Obscure GI Bleeding: Video Capture Endoscopy (VCE) Jeff Kufel P1 - EBM

GI Bleeding Three Categories: 1.Upper GI Bleed = bleeding above the Ampulla of Vater 2.Mid-GI Bleed = bleeding from Ampulla of Vater to Terminal Ileum 3.Lower GI Bleed = colonic bleeding *Preferred method for identifying and evaluating: Upper GI Bleeding – EGD Mid GI Bleeding – Video Capture Endoscopy (VCE) Lower GI Bleeding - Colonoscopy

Obscure GI Bleeding Bleeding of an unknown origin that persists or recurs following an initial negative endoscopic evaluation Comprises 5% of all GI Bleeding cases Majority of lesions located in the small intestine

Investigation of Obscure GI Bleeding 1.Push Enteroscopy: method of examining the small bowel utilizing a specialized, flexible endoscope. – endoscope is inserted through the mouth and passes beyond the Ligament of Treitz in order to view the distal duodenum and proximal jejunum Advantages: 1. readily available 2. relatively safe 3. permits both biopsy and endoscopic therapy Disadvantage: Cannot visualize the entire small bowel

Investigation of Obscure GI Bleeding 2. Double Balloon Enteroscopy : modified version of push enteroscopy involving an endoscope and a soft flexible overtube containing latex balloons. – The balloons are used to grip the intestine while the endoscope is inserted. – The endoscope is advanced beyond the overtube and inflated. The endoscope is brought back to the overtube. The overtube is inflated and endoscope is deflated, allowing the endoscope to move forward. This process is then continued until entire length is visualized.

Investigation of Obscure GI Bleeding Advantages: 1. Allows for movement of the endoscope through the small intestine without unnecessary discomfort to the patient or formation of “redundant loops” in the small bowel 2. It has the added benefit of being able to take biopsy samples and administer therapy throughout the entire small bowel Disadvantages: 1. Time to complete procedure (usually 3 hours or greater) 2. Requires two people to manipulate/advance the scope and control the balloons 3. Requires a combination of Antegrade and Retrograde double balloon enteroscopy for complete small bowel examination.

Investigation of Obscure GI Bleeding 3. Capsule Endoscopy : Preferred method for identifying Mid-obscure GI bleeding – Entails swallowing a capsule containing a small camera which images the entire small bowel as it passes through.

Investigation of Obscure GI Bleeding Advantages: 1. Non-invasive 2. Can evaluate entire small bowel 3. It can detect subtle mucosal changes such as erosive lesions of the small bowel Disadvantages: 1. Does not allow for biopsy samples to be taken or therapy to be administered.

Double Balloon Enteroscopy Video Capture Endoscopy

PICO Question P: Adult patients (40-65) with suspected obscure GI bleeding following a negative colonoscopy and EGD. I: Video Capture Endoscopy (VCE) C: Conventional Endoscopy: push enteroscopy, double balloon endoscopy, small bowel barium radiography O: Identification and evaluation of the source of obscure GI bleeding in the small intestine Q: In adult patients with a suspected obscure GI bleed (not found with colonoscopy or EGD), is VCE preferred over other forms of endoscopy and radiography for identification and evaluation?

VCE vs.. Push Enteroscopy Meta-Analysis – 14 studies with 396 participants Compared: Any obscure GI findings – 14 studies with 376 patients Compared: Clinically significant obscure GI findings Clinically significant findings were defined as lesions which definitely or probably represented the source of the obscure bleeding

VCE vs.. Push Enteroscopy Pre-defined Criteria for acceptance into Meta- Analysis study: 1.All patients acted as their own control – VCE had to be performed within 2 weeks of the push enteroscopy 2.Trials had to report all small bowel findings as well as clinically significant findings 3.Lesions had to be beyond the reach of colonoscopy or EGD to be included in study 4.Two independent researchers had to check and agree on the findings

VCE vs.. Push Enteroscopy 1.Any Obscure GI Findings: – VCE identified 63% compared to 28% for Push Enteroscopy 2. Clinically Significant Obscure GI Findings: – VCE : 56% – Push Enteroscopy: 26%

VCE vs.. Push Enteroscopy Incremental Yield (IY) = yield of VCE – yield of comparative modality Triester et al, 2005

VCE vs.. Push Enteroscopy Incremental Yield (IY) = yield of VCE – yield of comparative modality Triester et al, 2005

VCE vs.. Small Bowel Barium Radiography Same Meta-Analysis Study – Utilized 88 patients from 3 studies using same inclusion criteria Results: – Any Obscure GI Findings: 67% for VCE, 8% for Barium Radiography – Clinically Significant Obscure GI Findings: 42% for VCE compared to 6% for Barium Radiography

VCE vs.. Small Bowel Barium Radiography Triester et al, 2005

VCE vs.. Small Bowel Barium Radiography Triester et al, 2005

Small Bowel Crohn’s Disease Meta-Analysis Study: – VCE vs. Small Bowel Barium Radiography 250 patients from 9 studies Yield: VCE = 63%, Small Bowel Barium Radiography = 23% – VCE vs. Colonoscopy with ileoscopy 114 patients from 4 studies Yield: VCE = 61%, Colonoscopy with ileoscopy = 46% – VCE vs. CT enterography 93 patients from 3 studies Yield: VCE = 69%, CT enterography = 31%

Management of Obscure GI Bleeding Retrospective Cohort Study – 92 patients who had obscure GI bleeding and negative endoscopic evaluations of the upper and lower GI tract – defined criteria including having obscure GI bleeding and having undergone “at least 2 endoscopic examinations of the upper GI tract and at least 1 ileoconoscopy, all with negative results” – data was interpreted by a gastroenterologist with extensive enteroscopy experience – findings were considered positive if lesions were detected which could explain the obscure GI bleeding Hindryckx et al, 2008

Management of Obscure GI Bleeding 55 patients had a positive VCE (59.8%) which was not found on previous examinations Of these 55 patients, a clear diagnosis could be made in 53 cases (96.4%) The clear diagnosis allowed for immediate therapeutic strategies to be implemented

Recurrence of Obscure GI Bleeding Obscure GI Bleeding: The study defined obscure GI bleeding as “having evidence of melana, hematachezia, or a drop in hemoglobin of at least 2g/dL and a positive fecal occult blood test” Recurrent bleeding episode as “evidence of recent or active bleeding at least 30 days after the index bleed MacDonald et al, 2008

Recurrence of Obscure GI Bleeding The study utilized 42 patients who had a VCE to investigate obscure GI rebleeding over a follow up period of 18 months 42 patients, 24 had a positive VCE (57%) compared to 18 with a negative VCE (43%) 12 total patients had rebleeding episodes, with 10 patients from the positive VCE group (42%) compared to 2 patients from the negative VCE group (11%) MacDonald et al, 2008

Conclusion According to the American Gastroenterological Association in 2007, capsule endoscopy should be the method used to investigate obscure GI bleeding after a negative workup with EGD and colonoscopy is complete VCE is a better diagnostic tool for patients with obscure GI bleeding

Conclusion VCE has a distinct advantage over other methods in identifying and evaluating obscure GI bleeding VCE has a distinct advantage over other methods in diagnosing small bowel Crohn’s Disease Video Capsule Endoscopy has also been shown to be beneficial in instituting earlier treatment and identifying the cause of obscure GI bleeding

Conclusion VCE is beneficial in preventing further complications from the obscure GI bleed VCE can be utilized to predict future obscure GI bleeding in patients

Application VCE is less invasive, technically easy, well tolerated, allows visualization of the entire small intestine and has a low risk of complications compared to other methods. Utilizing VCE can also be cost effective, by determining the cause of obscure GI bleeding without having to repeat procedures or perform expensive invasive procedures

Application Although it cannot take biopsies or implement treatment, VCE is still the most comprehensive tool available for the identification and evaluation of obscure GI bleeding today. Perhaps in the future, this technology will advance to the point where biopsy sampling will be included in VCE.

Bibliography MacDonald J, Porter V, McNamara D. (2008). Negative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates. Gastrointestinal Endoscopy: Vol 68(6) pp Hindryckx P, Botelberge T, DeVos M, DeLooze D. (2008). Clinical impact of capsule endoscopy on further strategy and long-term clinical outcome in patients with obscure bleeding. Gastrointestinal Endoscopy: Vol 68 (1) pp Wong R, Tuteja A, Haslem D, Pappas L, Szabo A, Ogara M, DiSario J. (2006). Video capsule endoscopy compared with standard endoscopy for the evaluation of small bowel polyps in persons with familial adenomatous polyposis. Gastrointestinal Endoscopy: Vol 64 (4) pp.530 – 537. Lewis,B. (2007). Obscure GI bleeding in the world of capsule endoscopy, push and double balloon enteroscopies. Gastrointestinal Endoscopy: Vol 66 (3) pp Cave D, Fleischer D, Leighton J, Faigel D, Heigh R, Sharma V, Gostout C, Rajan E, Mergener K, Foley A, Lee M, Bhattacharya K. (2008). A multicenter randomized comparison of the Endocapsule and Pillcam SB. Gastrointestinal Endoscopy: Vol 68 (3) pp Olds G, Cooper G, Chak A. (2005). The yield of bleeding scans in acute lower gastrointestinal hemorrhage. Journal of Clinical Gastroenterology. Vol 39: Feldman M, Friedman L, Brandt L. (2006). Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 8 th Edition. Saunders Elsevier Inc., Philadephia, PA. Triester S, Leighton J, Leontiadis G, Fleisher D, Hara A, Heigh R, Shiff A, Sharma V. (2005). A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure Gastrointestinal bleeding. American Journal of Gastroenterology. Vol 100: Triester S, Leighton J, Leontiadis G, Fleisher D, Hara A, Heigh R, Shiff A, Sharma V. (2006). A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn’s Disease. American Journal of Gastroenterology. Vol 101: