Capsule endoscopy: impact on clinical decision making in patients with suspected small bowel bleeding

Background and study aim: Capsule endoscopy is widely used for diagnosis of small-bowel disease; however, the impact of capsule endoscopy on clinical management remains uncertain. We conducted a prospective study of the impact capsule endoscopy on clinical management decisions in 128 patients with suspected small-bowel pathology.

Methods: Prior to performing each procedure the gastroenterologist predicted the findings of capsule endoscopy and further management based on the clinical history and previous investigations. This prediction was compared with the actual results of capsule endoscopy and the following investigative and therapeutic management.

Results: The actual findings of capsule endoscopy and the further management were consistent with clinical prediction in 93/128 patients (73 %) and, irrespective of capsule endoscopy findings, no further procedures were required in 80 % of these patients. In 13 patients (10 %), gastric or colonic pathology was discovered that had not been detected on prior gastroscopy or colonoscopy. Thus, capsule endoscopy findings in the small bowel changed clinical management in 22 patients (17 %). In 4 patients, positive findings on capsule endoscopy that had not been predicted by the examiner prompted referral for abdominal surgery. Conversely, planned surgery was canceled in four other patients.

Conclusion: In this series of patients referred for capsule endoscopy, small-bowel findings and appropriate clinical management were predicted on clinical grounds alone in approximately three-quarters of patients. Repetition of standard upper and lower endoscopy may be useful in many patients prior to small-bowel imaging. Referral for capsule endoscopy should take into account whether the findings will impact on clinical management; however, capsule endoscopy is mandatory in patients in whom surgery for small-bowel bleeding is intended.

References

• 1 Iddan G, Meron G, Glukhovsky A. et al . Wireless capsule endoscopy.  Nature. 2000;  405 417
• 2 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
• 3 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
• 4 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
• 5 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
• 6 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
• 7 Liangpunsakul S, Chadalwada V, Rex D K. et al . Wireless capsule endoscopy detects small bowel ulcers in patients with normal results from state of the art enteroclysis.  Am J Gastroenterol. 2003;  98 1295-1298
• 8 Scapa E, Jakob H, Lewkowicz S. et al . Initial experience of wireless capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small bowel pathology.  Am J Gastroenterol. 2002;  97 2276-2279
• 9 Hartmann D, Schmidt H, Bolz G. et al . A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding.  Gastrointest Endosc. 2005;  61 826-832
• 10 Mishkin D S, Chuttani R, Croffie J. et al . ASGE Technology Status Evaluation Report: wireless capsule endoscopy.  Gastrointest Endoscopy. 2006;  63 539-545
• 11 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
• 12 Fireman Z, Eliakim R, Adler S. et al . Capsule endoscopy in real life: a four-centre experience of 160 consecutive patients in Israel.  Eur J Gastroenterol Hepatol. 2004;  16 927-931
• 13 Barkin J S, Frideman S. Wireless capsule endoscopy requiring surgical intervention: the world’s experience [abstract].  Am J Gastroenterol. 2002;  97 A83
• 14 Descamps C, Schmit A, van Gossum A. ”Missed” upper gastrointestinal tract lesions may explain ”occult” bleeding.  Endoscopy. 1999;  31 452-455
• 15 Kraus K, Hollerbach S, Pox C. et al . Diagnostic utility of capsule endoscopy in occult gastrointestinal bleeding.  Dtsch Med Wochenschr. 2004;  129 1369-1374
• 16 Bezet A, Cuillerier E, Landi B. et al . Clinical impact of push enteroscopy in patients with gastrointestinal bleeding of unknown origin.  Clin Gastroenterol Hepatol. 2004;  2 921-927
• 17 Schmidt A, Gay F, Adler M. et al . Diagnostic efficacy of push enteroscopy and long term follow-up of patients with small bowel angiodysplasias.  Dig Dis Sci. 1996;  41 2348-2352
• 18 Valle J, Alcantara M, Perez-Grueso M J. et al . Clinical features of patients with negative results from traditional diagnostic work-up and Crohn’s disease. Findings from capsule endoscopy.  J Clin Gastroenterol. 2006;  40 692-696
• 19 Daum S, Wahnschaffe U, Glasenapp R. et al . Capsule endoscopy in refractory celiac disease.  Endoscopy. 2007;  39 455-458
• 20 O’Loughlin C, Barkin J S. Wireless capsule endoscopy: summary.  Gastrointest Endosc Clin N Am. 2004;  14 229-237
• 21 Matsumoto T, Esaki M, Moriyama T. et al . Comparison of capsule endoscopy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis.  Endoscopy. 2005;  37 827-832
• 22 Rastogi A, Schoen R E, Slivka A. Diagnostic yield and clinical outcome of capsule endoscopy.  Gastrointest Endosc. 2004;  60 959-964
• 23 Cobrin G M, Pittman R H, Lewis B S. Increased diagnostic yield of small bowel tumors with capsule endoscopy.  Cancer. 2006;  107 22-27
• 24 Estevez E, Gonzalez-Conde B, Vazquez-Iglesias J L. et al . Incidence of tumoral pathology according to study using capsule endoscopy for patients with obscure gastrointestinal bleeding.  Surg Endosc. 2007;  21 1776-1780