoscopy: improving the transit time and the image view [abstract].  Gastrointest Endosc. 2004;  59 AB173
• 18 Mergener K, Enns R. Interobserver variability for reading capsule endoscopy examinations [abstract].  Gastrointest Endosc. 2003;  57 AB85