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Provocative Testing and Localization in Video Capsule Endoscopy

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Provocative Testing and Localization in Video Capsule Endoscopy 1 2 The Role of Provocative 3 4 Testing and Localization of 5 6 the Video Capsule Endoscope in 7 the Management of Small 8 9 Intestinal Bleeding Q4 10 11 a, b 12 Daniel L. Raines, MD *, Douglas G. Adler, MD Q5 Q6 Q7 13 Q1 Q2 14 15 KEYWORDS 16 Small intestinal bleeding Provocative angiography Provocative endoscopy 17 Video capsule endoscopy Device-assisted enteroscopy 18 19 20 KEY POINTS 21 Cases of small intestinal bleeding (SIB) are commonly encountered in clinical practice 22 despite advancements in medical technology that allow consistent visualization of the 23 entire gastrointestinal tract. 24 The use of antithrombotic agents to provoke bleeding has been found to be revealing in 25 cases of SIB when used in combination with angiography as well as endoscopy. 26 The performance of endoscopic procedures, including video capsule endoscopy (VCE) 27 and device-assisted enteroscopy (DAE) on active antiplatelet and/or anticoagulant ther- 28 apy is considered low risk and may improve diagnostic yield. 29 The use of VCE for gastrointestinal bleeding in the inpatient setting has been found to 30 improve diagnostic yield and decrease hospital stay. 31 Because DAE is required for therapeutic intervention in patients with small bowel 32 bleeding, access to this technology is essential for effective management in many cases. 33 34 35 Video content accompanies this article at http://www.giendo.theclinics.com/. 36 37 Q8 38 OBSCURE GASTROINTESTINAL BLEEDING Definitions 39 40 Small intestinal bleeding (SIB) has been described as bleeding that is undefined in 41 cause despite evaluation by standard upper endoscopy, colonoscopy, and small Q9 42 bowel follow-through (SBFT). The low diagnostic yield of SBFT combined with the Q10 43 advent of higher-yield small bowel studies has resulted in the removal of SBFT from 44 45 a b 46 1542 Tulane Avenue, Suite 423, New Orleans, LA, USA; University of Utah School of Med- 47 icine, 30 North 1900 East 4R118, Salt Lake City, UT 84132, USA * Corresponding author. 200 West Esplanade, Suite 200, Kenner, LA 70112. 48 E-mail address: [email protected] Gastrointest Endoscopy Clin N Am - (2021) -–- https://doi.org/10.1016/j.giec.2021.01.001 giendo.theclinics.com 1052-5157/21/ª 2021 Elsevier Inc. All rights reserved. GEC1206_proof ■ 5 February 2021 ■ 3:57 pm 2 Raines & Adler 49 algorithms for evaluation of gastrointestinal (GI) bleeding.1,2 Video capsule endoscopy 50 (VCE) is associated with a 38% to 83% diagnostic yield in patients with suspected 51 small bowel bleeding and is therefore recommended as the next step in management 52 after negative esophagogastroduodenoscopy (EGD)/colonoscopy.3 Computed to- 53 mography enterography (CTE) may be indicated after negative VCE, or as an alterna- 54 tive if VCE is contraindicated, and has a reported diagnostic yield of 40% in bleeding of 55 suspected small bowel origin.4,5 Device-assisted enteroscopy (DAE) by double 56 balloon, single balloon, or spiral technique is a useful study in patients with suspected 57 small bowel bleeding but is not available in all centers. Rates of total enteroscopy differ 58 by technique but the diagnostic yield for all techniques is similar, around 60% to 80%.6 59 The widespread adoption of these advanced technologies to evaluate for small 60 bowel bleeding sources resulted in a revision of definitions pertaining to obscure 61 bleeding in 2015. Examples of bleeding with negative evaluation by EGD and colonos- 62 copy are now termed suspected SIB. This group accounts for 5% of bleeding presen- 63 tations, most of which are small bowel in origin.7 Sources of blood loss in these cases 64 can be grouped into lesions within the reach of standard endoscopy that are missed, 65 accounting for 25% of sources, and lesions in the small intestine, accounting for 75%. 66 The term obscure GI bleeding is now typically reserved for cases in which a bleeding 67 source cannot be identified despite current standard-of-care evaluation, including 68 EGD, colonoscopy, VCE, and/or DAE and radiographic studies.2 69 70 Distribution of Bleeding Sources 71 Missed lesions should be considered as lesions that are difficult to detect (Table 1), 72 which includes lesions that are identifiable on closer inspection as well as vascular ab- 73 normalities, such as Dieulafoy lesions, which are difficult or impossible to detect un- 74 less actively bleeding (Fig. 1A, B).8 Bleeding sources that are commonly missed on 75 upper endoscopy include Cameron erosions, associated with a large hiatal hernia; 76 gastric antral vascular ectasia, which may appear as benign mucosal erythema; small 77 or concealed angioectasias (Figs. 2 and 3); and peptic ulcers that are positioned in a 78 location difficult to visualize. Missed lesions on colonoscopy include flat neoplasms as 79 well as angioectasias in the right colon. Missed lesions in the small bowel vary accord- 80 ing to patient age. In patients older than 50 years, angioectasias are the most common 81 cause of small bowel bleeding in the Western population and are the most common 82 missed small bowel lesion by VCE.2,9 In adults younger than 50 years, tumors of the 83 84 85 86 Table 1 Culprit sources in suspected small bowel bleeding 87 88 Missed Lesions on Upper Endoscopy Small Bowel Bleeding Sources 89 Cameron erosions Vascular lesions Ulcerative disorders 90 Peptic ulcer disease Angioectasias Crohn disease 91 GAVE Dieulafoy lesion NSAID enteropathy Angioectasias Aortoenteric fistula Ischemic enteropathy 92 Dieulafoy lesion Neoplasms Radiation enteropathy 93 Missed lesions on Carcinoid Meckel diverticulum 94 colonoscopy GIST 95 Flat neoplasms Adenocarcinoma 96 Angioectasias Lymphoma 97 Dieulafoy lesion 98 Abbreviations: GAVE, gastric antral vascular ectasia; GIST, GI stromal tumor; NSAID, nonsteroidal 99 antiinflammatory drug. GEC1206_proof ■ 5 February 2021 ■ 3:57 pm Management of Small Intestinal Bleeding Q3 3 100 101 102 103 104 105 106 FPO = 107 108 109 110 111 print & web 4C 112 Fig. 1. (A, B) Small bowel Dieulafoy lesion observed by VCE then subsequent DAE. 113 114 115 116 117 118 119 120 121 122 123 124 125 126 FPO 127 = 128 129 130 131 132 print & web 4C 133 Fig. 2. Dense gastric angioectasia. 134 135 136 137 138 139 140 141 142 143 144 FPO 145 = 146 147 148 149 print & web 4C 150 Fig. 3. Actively bleeding angioectasia by video capsule. GEC1206_proof ■ 5 February 2021 ■ 3:57 pm 4 Raines & Adler 151 152 153 154 155 156 157 158 FPO 159 = 160 161 162 163 164 print & web 4C 165 Fig. 4. Endophytic GIST marked with India ink (observed by laparoscopy). 166 167 small bowel are the most common bleeding source.10 The miss rate of VCE for small 168 bowel tumors is estimated to be 19%, especially for tumors such as GI stromal tumor 169 (GIST) that can be endophytic (Fig. 4).11 Therefore CTE is recommended after VCE in 170 patients less than 50 years old or in patients more than 50 years old with recurrent 171 bleeding or progressive anemia, although some tumors may remain undetected after 172 both VCE and CTE (Fig. 5).2,12 CTE may be combined with PET to show hypermeta- 173 bolic lesions such as adenocarcinoma (Fig. 6A, B). A Meckel scan is recommended as 174 an additional test, particularly in younger patients (Fig. 7). 175 176 Outcomes in Obscure Gastrointestinal Bleeding 177 Outcomes in patients with bleeding of unknown origin after negative EGD, colonos- 178 copy, and VCE have been evaluated in several studies. Two early studies of SIB 179 patient cohorts reported rebleeding rates of only 6% to 11% over an average 18- 180 month follow-up period.13,14 These studies also showed that negative capsule 181 endoscopy (CE) was predictive of lower rebleeding rates compared with patients Q11 182 with positive CE. However, subsequent studies of this patient population conflict 183 with these results. In 1 study, 26 patients with mostly overt obscure GI bleeding 184 (OGIB) were followed over an extended median follow-up period of 32 months and 185 rebleeding was observed in 35% of patients. In addition, this study found that 186 187 188 189 190 191 192 193 194 195 FPO 196 = 197 198 199 200 print & web 4C 201 Fig. 5. Ileal carcinoid tumor missed by VCE and CTE. GEC1206_proof ■ 5 February 2021 ■ 3:57 pm Management of Small Intestinal Bleeding 5 202 203 204 205 206 207 208 209 210 211 FPO = 212 213 214 215 216 print & web 4C 217 Fig. 6. (A, B) Metastatic adenocarcinoma of the ileum by PET–computed tomography (A) 218 and DAE (B). Q20 219 220 221 rebleeding rates between patients with negative CE and positive CE were almost iden- 222 tical and only specific therapy directed to the bleeding source resulted in a change in 223 the frequency of rebleeding.15 Although this study was retrospective and complicated 224 by a high rate of incomplete capsule examinations (67%), similar results were shown in 225 another study of patients with SIB and negative CE.16 This study found that 47% of 226 patients with a nondiagnostic first CE study experienced recurrent overt bleeding or 227 progressive anemia during a mean follow-up period of 25 months. Management of in- 228 dividual patients should therefore be tailored to the clinical course. In older patients 229 with persistent resolution of bleeding, expectant management after negative VCE 230 may be considered unless additional symptoms or clinical findings warrant further 231 testing.1,2 In younger patients and patients with recurrent overt bleeding or progres- 232 sive anemia, additional testing should be pursued. 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 Fig.
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