A new panenteric capsule endoscopy-based strategy in patients with melena and a negative upper gastrointestinal endoscopy: a prospective feasibility study

Abstract

Objective patients presenting with melena and nondiagnostic esophagogastroduodenoscopy are usually investigated with colonoscopy and if negative, with small bowel capsule endoscopy. In this pilot study, we tested feasibility and performance of panenteric capsule endoscopy (PCE) in patients presenting with melena and negative esophagogastroduodenoscopy. Methods Between January and December 2018, consecutive patients presenting with melena, clinically significant bleeding and negative esophagogastroduodenoscopy were invited to undergo PCE by swallowing PillCam Colon 2 (Medtronic Inc., Dublin, Ireland). PCE results, further diagnostic or therapeutic examinations, rebleeding rates at 30 days and 12 months were recorded. Results Out of 128 patients with melena, 23 had negative esophagogastroduodenoscopy. Of them, 12 (8 female, mean age 76 years) underwent PCE, which allowed complete small bowel and colonic evaluation in 12 (100%) and 11 (91.7%) patients, respectively. The small bowel and colon cleansing were adequate in 100 and 83.3%, respectively. No PCE-related complications were observed. The PCE diagnostic yield was 83.3%: significant findings were located in the small bowel, colon or both in 5 (41.7%), 4 (33.3%) and 1 (8.3%) patients, respectively. Device-assisted enteroscopy was performed in 6 (50%) patients. Thirty days and 1 year rebleeding rates were 0 and 18.1%, respectively. Conclusions In this proof-of-concept study, PCE was feasible and safe in patients with melena and negative esophagogastroduodenoscopy, identifying the bleeding site in 83% of patients. PCE lead to small bowel therapeutic interventions in 50% of patients, thus avoiding unnecessary standard colonoscopy. Further large prospective randomized studies investigating this strategy are warranted.

Single or double headed capsules for the investigation of suspected small bowel bleeding: Are two heads better than one

“…Our prospective study compares the performance of SB3 and PillCam Colon 2 capsules for the investigation of suspected small bowel bleeding. Previous studies of pan-intestinal capsule investigation and double headed small bowel capsules have suggested a bidirectional, double headed, capsule, including PillCam Colon 2, designed for colonic imaging, may have a diagnostic advantage in the small bowel (6,7,13,14). Our findings do not support this hypothesis.…”

“…A recent systematic review confirmed, pan-intestinal capsule studies with either CCE capsules or specifically designed pan-intestinal capsules (PCE) is a feasible technique, although the majority of studies included were undertaken in an IBD cohort rather than for bleeding (6). More recently, an Italian study confirmed pan-intestinal assessment using CCE (PillCam Colon 2, Medtronic Inc, Dublin, Ireland) was an effective investigation strategy in patients with melena (7). In this study, small bowel bleeding and interventions were undertaken in 50% of cases, suggesting double headed (DH) CCE capsules are a sensitive test for small bowel bleeding.…”

“…More patients had another diagnosis in the DH (19) than the SH (9), p<0.04, the majority were type 1a vascular lesions, "red spots" (7) or diminutive colonic polyps (6) (Table 2).…”

Very High Yield of Urgent Small-Bowel Capsule Endoscopy for Ongoing Overt Suspected Small-Bowel Bleeding Irrespective of the Usual Predictive Factors

“…Gastrointestinal (GI) bleeding is associated with significant healthcare costs [ 1 ]. Even though the presence of melena has conventionally been associated with bleeding proximal to the ligament of Treitz, prompting the use of esophagogastroduodenoscopy as the first diagnostic procedure, this clinical sign has modest localization value [ 2 , 3 ]. Moreover, recent studies have suggested a relative decrease in the incidence of upper GI bleeding [ 2 ].…”

Colon capsule for panendoscopy: a narrow window of opportunity

“…This becomes particularly relevant when the "timing of the procedure" or "disease extent" are key factors. Indeed, there is growing evidence supporting the use of a panenteroscopic approach in patients with digestive bleeding, in whom an upper digestive tract lesion has been excluded [13,14]. Initial data suggest that in these patients, a timely panenteric evaluation has relevant clinical (increased rate of diagnosis, crucial information for therapeutic work-up) as well as organizational/economic consequences (reduction of the number of unnecessary examinations and hospitalization time).…”