Clin Endosc.  2014 Sep;47(5):409-414. 10.5946/ce.2014.47.5.409.

Should Capsule Endoscopy Be the First Test for Every Obscure Gastrointestinal Bleeding?

• Tae CH
• Shim KN

• KMID: 2165371
• DOI: http://doi.org/10.5946/ce.2014.47.5.409

Abstract

Obscure gastrointestinal bleeding (OGIB) refers to gastrointestinal (GI) bleeding of unclear origin that persists or recurs after negative findings on esophagogastroduodenoscopy and colonoscopy. OGIB accounts for approximately 5% of all types of GI bleeding. More than 80% of OGIB cases originate in the small bowel. The ability to detect OGIB in the small bowel has significantly advanced and been revolutionized since the introduction of the capsule endoscopy and double-balloon enteroscopy techniques in 2000 and 2001, respectively. With these new methods for small-bowel evaluation, new guidelines have been proposed for the diagnosis and management of OGIB. However, some issues remain unsolved. The purpose of this article is to review the various modalities used for evaluating OGIB, including capsule endoscopy and double-balloon enteroscopy, and to help guide clinicians in their decisions on which modality will be the most effective.

Keyword

Capsule endoscopy; Double-balloon enteroscopy; Gastrointestinal hemorrhage

MeSH Terms

Capsule Endoscopy*
Colonoscopy
Diagnosis
Double-Balloon Enteroscopy
Endoscopy, Digestive System
Gastrointestinal Hemorrhage
Hemorrhage*

Figure

• 

  Fig. 1 Korea Gut Image Study Group guidelines for obscure gastrointestinal bleeding. Adapted from Shim et al. Clin Endosc 2013;46:45-53.29 Dashed arrows indicate less-preferred options. GI, gastrointestinal; EGD, esophagogastroduodenoscopy; CE, capsule endoscopy; CTE, computed tomography enterography; DE, deep enteroscopy; PE, push enteroscopy; SB, small bowel; IOE, intraoperative enteroscopy.

• 

  Fig. 2 American Society for Gastrointestinal Endoscopy guidelines in the management of overt gastrointestinal bleeding. Dashed arrows indicate less-preferred options. Positive test results should direct specific therapy. Because diagnostic tests can be complementary, more than one test may be needed, and the first-line test may be based on institutional expertise and availability. Adapted from ASGE Standards of Practice Committee et al. Gastrointest Endosc 2010;72:471-479, with permission from Elsevier.18 GI, gastrointestinal; EGD, esophagogastroduodenoscopy; PE, push enteroscopy; CT, computed tomography; OGIB, obscure gastrointestinal bleeding.

• 

  Fig. 3 American Society for Gastrointestinal Endoscopy guidelines for the management of occult gastrointestinal bleeding. Dashed arrows indicate less-preferred options. Positive test results should direct specific therapy. Because diagnostic tests can be complementary, more than one test may be needed, and the first-line test may be based on institutional expertise and availability. Adapted from ASGE Standards of Practice Committee et al. Gastrointest Endosc 2010;72:471-479, with permission from Elsevier.18 GI, gastrointestinal; EGD, esophagogastroduodenoscopy; CT, computed tomography; Hb, hemoglobin.

Reference

1. Liu K, Kaffes AJ. Review article: the diagnosis and investigation of obscure gastrointestinal bleeding. Aliment Pharmacol Ther. 2011; 34:416–423. PMID: 21692820.

2. Keum B, Chun HJ. Capsule endoscopy and double balloon enteroscopy for obscure gastrointestinal bleeding: which is better? J Gastroenterol Hepatol. 2011; 26:794–795. PMID: 21488944.

3. Teshima CW. Small bowel endoscopy for obscure GI bleeding. Best Pract Res Clin Gastroenterol. 2012; 26:247–261. PMID: 22704568.

4. Min YW, Kim JS, Jeon SW, et al. Long-term outcome of capsule endoscopy in obscure gastrointestinal bleeding: a nationwide analysis. Endoscopy. 2014; 46:59–65. PMID: 24254387.

5. Zhang BL, Chen CX, Li YM. Capsule endoscopy examination identifies different leading causes of obscure gastrointestinal bleeding in patients of different ages. Turk J Gastroenterol. 2012; 23:220–225. PMID: 22798110.

6. Akerman PA, Cantero D. Spiral enteroscopy and push enteroscopy. Gastrointest Endosc Clin N Am. 2009; 19:357–369. PMID: 19647645.

7. Lara LF, Bloomfeld RS, Pineau BC. The rate of lesions found within reach of esophagogastroduodenoscopy during push enteroscopy depends on the type of obscure gastrointestinal bleeding. Endoscopy. 2005; 37:745–750. PMID: 16032494.

8. Rey JF, Gay G, Kruse A, Lambert R. ESGE Guidelines Committee. European Society of Gastrointestinal Endoscopy guideline for video capsule endoscopy. Endoscopy. 2004; 36:656–658. PMID: 15243892.

9. Mehdizadeh S, Ross A, Gerson L, et al. What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers. Gastrointest Endosc. 2006; 64:740–750. PMID: 17055868.

10. Gross SA, Stark ME. Initial experience with double-balloon enteroscopy at a U.S. center. Gastrointest Endosc. 2008; 67:890–897. PMID: 18178204.

11. Pasha SF, Hara AK, Leighton JA. Diagnostic evaluation and management of obscure gastrointestinal bleeding: a changing paradigm. Gastroenterol Hepatol (N Y). 2009; 5:839–850. PMID: 20567529.

12. May A, Nachbar L, Pohl J, Ell C. Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations. Am J Gastroenterol. 2007; 102:527–535. PMID: 17222315.

13. Arakawa D, Ohmiya N, Nakamura M, et al. Outcome after enteroscopy for patients with obscure GI bleeding: diagnostic comparison between double-balloon endoscopy and videocapsule endoscopy. Gastrointest Endosc. 2009; 69:866–874. PMID: 19136098.

14. Teshima CW, Kuipers EJ, van Zanten SV, Mensink PB. Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis. J Gastroenterol Hepatol. 2011; 26:796–801. PMID: 21155884.

15. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol. 2005; 100:2407–2418. PMID: 16279893.

16. Zhang Q, He Q, Liu J, Ma F, Zhi F, Bai Y. Combined use of capsule endoscopy and double-balloon enteroscopy in the diagnosis of obscure gastrointestinal bleeding: meta-analysis and pooled analysis. Hepatogastroenterology. 2013; 60:1885–1891. PMID: 24719922.

17. Malik A, Lukaszewski K, Caroline D, et al. A retrospective review of enteroclysis in patients with obscure gastrointestinal bleeding and chronic abdominal pain of undetermined etiology. Dig Dis Sci. 2005; 50:649–655. PMID: 15844696.

18. Fisher L, Lee Krinsky M, et al. ASGE Standards of Practice Committee. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc. 2010; 72:471–479. PMID: 20801285.

19. Yoon W, Jeong YY, Shin SS, et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology. 2006; 239:160–167. PMID: 16484350.

20. Hakim FA, Alexander JA, Huprich JE, Grover M, Enders FT. CT-enterography may identify small bowel tumors not detected by capsule endoscopy: eight years experience at Mayo Clinic Rochester. Dig Dis Sci. 2011; 56:2914–2919. PMID: 21735085.

21. Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest Endosc. 1998; 48:606–617. PMID: 9852451.

22. Gerson LB. Is there a role for angiography in patients with obscure overt bleeding? Am J Gastroenterol. 2012; 107:1377–1379. PMID: 22951877.

23. Lecleire S, Iwanicki-Caron I, Di-Fiore A, et al. Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding. Endoscopy. 2012; 44:337–342. PMID: 22389234.

24. 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. PMID: 14988816.

25. Shinozaki S, Yamamoto H, Yano T, et al. Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy. Clin Gastroenterol Hepatol. 2010; 8:151–158. PMID: 19879968.

26. Tanaka S, Mitsui K, Yamada Y, et al. Diagnostic yield of double-balloon endoscopy in patients with obscure GI bleeding. Gastrointest Endosc. 2008; 68:683–691. PMID: 18561920.

27. Monkemuller K, Neumann H, Meyer F, Kuhn R, Malfertheiner P, Fry LC. A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding. Endoscopy. 2009; 41:715–717. PMID: 19670141.

28. Kitiyakara T, Selby W. Non-small-bowel lesions detected by capsule endoscopy in patients with obscure GI bleeding. Gastrointest Endosc. 2005; 62:234–238. PMID: 16046986.

29. Shim KN, Moon JS, Chang DK, et al. Guideline for capsule endoscopy: obscure gastrointestinal bleeding. Clin Endosc. 2013; 46:45–53. PMID: 23423225.

30. Koh SJ, Im JP, Kim JW, et al. Long-term outcome in patients with obscure gastrointestinal bleeding after negative capsule endoscopy. World J Gastroenterol. 2013; 19:1632–1638. PMID: 23539070.

31. 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; 69:850–856. PMID: 18950762.

32. Marmo R, Rotondano G, Rondonotti E, et al. Capsule enteroscopy vs. other diagnostic procedures in diagnosing obscure gastrointestinal bleeding: a cost-effectiveness study. Eur J Gastroenterol Hepatol. 2007; 19:535–542. PMID: 17556898.