Copy
View this email in your browser

SMALL BOWEL BLEEDING UPDATE

1. Terminology

Historically obscure bleeding referred to patients with overt or occult GI haemorrhage after performance of a normal upper and lower endoscopic examination. However this is now classified as small bowel bleeding, with obscure bleeding reserved for patients that have a negative small bowel evaluation
2. What are the common causes1?
3. What is a capsule endoscopy?
A capsule endoscopy is where a pill sized video capsule is swallowed to investigate small bowel bleeding. This capsule is disposable and usually passed within 24 to 48hours. It does not require sedation as the procedure is painless.
The capsule has its own built-in light and camera to take pictures of the inside of the small bowel. 2 - 4 images are taken per second for up to 9 hours. Approximately 1 in 10 patients may have a slow small bowel transit and the capsule may not be seen to reach the large bowel on the capsule endoscopy recording. The images are transmitted to a radio recorder (a walkman like device) that is connected to a belt worn around the waist.
4. When is a capsule endoscopy indicated?
 
There are strict MBS criteria for capsule eligibility:2
 
(a) The service is provided to a patient who:
      (i) has overt gastrointestinal bleeding or
      (ii) has gastrointestinal bleeding that is recurrent or persistent and iron deficiency
          anaemia (IDA) that is not due to coeliac disease. If the patient also has menorrhagia,
          this has been considered and managed.

And

(b)  An upper gastrointestinal endoscopy and a colonoscopy have been performed on the patient and have not identified the cause of the bleeding;


5. What is the yield in small bowel bleeding?
Capsule endoscopy had a diagnostic yield of 66.6% in a systematic review of 1960 patients with IDA.3 Angioectasias are the most common findings on capsule endoscopy (50%), followed by inflammation (26.8%) and tumors (8.8%) 4
 
6. Are there any contraindications?
a. Recent bowel obstruction or gastrointestinal strictures. Overall the risk of capsule retention is approximately 1%. This is not usually serious in the short term, but surgery may be needed to remove it.
 
b. Permanent pacemaker (PPM) and Defibrillator (ICD) – initially there was some concern about capsule transmission interfering with PPM or ICD function but this has not been shown to be a major issue in clinical practice. Occasionally some patients at high risk are placed in a cardiac ward for monitoring during the procedure.

c. Difficulty swallowing – The capsule endoscopy is larger than a large antibiotic capsule (Length 26.2mm, Diameter 11.4mm). This issue can be overcome with endoscopic placement if required, but this usually requires sedation.


7. Are there any alternatives to investigate the small bowel?
a. CT/MRI small bowel:
Consider prior to capsule endoscopy if established inflammatory bowel disease, prior radiation therapy, previous small bowel surgery and/or suspected small bowel stenosis.1  
CT small bowel helped identify the source of obscure gastrointestinal bleeding in 16 (24.6%) of 65 patients. The sensitivity, specificity, positive predictive value, and negative predictive value of CT enterography were 55.2% (16 of 29), 100% (32 of 32), 100% (16 of 16), and 71.1% (32 of 45), respectively. 5
 
MRI small bowel – Similar yield with no radiation but also no rebate available unless the patient has Crohn’s disease.

b. If the bleeding is severe a CT abdominal angiogram can be considered


8. Can capsule endoscopy miss lesions?
Yes, there is an incremental yield with either further small bowel imaging or a repeat capsule.

a. The diagnostic yield of CT small bowel in patients with a negative capsule study was 0% (0/11) in patients with occult bleeding versus 50% (7/14) in patients with overt bleeding (P < 0.01). 6

b. Repeat capsule endoscopy
If ongoing bleeding is present then positive findings were seen in 41.6% of patients. Overt bleeding and significant Hb drop (≥4g/dL) were predictors of diagnostic second CE. 7


9. Do I need to recover the capsule?
No, all the information is on the data recorder.

10. I didn’t notice passage of the capsule. What should be done?
If the capsule was seen to enter the caecum during the recording the retention rate is very low and spontaneous passage is expected. If the capsule is still in the small bowel at the end of the recording then an AXR is performed at 2 weeks to confirm capsule passage if not noted by the patient.

11. What are my potential options for management of capsule findings?
a. Conservative
b. Medications
c. Endoscopic management including Balloon assisted enteroscopy
d. Surgery

 
References:
  1. Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol. 2015 Sep;110(9):1265-87
  2. http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home
  3. Koulaouzidis A, Rondonotti E, Giannakou A, Plevris JN. Diagnostic yield of small-bowel capsule endoscopy in patients with iron-deficiency anemia: a systematic review. Gastrointest Endosc. 2012;76(5):983–992. 
  4. Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review. Gastrointest Endosc. 2010;71(2):280–286. 
  5. Lee SS, Oh TS, Kim HJ, Chung JW, Park SH, Kim AY, Ha HK. Obscure gastrointestinal bleeding: diagnostic performance of multidetector CT enterography. Radiology. 2011 Jun;259(3):739-48.
  6. Agrawal JR, Travis AC, Mortele KJ, Silverman SG, Maurer R, Reddy SI, Saltzman JR. Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy. J Gastroenterol Hepatol. 2012 Apr;27(4):751-9. 
  7. Viazis N, Papaxoinis K, Vlachogiannakos J, Efthymiou A, Theodoropoulos I, Karamanolis DG. Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test? Gastrointest Endosc. 2009 Apr;69(4):850-6. 
 
Images courtesy of GIVEN Imaging.

 
Article by Dev Segarajasingam

Dr Segarajasingam is a gastroenterologist with subspecialty interests in small bowel investigations and endoscopic ultrasound. He has extensive experience in capsule endoscopy and enteroscopy.


Click here to read more about Dev Segarajasingam
ADVANCED GI WA PTY LTD
Suite 10 / 95 Monash Avenue, NEDLANDS WA 6009

T: 08 9389 1733
E: info@advancedgiwa.com.au
W: https://www.advancedgiwa.com.au/
Healthlink: fbrennan
Copyright ©  2020 Advanced GI WA Pty Ltd, All rights reserved.

Want to change how you receive these emails?
You can update your preferences or unsubscribe from this list.

 
Facebook
Twitter
Link
Website






This email was sent to <<Email Address>>
why did I get this?    unsubscribe from this list    update subscription preferences
Advanced GI WA Pty Ltd · Suite 10, 95 Monash Avenue · Nedlands, WA 6009 · Australia

Email Marketing Powered by Mailchimp