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Main Recommendations MR1 ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2 ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3 ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4 ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5 ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6 ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7 ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn’s disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8 ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9 ESGE recommends, in patients with established Crohn’s disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10 ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11 ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

The primary aim of this study was to assess the reliability, intra- and inter-observer variation of the SPICE, Mucosal protrusion angle (MPA) and SHYUNG scores in differentiating a subepithelial mass (SEM) from a bulge.This retrospective multicentre study analysed the 3 scores, radiological studies, enteroscopy and/or surgical findings.100 patients with a potential SEM (mean age 57.6years) were recruited with 75 patients having pathology. In patients with a SEM the mean SPICE score was 2.04 (95% CI 1.82-2.26) as compared to 1.16 (95% CI 0.81-1.51) without any pathology (AUC 0.74, p0.001), with a fair intra-observer agreement (Kappa 0.3, p0.001) and slight inter-observer agreement (Kappa 0.14, p0.05). SPICE had a 37.3% sensitivity and 92.0% specificity in distinguishing between a SEM and bulge, whereas MPA90˚ had 58.7% and 76.0% respectively, with poor intra-observer(p = 0.05) and interobserver agreement (p = 0.64). The SHYUNG demonstrated a moderate intra-observer (Kappa 0.44, p0.001) and slight inter-observer reliability (Kappa 0.18, p0.001). The sensitivity of an elevated SHYUNG score (≥4) in identifying a SEM was 18.7% with a specificity of 92.0% (AUC 0.71, p = 0.002).Though these scores are easy to use, they have, at best, slight to moderate intra and inter-observer agreement. Their overall diagnostic performances are limited.

Background and Aims: Meckel's diverticulum (MD) may remain silent or be associated with adverse events such as GI bleeding. The main aim of this study was to evaluate indicative small-bowel capsule endoscopy (SBCE) findings, and the secondary aim was to describe clinical presentation in patients with MD. Methods: This retrospective European multicenter study included patients with MD undergoing SBCE from 2001 until July 2021. Results: Sixty-nine patients with a confirmed MD were included. Median age was 32 years with a male-to-female ratio of approximately 3:1. GI bleeding or iron-deficiency anemia was present in nearly all patients. Mean hemoglobin was 7.63 ± 1.8 g/dL with a transfusion requirement of 52.2%. Typical capsule endoscopy (CE) findings were double lumen (n = 49 [71%]), visible entrance into the MD (n = 49 [71%]), mucosal webs (n = 30 [43.5%]), and bulges (n = 19 [27.5%]). Two or more of these findings were seen in 48 patients (69.6%). Ulcers were detected in 52.2% of patients (n = 36). In 63.8% of patients (n = 44), a combination of double lumen and visible entrance into the MD was evident, additionally revealing ulcers in 39.1% (n = 27). Mean percent SB (small bowel) transit time for the first indicative image of MD was 57% of the total SB transit time. Conclusions: Diagnosis of MD is rare and sometimes challenging, and a preoperative criterion standard does not exist. In SBCE, the most frequent findings were double-lumen sign and visible diverticular entrance, sometimes together with ulcers.

The use of artificial intelligence in small bowel capsule endoscopy is expanding. This review focusses on the use of artificial intelligence for small bowel pathology compared with human data and developments to date.The diagnosis and management of small bowel disease has been revolutionized with the advent of capsule endoscopy. Reading of capsule endoscopy videos however is time consuming with an average reading time of 40 min. Furthermore, the fatigued human eye may miss subtle lesions including indiscreet mucosal bulges. In recent years, artificial intelligence has made significant progress in the field of medicine including gastroenterology. Machine learning has enabled feature extraction and in combination with deep neural networks, image classification has now materialized for routine endoscopy for the clinician.Artificial intelligence is in built within the Navicam-Ankon capsule endoscopy reading system. This development will no doubt expand to other capsule endoscopy platforms and capsule endoscopies that are used to visualize other parts of the gastrointestinal tract as a standard. This wireless and patient friendly technique combined with rapid reading platforms with the help of artificial intelligence will become an attractive and viable choice to alter how patients are investigated in the future.

Background: Video capsule endoscopy (VCE) is an attractive method for diagnosing and objectively monitoring disease activity in celiac disease (CeD). Its use, facilitated by artificial intelligence-based tools, may allow computer-assisted interpretation of VCE studies, transforming a subjective test into a quantitative and reproducible measurement tool. Objective: To evaluate and compare objective CeD severity assessment as determined with VCE by expert human readers and a machine learning algorithm (MLA). Methods: Patients ≥ 18 years with histologically proven CeD underwent VCE. Examination frames were scored by three readers from one center and the MLA, using a 4-point ordinal scale for assessing the severity of CeD enteropathy. After scoring, curves representing CeD severity across the entire small intestine (SI) and individual tertiles (proximal, mid, and distal) were fitted for each reader and the MLA. All comparisons used Krippendorff’s alpha; values > 0.8 represent excellent to ‘almost perfect’ inter-reader agreement. Results: VCEs from 63 patients were scored. Readers demonstrated strong inter-reader agreement on celiac villous damage (alpha=0.924), and mean value reader curves showed similarly excellent agreement with MLA curves (alpha=0.935). Average reader and MLA curves were comparable for mean and maximum values for the first SI tertile (alphas=0.932 and 0.867, respectively) and the mean value over the entire SI (alpha=0.945). Conclusion: A novel MLA demonstrated excellent agreement on whole SI imaging with three expert gastroenterologists. An ordinal scale permitted high inter-reader agreement, accurately and reliably replicated by the MLA. Interpreting VCEs using MLAs may allow automated diagnosis and disease burden assessment in CeD

Background Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center. Methods We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE–DBE concordance, hemoglobin (Hb) values before and after DBE, and complications. Results 807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1–5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients. Conclusion VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.

ObjectiveTo assess the risks and benefits of reverse mentoring of consultants by junior doctors.DesignA feasibility study divided into two phases: first a semistructured interview where performance of participating consultants was assessed by junior doctors and then a second phase allowing for feedback to be given on a one-to-one basis. Data collected through questionnaires with free text questions and Likert scores.SettingTertiary teaching hospital in the UK.ParticipantsSix junior doctors (66.6% male, age range 31–40 years) and five consultants (80% male, age range 35–65 years and consultants for 5–20 years).InterventionReverse mentoring session.Main outcome measureThe concerns and/or benefits of the process of reverse mentoring. Confidence was assessed in 7 domains: clinical practice, approach to juniors, approachability, use of technology, time management, strengths and areas for improvement using Likert scales giving a total out of 35.ResultsThe most common concerns cited were overcoming the hierarchical difference and a selection bias in both mentors and mentees. However, no participant experienced this hierarchical difference through the reverse mentoring process and no relationships were negatively affected. Mentors became more confident in feeding back to seniors (23 vs 29 out of 35, p=0.04) most evident in clinical practice and areas to improve (3 vs 4 out of 5, p=0.041 and 3 vs 5 out of 5, p=0.041, respectively).ConclusionWe present the first study of reverse mentoring in an NHS clinical setting. Initial concerns with regard to damaged relationships and hierarchical gradients were not experienced and all participants perceived that they benefited from the process. Reverse mentoring can play a role in engaging and training future leaders at junior stages and provide a means for consultants to receive valuable feedback from junior colleagues.

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Background and aims Capsule endoscopy (CE) interpretation requires the review of many thousands of images, with lesions often limited to just a few frames. In this study we aim to determine whether lesion detection declines according to the number of capsule videos read. Methods 32 participants, 16 of which were novices (NR) and 16 experienced (ER) capsule readers took part in this prospective evaluation study. Participants read six capsule cases with a variety of lesions, in a randomly assigned order during a single sitting. Psychomotor Vigilance Tests and Fatigue Scores were recorded prior to commencing and then after every two capsules read. Changes in lesion detection and measures of fatigue were assessed across the duration of the study. Results Mean agreement with the predefined lesions was 48.3% (SD:16.1), and 21.3% (SD:15.1) for the experienced and novice readers respectively. Lesion detection declined amongst experienced reader after the first study (p = 0.01), but remained stable after subsequent capsules read, while NR accuracy was unaffected by capsule numbers read. Objective measures of fatigue did not correlate with reading accuracy. Conclusion This study demonstrates that reader accuracy declines after reading just one capsule study. Subjective and objective measures of fatigue were not sufficient to predict the onset of the effects of fatigue.

The demand for small bowel (SB) capsule endoscopy (CE) is increasing in the UK. However, there remains a wide variation in the number of CE procedures performed in different centres. Across the UK there is a lack of a clear training pathway or certification process. A standardised national Joint Advisory Group (JAG) on Gastrointestinal Endoscopy approved a 1-year training and accreditation programme accessible to all professional groups that may wish to train in SB CE. Structured training is delivered using JAG-accredited CE courses and an electronic learning module. Prior to setting a knowledge-based assessment, a minimum of 50 SB CE cases are recommended to be read in tandem with a trainer at a local centre, with proficiency documented using Direct Observation of Procedural Skill (DOPS) assessments.

Capsule endoscopy has had significant development since it was introduced into the field of medicine in 2000. It is non-invasive, well tolerated, does not require sedation and is a first-line small bowel investigative modality. As it transits through the entire gastrointestinal (GI) tract, it has the potential to provide a pan-enteric examination.In this review we will discuss the new diagnostic modalities along with traditional methods which have been used for examination of the gastro intestinal (GI) tract. The main focus of this review will be on the use of capsule endoscopy for pan-enteric examination.Capsule endoscopy is an accepted first-line investigation for the small bowel. Diagnostic sensitivity of the colon capsule is comparable to colonoscopy in controlled trials and is being evaluated in high-risk patients in routine clinical practice in national programs. Preliminary data suggest that a magnetic-controlled examination of the upper GI tract could be developed to enable a complete upper GI examination.

Background Small bowel capsule endoscopy (SBCE) has an established role in the management of refractory celiac disease (RCD) for the detection of complications. The aim of this study was to define the role of SBCE in the management of patients with RCD. Method Patients with histologically confirmed RCD who underwent successive SBCEs were recruited retrospectively from 2 tertiary centers. Results Sixty patients with RCD were included. The percentage extent of the affected small bowel (SB) mucosa improved on repeating a second SBCE in 26 patients (49.1%) (median 27.6% vs. 18.1%, P=0.007). Patients with RCD type II had more extensive disease than those with RCD type I on first (41.4% vs. 19.2%, P=0.004) and second (29.8% vs. 12.0%, P=0.016) SBCE. Patients with RCD type I tended to show a greater improvement in percentage of abnormal SB involved on repeat SBCE compared to those with RCD type II (P=0.049). Nine patients (15%) had RCD-related complications. Five patients developed ulcerative jejunoileitis, 3 patients developed enteropathy-associated T-cell lymphoma, and 1 patient developed cutaneous T-cell lymphoma. Conclusions SBCE can be a useful tool for monitoring the effects of treatment, primarily following its initiation. Patients with RCD type II have more extensive SB disease, equating to a more aggressive disease pattern.

Capsule endoscopy (CE) is an established modality in the diagnostic algorithm of small bowel (SB) pathology. Its use has expanded for investigation of upper and lower gastrointestinal diseases with similar prototypes.This review covers the role and recent advances of CE, as a non-invasive investigative tool.The use of upper gastrointestinal CE is useful in patients who require surveillance for varices particularly in the current era of the COVID-19 pandemic. It has also shown high accuracy in the detection of upper gastrointestinal hemorrhage in patients presenting with a suspicion of hemorrhage. Findings on CE help to guide further management by device-assisted enteroscopy. The data on colon CE suggest comparable diagnostic accuracy to colonoscopy for polyp detection; however, more evidence is required in the high-risk group. Crohn's CE has become an integral part of the management of patients with Crohn's disease offering a comparative assessment tool post escalation of therapy. Artificial intelligence within CE has demonstrated similar if not better diagnostic yield compared to the human with a significantly shorter reading time. Artificial intelligence is likely to be in-built within CE reading platforms over the next few years minimizing reporting time and human error.

Introduction\ud \ud Patients with established coeliac disease (CD) can present with signs and symptoms requiring small bowel capsule endoscopy (SBCE) to assess for persistent disease beyond the duodenum and to rule out complications. There is paucity of data on extent of disease on SBCE in relation to histology, clinical and serological parameters. The aim of this study was to assess the relationship between symptoms, CD serology and Marsh classification of disease and extent of disease on SBCE in patients with established CD.\ud \ud \ud \ud Methods\ud \ud Hundred patients with established CD and 200 controls underwent a SBCE. SBCEs were reviewed by expert reviewers. Extent of disease on SBCE, CD findings and small bowel transit were recorded.\ud \ud \ud \ud Results\ud \ud Considering duodenal histology (D2; Marsh 3a or above) as the gold standard for diagnosing CD activity, the sensitivity of SBCE to delineate active disease was 87.2%. The specificity was 89.0%. Age at SBCE (P = 0.006), albumin (P = 0.004) and haemoglobin (P = 0.0001), Marsh score of histology from the duodenal bulb (D1) (P = 0.0001) and the second part of the duodenum (P = 0.0001), refractory CD (P = 0.007) on histology correlated with extent of affected small bowel (SB) mucosa on univariate analysis. On multiple regression analysis, albumin (P = 0.036) and Marsh score of histology (D1) (P = 0.019), vitamin B12 (P = 0.001) and folate levels (P = 0.008) were statistically significant. Extent of affected SB mucosa (11.0% vs 1.35%) was greater in patients with complications including those with refractory CD (P = 0.008).\ud \ud \ud \ud Conclusions\ud \ud This is the first study showing correlation between extent of disease and severity of duodenal histology, markers of malabsorption such as folate levels and vitamin B12 and complications of CD.

The diagnosis of small bowel lymphoma (SBL) can be challenging, as they are very rare and also have a varied presentation. In this review, we aim to provide a broad overview of the types of SBL and also about the various modalities used for their diagnosis. We also discuss the overview of treatment strategies for a gastroenterologist.Small bowel capsule endoscopy (SBCE) and devise-assisted enteroscopy (DAE) has revolutionized the way we investigate the small bowel. DAE also makes it possible to obtain histological samples for further characterization of SBL. This has led to a significant improvement in diagnosis and management of the disease in conjunction with cross-sectional imagining.The diagnosis and management of small bowel lymphoma remains challenging despite the development of newer techniques such as SBCE and DAE. The current available diagnostic modalities have limitations; in the absence of a gold standard, the current investigative modalities compliment each other in reaching the final diagnosis.

BACKGROUND AND AIM There is a lack of uniformity of reporting on features of celiac disease (CD) on small bowel capsule endoscopy (SBCE). This makes determining extent of disease and comparison of severity of disease challenging. METHODS De-identified SBCEs of 300 patients (78 CD [26%], 18 serology negative villous atrophy [6%], and 204 controls with normal duodenal histology [68%]) were included. Videos were reviewed by two experts. All patients had duodenal histology taken within 2 weeks of SBCE. The degree of agreement in CD features and extent of disease was then determined. The resulting score for each factor was used to determine overall severity of disease. RESULTS There was substantial agreement in the kappa coefficient for the detection of CD features between reviewers (0.67). Agreement for extent of affected small bowel (SB) mucosa was high (0.97). On multiple regression analysis, several features of CD correlated with extent of affected SB mucosa for both reviewers. The odds ratios derived from this analysis were then used to score features of CD, enabling scores of severity to be calculated for each patient. The median overall scores for patients increased significantly according to the independent classification of severity by the capsule reviewers: mild (20, 0-79), moderate (45, 25-123), and severe (89, 65-130) (P = 0.0001). CONCLUSION The good correlation of CD scores between expert reviewers confirms the validity of features of CD on SBCE. An objective score of CD features in the SB is useful in the follow up of patients with CD and serology negative villous atrophy.

Main RecommendationsThe European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize training in small-bowel endoscopy across European centers. The following criteria and framework for training in small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE), which aim to provide uniform and high quality training to ensure that small-bowel endoscopists are competent to operate independently, are based on the current literature and experience of experts in the field. Three main areas are covered: skills required prior to commencing training in small-bowel endoscopy; structured training for trainees to become independent endoscopists; and ways of ensuring competence is achieved. 1 Centers providing training in SBCE should perform a minimum of 75 – 100 SBCEs/year. 2 Experience in bidirectional endoscopies is desirable for structured training in SBCE. 3 SBCE courses should consist of at least 50 % hands-on training and cover information on technology, indications and contraindications for SBCE, pathologies that can be encountered on SBCE, and standard terminology that should be used during reporting of SBCE. An SBCE course should be completed prior to achieving competence in SBCE reporting. 4 Competence in SBCE can be assessed by considering a minimum of 30 SBCEs. Direct Observation of Procedural Skills, short SBCE videos, and multiple-choice questions can be useful to assess improvement in the skills of trainees. 5 Centers offering training in DAE should aim to carry out at least 75 DAEs/year, should have direct links with an SBCE service, and should allow regular discussion of cases at a radiology small-bowel MDT. Training centers with lower numbers are encouraged to offer training by “buddying-up” with other centers, or using mentoring systems. 6 DAE trainees must be independent in bidirectional endoscopies and have experience in level 1 polypectomy prior to commencement of training. They should also be competent in reviewing SBCEs. 7 Training in DAE should be structured with a minimum of 75 procedures, including 35 retrograde DAEs, with therapeutic procedures undertaken in at least 50 % of the DAEs performed. Training should cover the indications, contraindications, complications including prevention, and technicalities of the DAE procedure; formal evaluation should follow. DAE trainees must acquire skills to independently manage and advise on small-bowel pathology following DAE procedures. 8 It is highly recommended that international societies develop online modules and courses on DAE, which are currently lacking across Europe.

Objective The relation between symptomatology, serology and findings on small bowel capsule endoscopy (SBCE) in patients with coeliac disease (CD) remains unclear. Clarifying such associations will help to determine whether symptoms and serology can predict severity and extent of disease on SBCE. Methods Patients with newly diagnosed CD were recruited. Information on SBCE was recorded. Signs and symptoms at presentation, serological markers and histological classification of the disease in the duodenum were noted. Results Sixty patients with newly diagnosed CD (mean age: 44.9 years, SD: ±17.4, 17-76) were included in this study. Older patients (P = 0.025) and patients presenting with iron deficiency anaemia had more extensive small bowel (SB) involvement (25.7% vs. 13.5%; P = 0.026). Those with weight loss were more likely to have SB involvement beyond the duodenum (37.5% vs. 5.8%; P = 0.027). Patients presenting with iron deficiency anaemia (53.5 vs. 42.4 years; P = 0.038) and weight loss (60.5 vs. 42.4 years; P = 0.009) were significantly older at diagnosis. Serum albumin was lower in those patients diagnosed later on in life (Pearson correlation -0.0361; P = 0.007). There was no significant association between anti-tissue transglutaminase antibody (P = 0.396) and extent of affected SB mucosa. Patients with more severe Marsh scores on histology from the duodenal bulb had more extensive SB involvement (P = 0.017). Conclusions This is the largest study on the use of SBCE in newly diagnosed CD. Older patients are likely to have more extensive disease on SBCE at diagnosis. Symptoms and serology had no impact on the findings on SBCE apart from weight loss and iron deficiency anaemia.

IntroductionConventional oral upper gastrointestinal (GI) endoscopy can obe uncomfortable. By comparison, transnasal endoscopy (TNE) and magnet assisted capsule endoscopy (MACE) have superior tolerability. A cost comparison of competing upper GI endoscopic modalities have yet to be performed.MethodsWe performed a cost comparison study of oral, TNE and MACE by a combination of activity-based costing and averaging of fixed costs over 24 481 upper GI endoscopies performed for dyspepsia over a 10-year period.ResultsOn average, 9.4 procedures were performed daily. TNE was cheapest at €125.90 per procedure, costing 30% less than oral endoscopy at €184.10 and threefold cheaper than MACE at €407.10. Flexible endoscope reprocessing cost €53.80. TNE was cheaper than oral endoscopy as sedation was not required. Oral endoscopies have a further rate of infectious complications, estimated to cost €16.20 per oral procedure in inpatient admissions. Oral and TNE equipment are more expensive to purchase and maintain than MACE costing €79 330 and €81 819, respectively compared with MACE at €15 420 per annum. However, capsule endoscopes cost significantly more per procedure at €369.00 than the consumables for flexible endoscopy (per oral €12.30, TNE €5.30).ConclusionsTNE cost less to perform than conventional per oral endoscopy. The cost of capsule endoscopes will need to be reduced significantly if routine use is to be expected.

Background and study aims Oropharyngeal intubation during Esophagogastroduodenoscopy (EGD) is uncomfortable, associated with aerosol generation and transmission of airborne microbes. Less-invasive alternatives may be better tolerated. In this study, patient tolerance and acceptability of EGD and transnasal endoscopy (TNE) have been compared with magnet-controlled capsule endoscopy (MACE). Patients and methods A comparison of MACE with EGD and TNE in the investigation of dyspepsia was performed. Factors affecting patient tolerance and acceptability were examined using the Endoscopy Concerns Scale (ECS) and Universal Patient Centeredness Questionnaire (UPC-Q). Results Patients were significantly more distressed (scoring least to most distress: 1–10) by gagging (6 vs 1), choking (5 vs 1), bloating (2 vs 1), instrumentation (4 vs 1), discomfort during (5 vs 1) and after (2 vs 1) EGD compared to MACE (all P Conclusions Gagging and choking during instrumentation, the main causes of patient distress during EGD, occurred less during TNE but tolerance, acceptability and patient experience favored MACE.

Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA—for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease— with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.

Background and Aims Acute upper GI bleeding is common and requires investigation with EGD, but endotherapy is not always necessary. Magnetically assisted capsule endoscopy (MACE) uses a capsule steerable by an external magnet and allows examination of the upper GI tract and small bowel, but its role in acute upper GI bleeding has not been assessed. Methods We conducted a prospective cohort study comparing the diagnostic yield of MACE and EGD in patients with suspected acute upper GI bleeding. Patient tolerance, mucosal visibility by MACE, and frequency of small-bowel bleeding were assessed. Whether or not MACE could safely predict discharge of patients was also determined. Results Thirty-three patients were included for analysis (median age, 60 years; 75.8% male). MACE detected more focal lesions (peptic, vascular, and fresh/altered blood without a clear source) than EGD (40 versus 25, respectively, P = .02) but statistical significance was not reached for significant lesions (considered to be the bleeding source; 14 vs 13, respectively, P = 1). Capsule endoscopy identified an additional cause for bleeding in the small bowel in 18%. Visualization by MACE was excellent in most areas; views of the esophagus, gastroesophageal junction, fundus, and duodenal bulb were suboptimal. MACE was better tolerated than unsedated EGD and correctly identified patients who were safe for discharge. Conclusions MACE had higher diagnostic yield for focal lesions and was better tolerated than EGD. It also correctly predicted safe discharge for patients with acute upper GI bleeding. (Clinical trials registration number: NCT02690376.)

Background Device assisted enteroscopy (DAE) is increasingly being carried out in elderly patients. This provides a challenge due to the underlying varied physiology and comorbidities these patients have. Methods We performed a systematic literature search for studies on elderly patients undergoing DAE. We calculated the pooled diagnostic (DY) and therapeutic yields (TY), major adverse events, length of small bowel examined and sedation administered. These were also compared to younger patients. Results Fourteen high quality articles on DAE in the elderly were included in this analysis (3289 total, 1712 elderly) patients. Nine of these studies were included in the final meta-analysis (681 elderly, 1577 young patients). The overall DY of DAE, double balloon enterosocpy (DBE) and single balloon enteroscopy (SBE) were 0.68 (p = 0.000001), 1.74 (p = 0.0001) and 1.90 (p = 0.009). The TY of DAE, DBE and SBE were 0.45 (p = 0.00001), 2.20 (p = 0.00001) and 2.36 (p = 0.00001). On comparison of elderly and young patients, DY (1.83; 95% CI: 1.49, 2.24; p = 0.00001) and TY (2.28; 95% CI: 1.79, 2.89) were better in elderly patients. There was no difference in adverse events in both groups (2.16; 95% CI: 0.82, 5.69, p = 0.12). Elderly patients were given less sedation than younger patients during DAE. Conclusions DAE has a higher DY and TY in the elderly than younger patients. DAE can be safely carried out in the elderly with less sedation.

The review discusses the roles of small bowel capsule endoscopy and deep enteroscopy in patients with Crohn's disease. It highlights recent advances in the field and identifies areas where evidence is lacking.Small bowel capsule endoscopy has an important role in the follow-up of patients with Crohn's disease after escalation of therapy and in the postoperative assessment period following surgical resection. Device-assisted enteroscopy offers the therapeutic advantage of small bowel dilatation, which may result in a reduction in the number of surgical resections required, thus avoiding long-term complications, such as short bowel syndrome and malabsorption.Capsule endoscopy has an established role in the diagnosis and management of small bowel Crohn's disease. It is used in the setting of suspected Crohn's disease when ileocolonoscopy is negative and for the assessment of extent of small bowel disease in established Crohn's disease. It is relatively well tolerated because of the provision of patency capsule endoscopy to minimize the risk of inadvertent capsule retention. Device-assisted enteroscopy aids with the diagnosis of Crohn's disease as it enables histology to be taken from inflamed areas within the small bowel. Therapeutic procedures can be carried out during device-assisted enteroscopy including dilatation of Crohn's disease-related strictures and retrieval of retained capsules.

BackgroundThe main risk of capsule endoscopy is retention of the capsule behind a stricture. Passage of an intact Agile patency device (Medtronic, Dublin, Ireland) through the small bowel is widely used to ensure luminal patency, although capsule retention has occurred in patients who have had a reassuring patency study. The device is designed to remain intact for at least 30 hours postingestion, such that loss of signal from the radiofrequency identification tag contained within, or absence of the device on radiological imaging, implies unimpeded intestinal transit.AimTo identify the rate of premature dissolution (MethodsOutcomes of all consecutive patients having an Agile patency device were analysed.ResultsPremature dissolution of the patency device occurred in 5 of 307 patients, an incidence of 1.3%. This was recognised by the detection of a persistent radiofrequency signal after radiological imaging had failed to identify the patency device, prompting a careful search for the radiofrequency tag on the CT scout film. The tag was difficult to detect because of an oblique lie making it appear smaller than its 13×3 mm size and confusion with intra-abdominal or other metallic fragments.ConclusionsIn the absence of radiological evidence of an intact Agile patency device, premature dissolution should be suspected in patients registering a persistent radiofrequency signal and confirmed by identifying the radiofrequency identification tag. Failure to do so might result in false reassurance that capsule endoscopy could be performed without risk of retention.

Background and aimAlthough recommended, the P-score used for assessing the pertinence / relevance of findings seen in small bowel (SB) capsule endoscopy (CE) is based on a low level of knowledge. The aim of this study was to evaluate the clinical relevance of the most frequent SBCE findings through an illustrated script questionnaire.Materials and MethodsSixteen types of SBCE findings were illustrated four times each in three different settings (occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease), and with a variable number (n = 1/n = 2–5/n ≥ 6), thus providing a questionnaire with 192 scenarios and 576 illustrated questions. Fifteen international experts were asked to rate the finding's relevance for each question as very unlikely (−2) / unlikely (−1) / doubtful (0) / likely (+1) / very likely (+2). The median score (≤−0.75, between -0.75 and 0.75, or ≥0.75) obtained for each scenario determined a low (P0), intermediate (P1) or high (P2) relevance, respectively.Results8064 answers were analyzed. Participation and completion rates were 93% and 100%, respectively. In overt or occult OGIB, resultant P2 findings were 'typical angiectasia', 'deep ulceration', 'stenosis', and'blood', whatever their numbers, and 'superficial ulcerations' when multiple. While in suspected CD, consensus P2 lesions were 'deep ulceration' and 'stenosis' whatever their numbers, and 'aphthoid erosions' and 'superficial ulcerations' when multiple.ConclusionThis study establishes a guide for the evaluation of relevance of SBCE findings. It represents a step forward for SB-CE interpretation and is intended to be used as a tool for teaching and academic research.