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PROSPECTIVE EVALUATION OF PATIENTS REFERRED FOR OBSCURE BLEEDING: HOW MANY PATIENTS ACTUALLY HAVE SMALL BOWEL BLEEDING? UPDATE AT ONE YEAR
J Staples, I Zandieh, J Al Ali, RA Enns
Department of Medicine, University of British Columbia
A large proportion of patients undergoing capsule endoscopy (CE) for obscure gastrointestinal bleeding (OGIB) are found to have culprit lesions within reach of standard endoscopic procedures. Moreover, many patients initially referred with OGIB are found to have abnormalities on repeat endoscopic examination, excluding them from consideration within a ‘capsule database’. This is an extension of a study presented previously. OBJECTIVE: The aim of this study was to prospectively evaluate consecutive referrals for suspected OGIB and the subsequent investigations undertaken. The main focus was in identifying the proportion of patients in whom CE was ultimately deemed necessary, and those in whom CE was able to demonstrate a small bowel bleeding source.
METHODS: We undertook a prospective evaluation of all patients referred with a diagnosis of OGIB between July 1 2005 and June 30 2006. The number of patients who ultimately did and did not undergo capsule endoscopy (CE) was identified along with their ultimate diagnoses. Investigations were performed at the discretion of the principle investigator.
RESULTS: One hundred patients (Mean age 63 years; 49% females; 41% with overt GI blood loss) met our entry criteria. A total of 49 patients underwent investigations by the principle investigator prior to consideration of CE. Initial investigations performed include: 33 enteroscopies, 26 colonoscopies, 14 esophagoduodenoscopies, and 15 “Other” (SBFT, barium enema, flexible sigmoidoscopy, CT scan, CT enteroclysis, RBC Scan, or Meckel’s Scan). 37 patients did not undergo CE: 14 patients had a diagnosis established using initial non-CE investigations, and 21 of the patients without a diagnosis were managed expectantly. Of the 63 patients undergoing CE, 13 (21%) had a bleeding source visualized by capsule but within reach of traditional endoscopy. Among all 100 referrals for suspected OGIB, a small bowel bleeding source was ultimately identified in only 19 patients. No bleeding source identified in 42 patients.
CONCLUSION: Only 63% of patients referred for further investigation of suspected OGIB were felt to require CE, and a bleeding source within the small bowel was demonstrated in just 19% of referrals. A ‘Direct to Capsule’ method of investigating suspected OGIB may be an inefficient and ineffective use of resources. Selective repetition of specific tests should always be considered in these patients.