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PRACTICE: H R Dalton and G F Maskell Investigating occult gastrointestinal haemorrhage BMJ 2008; 337: a422 [Full text]

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Capsule endoscopy in District General Hospital Setting

Elmuhtady M Said, S75 2EP   (12 July 2008)

use of anticoagulation during wireless capsule endoscopy

oscar,m jolobe   (14 July 2008)

Consider push enteroscopy where upper gastrointestinal bleeding suspected

Shivaram Bhat, Grant Caddy (consultant gastroenterologist), Tony Tham (consultant gastroenterologist)   (18 July 2008)

Investigating Occult Gastrointestinal Haemorrhage

Ossie Ferdinand Uzoigwe, S10 1DG   (18 July 2008)

Capsule endoscopy in District General Hospital Setting 12 July 2008
Elmuhtady M Said, Staff Grade Gastroenterologist Barnsley Disrict General Hospital, S75 2EP Send response to journal: Re: Capsule endoscopy in District General Hospital Setting	Dear Editor, We read with great interest the article by H R Dalton and G F Maskell.Since the advent of capsule endoscopy (CE) in 2001, its use has surged worldwide particularly in tertiary centres. It has developed an established role as modality of investigation of the small bowel, particularly in patients with obscure gastrointestinal bleeding (OGB), where conventional bidirectional endoscopy has been negative. However there is a paucity of data on the use of CE in a district hospital setting in the United Kingdom (UK). Hence, the feasibility and clinical utility of providing a CE service in a UK district hospital is unknown. we recently ran an audit to evaluate the diagnostic yield of CE in our hospital. The CE service is currently being provided by a sole gastroenterologist.In this small study,sixty nine patients underwent CE over the 34 months. There were 41 females (59.4%) and 28 males (40.6%) with a mean age of 63 years (range: 17-91).The main indications for CE were iron deficiency anaemia (IDA): 66.6% (n=46), overt bleeding 17.3% (n=12), investigation of small bowel Crohn’s disease 11.5% (n=8) and investigation for abdominal pain in one patient (1.4%),weight loss in one patient and persistant diarrhoea in one patient.Complete small bowel examination was achieved in 63 patients. In 6 patients (8.6%) CE was unsuccessful due to poor bowel preparation (n=3) and gastric retention (n=3.The diagnostic yield for all indications was 53.6% (n=37). The commonest finding was small bowel angiodysplasia in 48.6% (n=18). Other findings included apthoid ulcers, inflammation and oedema suggestive of Crohn’s disease in 16.2% (n=6), localised small bowel erosions in 16.2 (n=6), erosive gastritis in 13.5% (n=5), phlebectasia in 2.7% (n=1) and small bowel polyps in a further 2.7% (n=1). CE was normal in 40.5% (n=28) patients. Based on findings on CE, clinical recommendations were made which included referral for enteroscopy (for argon plasma coagulation of angiodysplasia and removal of small bowel polyps), repeat ileo-colonoscopy for histology of ulcers and step up of inflammatory bowel disease directed therapy. Our small study has shown that CE is safe, non invasive and feasible in a district hospital setting. It has a high diagnostic yield in routine clinical practice with an impact on patient management. Further follow up is required to ascertain if these changes have resulted in improved health outcomes. Dr E M Said Competing interests: None declared
use of anticoagulation during wireless capsule endoscopy 14 July 2008
oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester M13 9PP Send response to journal: Re: use of anticoagulation during wireless capsule endoscopy	As the authors point out, capsule endoscopy has ehnanced the detection rate for obscure gastrointestinal bleeding, including bleeding attributable to small bowel telengiectasia(1). Gastrointestinal stromal tumor, however, is a source of bleeding which may be difficult to detect between episodes of active bleeding, as shown by one case report(2). In that instance initial capsule endoscopy was negative because the patient was not actively bleeding at the time. After initiation of anticoagulation with heparin repeat capsule endoscopy showed several small bleeding lesions in the proximal small bowel which were attributable to a stromal tumour. Accordingly, the authors suggested that provocation of bleeding during capsule endoscopy may incease its sensitivity(2) References (1) Dalton HR., Maslell GF Investigating occult gastrointestinal haemorrhage British Medical Journal 2008:337:111-3 (2) Rieder F., Schneidewind A., Bolder U et al Use of anticoagulation during wireless capsule endoscopy for inverstigation of recurrent obscure gastrointestinal bleeding Endoscopy 2006:38:526-8 Competing interests: None declared
Consider push enteroscopy where upper gastrointestinal bleeding suspected 18 July 2008
Shivaram Bhat, Specialty Registrar in Gastroenterology Ulster Hospital Dundonald, Upper Newtownards road, Belfast, BT16 1RH, Grant Caddy (consultant gastroenterologist), Tony Tham (consultant gastroenterologist) Send response to journal: Re: Consider push enteroscopy where upper gastrointestinal bleeding suspected	The article by Dalton and Maskell is a useful summary for those investing obscure GI bleeding(1). We have a number of points to add. The main learning point in the authors’ article is that capsule endoscopy is the first line investigation in patients with obscure gastrointestinal bleeding with a normal oesophagogastroduodenoscopy (OGD) and colonoscopy. Recent BSG guidelines recommend tailoring next line investigation based on whether upper or lower gastrointestinal blood loss is suspected(2). These guidelines advocate consideration of a second look OGD in those patients with suspected upper gastrointestinal blood loss. Previous studies have shown that 12-64% of lesions detected on push enteroscopy are within reach of a standard endoscope(2). Capsule endoscopy is an excellent modality for visualising the small bowel. However it has a number of drawbacks. Incomplete examination due to poor bowel preparation or slow transit time can occur in 10-25% of cases(2). Reporting is time consuming compared with standard endoscopy (60 -90minutes). Equipment is expensive and may not be available in all centres. Lastly, the inability to perform biopsies or therapy to suspected pathology. Our practice is to perform push enteroscopy in patients with suspected upper gastrointestinal blood loss and negative bi-directional standard endoscopy. This method allows a second look OGD to be performed together with examination of the proximal small bowel. It has the added advantage of allowing biopsy or therapy to suspected bleeding lesions. It is our practice that if push enteroscopy is negative then to proceed with capsule endoscopy. 1) Dalton HR., Maslell GF Investigating occult gastrointestinal haemorrhage British Medical Journal 2008:337:111-3 2) Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and capsule endoscopy in adults. British Society of Gastroenterology. 2008. Competing interests: None declared
Investigating Occult Gastrointestinal Haemorrhage 18 July 2008
Ossie Ferdinand Uzoigwe, Student 8 Harcourt Crescent, Sheffield, S10 1DG Send response to journal: Re: Investigating Occult Gastrointestinal Haemorrhage	Dear Editor, I read with interest the informative and compelling article by Dalton and Maskell on the diagnostic utility of capsule endoscopy1. The authors have made an important oversight, however, in failing to mention intraoperative enteroscopy. It is a safe and effective means of investigating obscure gastrointestinal bleeding (OGB). It is classed by The British Society of Gastroenterologists as the gold standard in the evaluation of OGB2. It has consistently been show to have diagnostic yields of 70 to 100%2. In the case described by Dalton and Maskell the presence of telangiectasia throughout the entirety of the small bowel increased the likelihood of capsule endoscopy identifying the underlying pathology. However where the lesion is discrete or localised diagnostic problems may be encountered3. In cases where there is a diagnostic urgency, for example in instances of small bowel neoplasia, the discrete lesion may be missed by the capsule endoscope. In addition the enteroscope may visualise the lesion but the images may not be sufficient to found a diagnosis or worse still lead to an incorrect diagnoiss3. In such cases intraoperative laparotomy can be used as an adjunctive confirmatory investigation to capsule endoscopy. It may be performed laparoscopically or via a small laparotomy2. It also offers the option of tissue biopsy and curative surgical resection. The important message is that capsule endoscopy should not be the last word in OGB. In many ways capsule endoscopy and intraoperative enteroscopy can actually act as complimentary investigations. The latter should be performed before the gastrointestinal tract is abandoned as the source of obscure blood loss. 1. Maskell GF, Dalton HR. Investigating occult gastrointestinal haemorrhage. BMJ 2008; 337 2. Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and capsule endoscopy in adults. Gut 2008; 57:125-136 3. Ross A, Mehdizadeh S, Tokar J, Leighton JA, Kamal A, Chen A, Schembre D, Chen G, Binmoeller K, Kozarek R, Waxman I, Dye C, Gerson L, Harrison ME, Haluszka O, Lo S, Semrad C. Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy. Dig Dis Sci. 2008; 53:2140 Competing interests: None declared