Hardly any of the medical innovations seen in recent decades has given rise to so much interest and enthusiasm as the introduction of capsule endoscopy (CE). The method fulfilled every endoscopist's dream of being able to examine endoscopically not only the stomach and colon, but the whole gastrointestinal tract. All previous attempts to achieve total enteroscopy using conventional endoscopes had to a greater or lesser extent failed.However, assessing the real significance of capsule endoscopy in small-bowel diseases requires prospective studies comparing the capsule with push enteroscopy (PE), intraoperative endoscopy, and other imaging procedures in relation to defined issues.Six valid full papers have now been published on the detection of mid-gastrointestinal bleeding with CE, showing a trend toward similar results [1 ± 6]. In comparison with push enteroscopy, CE produces approximately twice as many positive findings. Conventional procedures such as small-bowel radiography, angiography, and nuclear medicine techniques (e. g., blood pool scintigraphy) have been relegated to the status of reserve procedures [1]. Whether push enteroscopy should be used before CE is an open question, at least in relation to obscure occult mid-gastrointestinal bleeding. In obscure overt bleeding from the mid-gastrointestinal tract, the first choice is undoubtedly PE, since coagula and blood can be rinsed away with this method and therapeutic hemostatic procedures can also be carried out.However, what is the use of better detection of bleeding sources in the mid-gastrointestinal tract if it does not have a positive influence on the outcome for patients? While this question was never asked in connection with ªolderº procedures in the fields of radiography, nuclear medicine, and endoscopy, it can now justifiably be asked not only of CE but also of the ªolderº procedures as well ± not only for scientific reasons, but in particular for economic reasons. However, scientific research is faced with substantial methodological problems in answering this question, since it is not only ªacute eventsº that need to be investigated; complex and meticulous follow-up procedures need to be recorded over long periods. In their paper in this issue of Endoscopy, Delvaux et al. can therefore take the credit for what is in our view the best-validated paper on the topic to date [7]. In 44 patients with occult or overt bleeding, CE diagnosed mid-gastrointestinal bleeding in nearly 40 % of cases. After appropriate endoscopic, surgical, or medical therapy, recurrent bleeding was only observed in one patient after a follow-up period of 1 year. Conversely, a different plausible explanation for the anemia was found in all of the patients with negative CE findings, so that the negative predictive value was as high as 100 %. Although the study by this French group will require further confirmation from similarly good outcome studies, as it was a single-center investigation with a small number of cases, this important study further bolsters the significance of CE...
