A randomized controlled trial comparing efficacy of early video capsule endoscopy with standard of care in the approach to nonhematemesis GI bleeding (with videos)

Abstract

Background and Aims: Patients presenting with nonhematemesis GI bleeding (NHGIB) represent a diagnostic challenge for physicians. We performed a randomized controlled trial to assess the benefits of deployment of a video capsule soon after admission in the management of patients presenting with melena, hematochezia, or severe anemia compared with standard of care management. Methods: Patients admitted with NHGIB were randomized and placed into 1 of 2 study groups. In the experimental group, patients ingested a video capsule soon after admission to the hospital. These patients had further endoscopic workup based on the findings from the capsule. Patients in the control group underwent endoscopic evaluation (ie, upper endoscopy, capsule endoscopy, and/or colonoscopy) to identify the source of bleeding as directed by the attending gastroenterologist’s interpretation of their clinical presentation. The primary endpoint for this study was the rate of localization of bleeding during hospitalization. Results: Eighty-seven patients were included in this study: 45 randomized to the standard of care arm and 42 to the early capsule arm. A bleeding source was localized in 64.3% of the patients in the early capsule arm and in 31.1% of the patients in the standard of care arm (P < .01). The likelihood of endoscopic localization of bleeding over time was greater for patients receiving early capsule endoscopy compared with those in the standard of care arm (adjusted hazard ratio, 2.77; 95% confidence interval, 1.36–5.64). Conclusions: For patients admitted to the hospital for NHGIB, early capsule endoscopy is a safe and effective alternative for the detection of the source of bleeding. (Clinical trial registration number: NCT02442830.) (Gastrointest Endosc 2019;89:33–43.)

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.…”

“…At multivariate analysis, patients receiving early CE were more likely to have a localized bleeding source (odds ratio[OR] 5.28), vascular causes of bleeding (OR 10.73) and colonic source of bleeding (OR 4.09). Notably, early CE allowed for earlier localization of bleeding and was the strongest independent predictor of bleeding localization over time (hazard ratio 2.77) . Larger studies analyzing the long‐term benefits of first‐line CE should now demonstrate whether this approach would impact on patient survival, bleeding recurrence, length and costs of hospital stay.…”

“…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.…”

“…randomized 87 patients presenting with non‐hematemesis GI bleeding to receive early CE as the first‐line examination versus conventional investigative pathways (i.e. upper, then lower and finally mid gut endoscopy) . At multivariate analysis, patients receiving early CE were more likely to have a localized bleeding source (odds ratio[OR] 5.28), vascular causes of bleeding (OR 10.73) and colonic source of bleeding (OR 4.09).…”

Optimising the use of small bowel endoscopy: a practical guide

“…Early SBCE following presentation with obscure gastrointestinal bleeding in the emergency department has been shown to be superior to standard investigations in the identification of vascular lesions with no additional costs 37. The role of SCBE has also been investigated in an intensive care setting 38.…”