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A 78-year-old man attended for outpatient capsule endoscopy, to investigate a recent history of unexplained small bowel bleeding. His previous medical history included an abdominal aortic aneurysm repair 6 years ago. Soon after capsule ingestion, he experienced sudden onset abdominal pain and collapsed on hospital grounds. He was rapidly transferred to the emergency department as he was haemodynamically unstable, and a significant per rectum (PR) bleed was found on examination. The patient was quickly stabilised following fluid resuscitation. CT angiography was performed which did not show active bleeding. However, use of the real-time capsule viewer indicated a profuse active jejunal bleed originating from the aortic graft, suggestive of an aortoenteric fistula. The patient underwent emergency endovascular cuff placement, and subsequent endovascular abdominal aortic stent grafting, to good effect., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Angioectasias are a prominent cause of small bowel (SB) bleeding frequently identified during capsule endoscopy (CE). Subsequent management depends upon grade/severity and location. There is increasing evidence that the location of SB angioectasias is not random. We aimed to map the distribution of SB angioectasias, and assess whether this impacted clinical outcomes. Materials and methods: Retrospective study examining CEs performed over a 10-year period at a tertiary referral centre. Information regarding number, location, and Saurin classification (P0-2) of SB angioectasias was collected. Clinically significant angioectasias (P1/P2) and active SB bleeding were analysed further. Outcomes of patients with P2 angioectasias or active SB bleeding were recorded. Results: 164 SBCE examinations reported angioectasias. 554 P1-2 angioectasias and active bleeds were seen, 435 (78.52%) within the first tertile of SB transit time (SBTT). 277 (50%) angioectasias were identified within the first 10% of SBTT. 40/75 (53.3%) patients with >1 P2 angioectasia and/or active bleed were referred for intervention. Of initial interventions, 24 patients underwent upper GI endoscopy; 13 underwent double balloon enteroscopy (DBE). 9/37(24.3%) had no identifiable angioectasias on endoscopy. Of those receiving ablative therapy, 20/28 (71.4%) re-presented with iron-deficiency anaemia or bleeding. In this group, average angioectasia position was 15.6% of SBTT, compared with 7.9% in those who did not re-represent ( p  = 0.344). Patients who re-presented had an average 1.6 additional P1 angioectasias, compared with 7.6 amongst those who did not return ( p  = 0.017). Conclusions: Clinically significant angioectasias are overwhelmingly located within the proximal SB. The majority are within reach of conventional endoscopy. However, AEs are often multiple and many patients re-present following intervention.

Background and Aims: Small-bowel bleeding is the primary indication for capsule endoscopy (CE). Many experts advocate a "watch-and-wait" policy in negative CE. This meta-analysis examines the odds of rebleeding after negative index CE and the impact on long-term follow-up., Methods: A comprehensive literature search identified articles examining the rebleeding rate after negative CE. Demographic and clinical information with emphasis on outcomes was retrieved, pooled, and analyzed. Heterogeneity among studies was assessed using the I 2 statistic. A random effects model was used as the pooling method because of high heterogeneity. Risk of bias was assessed using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. The primary outcome evaluated was the pooled odds ratios (ORs) for rebleeding after a negative CE for obscure GI bleeding (OGIB)., Results: Twenty-six studies with 3657 patients were included. The pooled rate of rebleeding after negative CE was .19 (95% CI, .14-.25; P < .0001). The pooled OR of rebleeding was .59 (95% CI, .37-.95; P < .001). The effect was more pronounced in studies with a short follow-up (OR, .47; 95% CI, .24-.94; P < .001). There was no statistically significant difference in rebleeding after CE for occult and overt OGIB. Prospective studies showed a lower OR of rebleeding of .24 (95% CI, .08-.73; P = .01). Most studies were high quality., Conclusions: Our analysis shows that negative CE provides adequate evidence of a subsequently low risk of rebleeding. Such patients can therefore be safely managed with watchful waiting. However, patients who rebleed after 2 years may need to be investigated for a new source of blood loss., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Esophageal capsule endoscopy (ECE) is considered to be an alternative to conventional esophagogastroduodenoscopy (EGD); however, its indications continue to expand. This report presents results from the use of ECE in patients with hemophilia at a tertiary referral academic center over a 7-year period. A total of 16 patients with hemophilia, who were all at risk of new-variant Creutzfeldt-Jakob disease due to previous treatment with UK plasma-derived pooled blood products, underwent a total of 28 ECE examinations. Main outcomes were the diagnostic yield of ECE, requirement for subsequent conventional EGD, and any variceal bleeding episodes during the follow-up period. The overall diagnostic yield was 67.8 % (19 /28 ECEs). Only one patient underwent conventional EGD, for esophageal biopsies. There were no variceal hemorrhage events in any of the patients on variceal screening follow-up. ECE is a useful and acceptable alternative to conventional endoscopy in selected patient groups (i. e. patients with hemophilia). In this group, ECE can eliminate the need for prior administration of clotting factors., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Three-dimensional imaging in capsule endoscopy is not currently feasible due to hardware limitations. However, software algorithms that enable three-dimensional reconstruction in capsule endoscopy are available., Methods: Feasibility study. A phantom was designed to test the accuracy of three-dimensional reconstruction. Thereafter, 192 small-bowel capsule endoscopy images (of vascular: 50; inflammatory: 73; protruding structures: 69) were reviewed with the aid of a purpose-built three-dimensional reconstruction software. Seven endoscopists rated visualisation improved or non-improved. Subgroup analyses performed for diagnostic category, diagnosis, image surface morphology and colour and SBCE equipment used (PillCam(®) vs. MiroCam(®))., Results: Overall, phantom experiments showed that the three-dimensional reconstruction software was accurate at 90% of red, 70% of yellow and 45% of white phantom models. Enhanced visualisation for 56% of vascular, 23% of inflammatory and <10% of protruding structures was noted (P=0.007, 0.172 and 0.008, respectively). Furthermore, three-dimensional software application enhanced 53.7% of red, 21.8% of white, 17.3% of red and white, and 9.2% of images of lesions with colour similar to that of the surrounding mucosa, P<0.0001., Conclusions: Application of a three-dimensional reconstruction software in capsule endoscopy leads to image enhancement for a significant proportion of vascular, but less so for inflammatory and protruding lesions. Until optics technology allows hardware-enabled three-dimensional reconstruction, it seems a plausible alternative., (Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.)

Aim: To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices., Methods: Retrospective observational study in a Tertiary Referral Centre. Between January 1999-October 2005, we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices. Patient details including age, gender and aetiology of liver disease/segmental portal hypertension were documented. The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle. All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded. Initial haemostasis rates, rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy. The duration of follow up was also listed. The study was conducted according to the United Kingdom research ethics guidelines., Results: Thirty-seven patients were included. 33 patients (89%) had thrombin (250 U/mL) for gastric varices, 2 (5.4%) for duodenal varices, 1 for rectal varices and 1 for gastric and rectal varices. (1) Gastric varices, an average of 15.2 mL of thrombin was used per patient. Re-bleeding occurred in 4 patients (10.8%), managed in 2 by a transjugular intrahepatic portosystemic shunt (TIPSS) (one unsuccessfully who died) and in other 2 by a distal splenorenal shunt; (2) Duodenal varices (or type 2 isolated gastric varices), an average of 12.5 mL was used per patient over 2-3 endoscopy sessions. Re-bleeding occurred in one patient, which was treated by TIPSS; and (3) Rectal varices, an average of 18.3 mL was used per patient over 3 endoscopy sessions. No re-bleeding occurred in this group., Conclusion: Human thrombin is a safe, easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices.

Background: Analysis of small-bowel capsule endoscopy (SBCE) is time-consuming. QuickView (QV) has been added to the RAPID software to reduce the reading times. However, its validity is still under intense review. Recently, we have shown that Blue Mode (BM) provides improvements in images for most lesion categories., Aim: To assess the validity of QuickView with white light (QVWL) and QuickView with Blue Mode (QVBM) reading, in a group of patients who underwent SBCE in our centre, by comparing it with the standard video sequence review (used as reference) by experienced SBCE readers., Methods: This was a retrospective study; all SBCE (August 2008-November 2011), performed with PillCam SB, with complete small-bowel visualization were included. A clinician with previous SBCE experience, unaware of the SBCE reports, reviewed prospectively the video streams on RAPID platform using QVWL and QVBM. All SBCE had been reported previously using the standard mode; these reports were considered as the reference. There were 106 cases of obscure gastrointestinal bleeding (OGIB), 81 cases of known or suspected Crohn's disease (CD) and 10 cases of polyposis syndromes., Results: The mean small-bowel evaluation was 475 (± 270) s and 450 (± 156) s for QVWL and QVBM, respectively. In the OGIB (n=106; 21 overt/85 occult), with QVWL, 54 [P0 (28), P1 (18), P2 (8)] lesions were detected, 63 [P0 (48), P1 (13), P2 (2)] with QVBM, as compared with 98 [P0 (67), P1 (23), P2 (8)] by standard (reference) reporting. For P1+P2 lesions, the sensitivity, specificity, positive predictive value and negative predictive value for QVWL (as compared with reference reporting) were 92.3, 96.3, 96 and 92.8%, respectively. For QVBM, the above values were 91, 96, 96.2 and 90.6%, respectively. Eighty-one (n=81) patients underwent SBCE for small-bowel evaluation on the basis of a clinical history of suspected or known CD. With QVWL, 71 mucosal ulcers were detected, 68 with QVBM, as compared with 155 mucosal ulcers with reference reading. Finally, in the polyposis category with QVWL and QVBM, four polypoid lesions were detected compared with seven with standard (reference) review., Conclusion: QV can be used confidently in OGIB in an urgent inpatient setting and in outpatients with occult OGIB or suspected CD. Furthermore, BM does not confer any additional advantage in the QV setting. Standard review settings should be used in all other cases.

Background & Aim: The role of Small-Bowel Capsule Endoscopy (SBCE) in Iron Deficiency Anemia (IDA) alone is still under validation. We aim to assess the usefulness of SBCE in patients with IDA alone., Methods: Retrospective study; patients with IDA (no GI symptoms or known previous diagnosis), who underwent SBCE were included. SBCE findings were classified as clinically significant/sinister (small-bowel malignancy, significant/sinister inflammation and/or strictures and coeliac disease) or vascular, i.e., signifcant/angioectasias (P1/P2 lesions)., Results: A total of 221 (151F/70M) patients had SBCE for IDA as the sole indication. The diagnostic yield (DY) was 30.7% (68/221). The DY for significant/sinister pathology and significant/angioectasias was 9% and 21.7%, respectively. In those ≤ 40 years (20; 13F/7M), significant pathology was found in 25% (5/20); in the >40-year group (201; 138F/63M), significant/sinister pathology was found in 7.5% (15/201), p = 0.0231. None of the patients ≤40 years had angioectasias, such lesions were found in 48/201 (21.7%) of those >40 years, p = 0.009. Fifty percent of those >80 years (16; 12F/4M) had angioectasias, but none had significant/sinister pathology (p = 0.0126). On multiple regression analysis, only prior blood transfusion was predictive of higher DY in SBCE., Conclusions: IDA alone is one of the main indications (27%) for referral to SBCE; the majority of patients are >40 years. In our cohort, the DY of SBCE for IDA was 30.7% and the commonest finding was angioectasias. The detection rate of sinister small-bowel pathology for those >40 years is low decreasing to zero in the >80 age group. In contrast, 25% of those ≤40 years had a sinister diagnosis.