Earlier use of capsule endoscopy in inpatients with melena or severe iron deficiency anemia reduces need for colonoscopy and shortens hospital stay

Abstract

Background and study aims Capsule endoscopy(CE) is a well-established investigation for iron deficiency anemia (IDA) and melena, usually following negative upper and lower endoscopy. We aimed to study the effect of earlier CE in the investigative pathway for inpatients with IDA or melena at a large tertiary referral centre. Patients and methods We analyzed inpatients undergoing CE for IDA or melena from 2005 to 2017, without signs/symptoms suggesting lower gastrointestinal tract pathology. Patients underwent CE following negative upper and lower gastrointestinal endoscopy (Group 1), or negative upper gastrointestinal endoscopy (UGIE) only (Group 2). Results One hundred and seventy inpatients underwent CE for IDA (n = 44) and melena (n = 126). In Group 1, 46/95 (48.4%) patients had small bowel (SB) findings. CE found 16/95 (16.8 %) gastric and 12/95 (12.6 %) colon findings. Three of 12 patients with colon findings required repeat colonoscopy. One hundred and three colon investigations were carried out for 95 admissions. In Group 2, 33/75 (44.0%) patients had SB findings. There were 12/75 (16.0 %) gastric and 11/75 (14.7 %) colon findings. In patients with positive CE, significant colonic findings led to colonoscopy in 10 of 39 patients (diagnostic yield 6/10). Thirty-six patients had negative CE; 15 underwent colonoscopy (diagnostic yield 9/15). The remaining 21 of 36 patients with no further colonoscopy did not develop adverse outcomes related to colonic pathology. Twenty-six colon investigations were carried out in 75 admissions. Patients in Group 2 had shorter mean times from admission to CE (5.08 ± 3.80 vs. 6.38 ± 3.80 days; P = 0.02) and hospital stays (10.5 ± 9.58 vs. 12.5 ± 11.4 days; P = 0.04) compared to Group 1. Conclusion Earlier use of CE in inpatients with melena or IDA, no signs of lower gastrointestinal pathology and negative UGIE resulted in shortened hospital stays, significant DY from both small bowel and upper gastrointestinal tract, and two-thirds less unnecessary colon investigations without affecting clinical outcomes.

Endoscopic ultrasonography and small‐bowel endoscopy: Present and future

“…Second, CE is a widespread, well‐tolerated diagnostic tool that perfectly fits with the need for a timely on‐demand SB assessment even in an emergency setting and at the patient's bedside . Notably, the diagnostic yield of enteroscopy decreases substantially with time.…”

“…Very recently, three different studies (one prospective from Germany, one retrospective from Scotland, one prospective RCT from the USA) have raised the debate on the early use of CE in non‐hematemesis GI bleeding. Two of them have shown that CE carried out soon after negative upper endoscopy allows for immediate detection of the bleeding site. In the third study, Marya et al .…”

“…[137][138][139][140][141] Second, CE is a widespread, well-tolerated diagnostic tool that perfectly fits with the need for a timely on-demand SB assessment even in an emergency setting and at the patient's bedside. [141][142][143][144] Notably, the diagnostic yield of enteroscopy decreases substantially with time. In a milestone study published in 2004, the diagnostic yield of CE was 92% for patients with overt bleeding, 44% for occult bleeders, 67% for patients with prior overt bleeding who had been studied within 1-2 weeks, and 33% at 3-4 weeks.…”

“…[133][134][135][136]153,154 Initial DAE can be considered in selected hemodynamically stable patients in cases of massive hemorrhage, when the endoscopic target has already been identified by cross-sectional imaging, or when CE is contraindicated. [133][134][135][136] Very recently, three different studies (one prospective from Germany, 144 one retrospective from Scotland, 143 one prospective RCT from the USA 142 ) have raised the debate on the early use of CE in non-hematemesis GI bleeding. Two of them 143,144 have shown that CE carried out soon after negative upper endoscopy allows for immediate detection of the bleeding site.…”

“…[133][134][135][136] Very recently, three different studies (one prospective from Germany, 144 one retrospective from Scotland, 143 one prospective RCT from the USA 142 ) have raised the debate on the early use of CE in non-hematemesis GI bleeding. Two of them 143,144 have shown that CE carried out soon after negative upper endoscopy allows for immediate detection of the bleeding site. In the third study, Marya et al randomized 87 patients presenting with non-hematemesis GI bleeding to receive early CE as the first-line examination versus conventional investigative pathways (i.e.…”