Capsule Endoscopy or Push Enteroscopy for First-Line Exploration of Obscure Gastrointestinal Bleeding?

doi:10.1053/j.gastro.2006.12.002

Gastroenterology

Volume 132, Issue 3, March 2007, Pages 855-862

https://doi.org/10.1053/j.gastro.2006.12.002 Get rights and content

Background & Aims: The position of capsule endoscopy (CE) relative to push enteroscopy (PE) in the diagnostic algorithm of obscure gastrointestinal bleeding is unclear, as previous studies involved the use of both techniques in all patients. We therefore conducted a trial in which patients were randomized to undergo one or other exploration.

Methods: All consecutive patients referred for obscure gastrointestinal bleeding were randomized between CE and PE as the first-line exploration. The alternative method was only used if the first-line method revealed no definite bleeding source, or if required for clinical reasons during follow-up.

Results: CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001).

Conclusions: CE has a higher diagnostic yield than PE in obscure gastrointestinal bleeding, and a strategy based on CE as first-line exploration avoids unnecessary explorations.

Section snippets

Materials and Methods

Between March 2002 and June 2004, all consecutive patients referred to the 2 participating centers for investigation of OGIB were eligible for randomization. The inclusion criteria were an overt bleeding within the previous 6 months, or a chronic (more than 3 month) iron-deficiency anemia (hemoglobin <10 g/dL) without obvious gynecologic or proctologic bleeding and negative prior investigations, including upper gastrointestinal endoscopy, colonoscopy, and small-bowel barium series or computed

Patients

A flow chart of the trial is shown in Figure 1. Eighty-nine patients referred for OGIB by physicians working either in the participating centers or elsewhere were enrolled and randomized. Two patients did not meet the general inclusion or exclusion criteria (one had an abdominal tumor detected by sonography after randomization, and one had a gastric ulcer revealed by endoscopic examination, the results of which were not available at inclusion). Nine patients refused the allocated strategy soon

Discussion

This first randomized study comparing the performances of CE and PE as first-line explorations for OGIB provides evidence that CE is significantly superior to PE for identifying a definite bleeding source. CE missed no small-bowel lesions that were found by PE, whereas PE missed lesions that were subsequently detected by CE in 26% of patients. These results and the comparison of the 2 strategies tested here suggest that CE should be used as the first-line exploratory method for OGIB.

Standard CE

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: Supported by a grant from Comité d’Evaluation et de Diffusion des Innovations Technologiques (CEDIT), Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France.

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Clinical–alimentary tractCapsule Endoscopy or Push Enteroscopy for First-Line Exploration of Obscure Gastrointestinal Bleeding?

Section snippets

Materials and Methods

Patients

Discussion

Gastroenterol Clin North Am

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastroenterol Clin Biol

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Diagnostic yield of push-type enteroscopy in relation to indication

Gut

Clinical evaluation of push-type enteroscopy

Endoscopy

Two way push videoenteroscopy in investigation of small bowel disease

Gut

Wireless capsule endoscopy

Nature

Clinical–alimentary tract
Capsule Endoscopy or Push Enteroscopy for First-Line Exploration of Obscure Gastrointestinal Bleeding?