Underwater Endoscopic Mucosal Resection Vs Conventional Endoscopic Mucosal Resection for Superficial Nonampullary Duodenal Epithelial Tumors in the Western Setting.

BACKGROUND & AIMS: Conventional endoscopic mucosal resection (C-EMR) is established as the primary treatment modality for superficial nonampullary duodenal epithelial tumors (SNADETs), but recently underwater endoscopic mucosal resection (U-EMR) has emerged as a potential alternative. The majority of previous studies focused on Asian populations and small lesions (≤20 mm). We aimed to compare the efficacy and outcomes of U-EMR vs C-EMR for SNADETs in a Western setting. METHODS: This was a retrospective multinational study from 10 European centers that performed both C-EMR and U-EMR between January 2013 and July 2023. The main outcomes were the technical success, procedure-related adverse events (AEs), and the residual/recurrent adenoma (RRA) rate, evaluated on a per-lesion basis. We assessed the association between the type of endoscopic mucosal resection and the occurrence of AEs or RRAs using mixed-effects logistic regression models (propensity scores). Sensitivity analyses were performed for lesions ≤20 mm or >20 mm. RESULTS: A total of 290 SNADETs submitted to endoscopic resection during the study period met the inclusion criteria and were analyzed (C-EMR: n = 201, 69.3%; U-EMR: n = 89, 30.7%). The overall technical success rate was 95.5% and comparable between groups. In logistic regression models, compared with U-EMR, C-EMR was associated with a significantly higher frequency of overall delayed AEs (odds ratio [OR], 4.95; 95% CI, 2.87-8.53), postprocedural bleeding (OR, 7.92; 95% CI, 3.95-15.89), and RRAs (OR, 3.66; 95% CI, 2.49-5.37). Sensitivity analyses confirmed these results when solely considering either small (≤20 mm) or large (>20 mm) lesions. CONCLUSIONS: Compared with C-EMR, U-EMR was associated with a lower rate of overall AEs and RRAs, regardless of lesion size. Our results confirm the possible role of U-EMR as an effective and safe technique in the management of SNADETs.

Endoscopic "purse-string" to close a rectal endoscopic submucosal dissection eschar with intentional muscular sectioning.

This case demonstrates the utility of the "purse string" to close large defects and shows that optical diagnosis may have pitfalls in evaluating the invasion of neoplastic lesions, particularly large ones.

Effective submucosal tunneling endoscopic resection (STER) of a giant esophageal leiomyoma.

We report the successful removal of a giant esophageal leiomyoma using submucosal tunneling endoscopic resection in a 37-year-old woman with significant dysphagia.

Are sarcopenia, frailty and malnutrition prognostic markers of liver disease decompensation in the ambulatory setting? - A prospective cohort study.

BACKGROUND: Sarcopenia, frailty and malnutrition are associated with adverse outcomes in liver cirrhosis. Studies assessing the prognostic value of these conditions in ambulatory patients with cirrhosis are scarce. METHODS: A prospective cohort study was conducted, with consecutive inclusion of all patients with cirrhosis observed in the Hepatology outpatient clinic of a Portuguese tertiary centre. At study enrolment, evaluation of muscle mass (ultrasound quadriceps femoris thickness), muscle strength (handgrip dynamometry) and nutritional status (Patient-Generated Subjective Global Assessment Short Form) was held. Follow-up ended upon the occurrence of a composite endpoint, comprising liver decompensation events and liver-related death, or last medical appointment/non-liver related death before the end of the study. The prognostic value of anthropometrical parameters and nutritional status in the composite endpoint was assessed using a multivariate Cox regression analysis, adjusted for several confounders. RESULTS: Ninety patients were enrolled (80% male), with a mean age of 63.5±10.5 years. The median follow-up was 30 (interquartile range 38) weeks, during which 12 patients reached the composite endpoint. These patients presented a lower mean handgrip strength [23.1±6.41 vs 30.3±10.4 Kg, p=0.04], compared to patients who did not reach the composite endpoint. On Cox regression multivariate analysis, however, no independent predictors of the composite endpoint were found, apart from previous decompensation episodes. CONCLUSION: In this study, muscle strength was lower in the group of patients with cirrhosis who presented a liver-related event. Handgrip strength might be a promising tool in the ambulatory setting to identify patients at risk of liver decompensation and liver-related death in the short term.

Does urgent balloon-assisted enteroscopy impact rebleeding and short-term mortality in overt obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: The diagnostic yield (DY) and therapeutic yield (TY) of balloon-assisted enteroscopy (BAE) in overt obscure gastrointestinal bleeding (OGIB) is higher in the first 72 h. This study aimed to evaluate if this higher DY and TY after urgent BAE impacted the rebleeding rate, time to rebleed and short-term mortality. METHODS: Retrospective cohort-study, which consecutively included all patients submitted to BAE for overt OGIB, between 2010 and 2019. Patients were distributed in 2 groups: (1) Urgent BAE; (2) Non-urgent BAE. Rebleeding was defined as an Hb drop >2 g/dL, need for transfusional support or presence of melena/hematochezia. RESULTS: Fifty-four patients were included, of which 17 (31.5%) were submitted to BAE in the first 72 h. DY and TY of urgent BAE (DY 88.2%; n = 15; TY 94.1%; n = 16) was higher compared to non-urgent BAE (DY 59.5%; n = 22; TY 45.9%; n = 17) (DY p = .03) (TY p = .001). The rebleeding rate at 1, 2, and 5 years was 32.0%, 34.0%and 37.0%, respectively. Rebleeding was lower after urgent BAE (17.6%; n = 3) compared to non-urgent BAE (45.9%; n = 17) (p = .04). Rebleeding tended to occurr earlier in non-urgent BAE, being at 6-months (32.5%) and 36 months (41.3%) (p = .05). OGIB related 30-day mortality was 5.4% (n = 2) for non-urgent BAE and 0% for urgent BAE (p = .5). CONCLUSION: Urgent BAE might be associated with higher DY and TY with lower rebleeding and trend toward higher rebleeding-free time.

Endoscopic and histologic activity assessment considering disease extent and prediction of treatment failure in ulcerative colitis.

BACKGROUND AND AIMS: DUBLIN score allows evaluation of disease activity and extent in ulcerative colitis (UC). This study aimed to evaluate DUBLIN score as a predictor of therapeutic failure as well as to associate endoscopic and histological activity scores to assess their joint performance. METHODS: Retrospective cohort study, with consecutive inclusion of patients undergoing total colonoscopy with serial biopsies between 2016 and 2019. DUBLIN score (0-9) was calculated as the product of Mayo endoscopic score (MSe 0-3) by disease extent (E1-E3). Histological activity was evaluated through Nancy score (0-4). Activity scores were correlated with biomarkers, treatment failure (therapeutic escalation, hospitalization and/or colectomy) and clinical remission at 6 months (Mayo partial score ≤ 1). RESULTS: One-hundred and seven patients were included. In 38.3% (n = 41) there was evidence of endoscopic activity (MSe ≥ 2) and in 50.5% (n = 54) histological activity (Nancy ≥ 2). MSe and DUBLIN scores showed good correlation (r = 0.943; p < .001) and both were significantly higher in patients with histological activity (p < .001). Therapeutic failure occurred in 25.2% (n = 27). MSe, DUBLIN, and Nancy scores were significantly associated with therapeutic failure (p < .001). The areas under the (AUC) ROC curve were 0.74 (MSe; p < .001), 0.78 (DUBLIN; p < .001) and 0.84 (Nancy; p < .001). Joint evaluation of endoscopic and histological activity by combining DUBLIN and Nancy scores was associated with therapeutic failure with a significantly higher AUC of 0.84 (p < .001) compared to the Dublin score alone (p = .003). CONCLUSION: Mayo and DUBLIN endoscopic scores correlated with each other and with histological activity. The joint evaluation of endoscopic and histological activity allowed to predict with greater accuracy treatment failure.

Prediction of adenoma recurrence after piecemeal endoscopic mucosal resection: interobserver agreement and utilization of the Sydney EMR recurrence tool.

Background and aims: Piecemeal endoscopic mucosal resection (pEMR) allows resection of larger non-invasive colorectal lesions. Adenoma recurrence is an important limitation and occurs in ≤20%. The present study aimed to validate the Sydney EMR recurrence tool (SERT) score as a predictor of both endoscopic and histologic recurrence and evaluate interobserver agreement in adenoma recurrence based on endoscopic scar assessment, among nonexperts in EMR.Methods: Retrospective cohort and cross-sectional study, in which all patients submitted to pEMR in a tertiary care center in Portugal, between 2012 and 2018 were included. SERT-score was calculated for all lesions and compared with the SMSA (size, morphology, site, access) score already validated as a predictor of adenoma recurrence. Image based offline analysis was performed to evaluate adenoma recurrence prediction and assess the interobserver agreement within a heterogeneous group of participants, mostly composed by nonexperts in EMR.Results: There was a moderate positive correlation between the SERT and SMSA scores (p <.001; r = 0.61). SERT-score was significantly associated with endoscopic recurrence (p =.005) and histologic recurrence (p = .015). Endoscopic prediction of recurrence had high coefficient of agreement (k-0.806; p < .001).Conclusion: Histologic recurrence after pEMR can be predicted by SERT score and optical diagnosis of recurrent adenoma has high interobserver agreement between nonexperts in EMR.

Choledocholithiasis in elderly patients with gallbladder in situ - is ERCP sufficient?

INTRODUCTION: Along with increased life expectancy, the proportion of elderly patients with choledocholithiasis will increase and with this, the need for endoscopic cholangiopancreatography (ERCP). Current recommendations suggest laparoscopic cholecystectomy in all patients with choledocholithiasis to prevent biliary events. However, adherence to these recommendations is low, especially in older patients. METHODS: Retrospective study that included non-cholecystectomized patients aged > =75 years who underwent ERCP for choledocholithiasis from 2013-2016 (n = 131). A new biliary event was defined as the need for a new ERCP, cholecystitis, cholangitis or gallstone pancreatitis. AIM: The aim of this study was to compare the outcomes of new biliary events and mortality in cholecystectomized vs non-cholecystectomized patients after ERCP. RESULTS: Cholecystectomy was performed in 22% of the patients (92% laparoscopic). The post-cholecystectomy complication rate was 13% and the mortality rate was 7%. During the follow-up period (669 ± 487 days) a new biliary event occurred in 20% of patients - 10% new ERCP, 9% cholecystitis, 9% cholangitis and 2% pancreatitis. Cholecystectomized patients had fewer events (7% vs 24%, p = .048) and longer time to event (p = .016). There was no statistically significant difference in all-cause mortality (14% vs 27%, p = .13), mortality related to lithiasis (0% vs 9%, p = .11) or time to mortality from all causes (p = .07) and related to biliary events (p = .07). CONCLUSIONS: In this group of elderly patients, cholecystectomy after ERCP prevented the occurrence of new biliary events but resulted in a non-statistically significant difference in mortality.

Predictive factors of an incomplete examination and inadequate small-bowel cleanliness during capsule endoscopy.

AIM: the aim of this study was to determine predictive factors for an incomplete capsule endoscopy and an inadequate small-bowel preparation in capsule endoscopy. METHODS: predictive factors for an incomplete capsule endoscopy were evaluated. Therefore, all patients with incomplete examinations performed between June 2009 and February 2016 were retrospectively included and compared with all patients with complete procedures performed between January 2014 and February 2016. Predictive factors of an inadequate small-bowel cleanliness were assessed. Therefore, the subset of patients that underwent capsule endoscopy between January 2014 and February 2016, including incomplete examinations, were evaluated. Small-bowel cleanliness was evaluated according to a quantitative index and a qualitative evaluation scale. Data with regard to patient and capsule endoscopy was analyzed. RESULTS: 31 incomplete and 122 complete capsule endoscopies were included in the analysis of predictive factors for an incomplete capsule endoscopy. The degree of dependency (OR = 4.67; p = 0.028), performance of a capsule endoscopy in hospitalized patients (OR = 4.04; p = 0.006) and prior abdominal surgery (OR = 3.45; p = 0.012) were independent predictive factors of an incomplete procedure. 130 patients were included in the analysis of predictive factors for an inadequate small-bowel cleanliness. The mean quantitative index value was 7.3 (s.d. ± 2.3); 41.6% and 58.5% of capsule endoscopies were classified as poor-fair and good/excellent respectively, according to the qualitative evaluation. Independent predictive factors for an inadequate preparation according to the quantitative index included male gender (Beta = -0.79; p = 0.028), small-bowel transit time (Beta = -0.007; p < 0.0001) and cardiac disease (Beta = -1.29; p = 0.001). Associated factors according to the qualitative evaluation included male gender (OR = 0.406; p = 0.027) and small-bowel transit time (SBTT) (OR = 0.993; p < 0.0001). CONCLUSION: inpatient status, higher degrees of dependency and abdominal surgery are predictive factors for an incomplete capsule endoscopy; male gender and higher small-bowel transit time are predictive factors for an inadequate cleanliness.

Fecal microbiota transplantation in refractory or recurrent Clostridium difficile infection: a real-life experience in a non-academic center.

AIM: this study aimed to describe the efficacy and safety of fecal microbiota transplantation (FMT) for the treatment of refractory and recurrent Clostridium difficile infection (CDI). METHODS: this was an observational study of patients with refractory or recurrent CDI treated with FMT between June 2014 and January 2017. Primary and secondary outcomes were the resolution of diarrhea without CDI recurrence within two months after one or more FMT. A descriptive analysis was performed. RESULTS: thirty-four FMT were performed in 28 patients, 88.2% (n = 30) using an upper route with a gastroscopy and 11.8% (n = 4) with colonoscopy; 50% (n = 17) of FMT were due to recurrent CDI and 50% (n = 17) were due to refractory CDI. The overall cure rate of upper FMT was 87.5% (21/24) and 100% (4/4) when colonoscopy was performed. A cure was achieved after one FMT in 88% (22/25) of cases and after two or more FMT in 8% (2/25) of cases, resulting in an overall cure rate of 96% (24/25). No severe adverse events were reported. CONCLUSION: FMT constitutes an effective and safe approach for the management of refractory and recurrent CDI, with an overall cure rate of 96% and no reported severe adverse events.

High short-term rebleeding rate in patients undergoing a second endoscopic therapy for small-bowel angioectasias after recurrent bleeding.

BACKGROUND: Angioectasias represents the most frequently found lesion in the small bowel by device-assisted enteroscopy for obscure gastrointestinal bleeding in Western countries. Recurrence of gastrointestinal bleeding after angioectasias therapy remains unclear and data regarding the efficacy of additional endoscopic therapeutic sessions to reduce the rebleeding rate is limited. AIM: To evaluate the rebleeding rate in small bowel angioectasias after a second endoscopic treatment with balloon-assisted enteroscopy after an initial bleed during the first endoscopic treatment. METHODS: A retrospective double-center study of patients with small-bowel angioectasias undergoing a second enteroscopy treatment due to a first rebleeding episode. The endpoint was rebleeding, defined as the need for a blood transfusion, the presence of overt bleeding or a decrease in hemoglobin ≥ 2 g/dL. RESULTS: Fifteen of 37 (40.5%) patients with small-bowel angioectasias that underwent a second endoscopic therapy after a first rebleeding episode (n = 15) experienced a second rebleeding episode. Kaplan-Meier curve analysis showed that most rebleeding episodes occurred within the first 12 months of follow-up, resulting in a rebleeding rate of 33.1% at 6 months, 39.1% at 12 months and 52.6% at 24 months. CONCLUSIONS: Despite the high absolute short-term rebleeding rate, further endoscopic treatments may be beneficial due to the effective reduction of rebleeding in a subset of patients.

Evaluation and comparison of capsule endoscopy scores for assessment of inflammatory activity of small-bowel in Crohn's disease.

INTRODUCTION: Capsule endoscopy (CE) has the highest sensitivity in the evaluation of small-bowel mucosa in Crohn's disease (CD). Recent guidelines recommend the use of validated CE scores to assess small-bowel inflammatory activity in CD. Lewis score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) are the currently available validated scores, but comparative studies are scarce. Moreover, correlation of these endoscopic scores with biomarkers and clinical activity is lacking. This study aims to compare LS with CECDAI, to determine cutoff values for CECDAI similar to those of LS (135-790), and to correlate LS and CECDAI with biomarkers and symptoms. STUDY: All patients with CD who underwent CE between March/2010 and February/2016 were included. LS and CECDAI were determined after analysis of each CE. In patients with small-bowel CD, C-reactive protein (CRP) and Harvey-Bradshaw index (HBI) were evaluated. STATISTICAL ANALYSIS: descriptive statistics, Spearman's correlation coefficient and linear regression analysis. SIGNIFICANCE: p<0.05. RESULTS: Fifty-three patients were included and the mean values obtained for LS were 1147±1453, CECDAI 11.3±6.9, CRP 0.92±1.5mg/dL and HBI 2.4±2.8. There was a very strong correlation between LS and CECDAI (rs=0.878; p<0.0001) and thresholds values of 135-790 in LS corresponded to 7.7-10.3 cutoff values in CECDAI, respectively. Neither CRP correlated with LS (rs=0.068; p=0.72) or CECDAI (rs=-0.004; p=0.98), nor HBI with LS (rs=-0.15; p=0.40) or CECDAI (rs=-0.10; p=0.23). CONCLUSION: Correlation between the two CE activity scores was very strong, with LS thresholds of 135-790 corresponding to CECDAI values of 7.7-10.3. HBI and CRP had no correlation with CECDAI and LS.

Validation of SPICE, a method to differentiate small bowel submucosal lesions from innocent bulges on capsule endoscopy.

BACKGROUND AND AIMS: Small bowel submucosal lesions (SBSL) and innocent bulges may have an identical appearance and be difficult to distinguish on small bowel capsule endoscopy (SBCE). Recently, Girelli et al. proposed a score, smooth, protruding lesion index on capsule endoscopy (SPICE), in order to differentiate between the two. We aimed to evaluate and validate SPICE as a differentiation method between innocent bulges and SBSLs. METHODS: We evaluated all SBCEs performed in our department between January 2005 and September 2015, and selected the ones with a smooth, round, protruding lesion in the small bowel. Lesions with suspicious characteristics were excluded. A video clip of the region of interest was created and SPICE was assigned blindly and independently by two endoscopists. We determined the discriminative ability of SPICE using the definitive diagnosis of each patient as the standard criteria. RESULTS: We included 30 SBCEs corresponding to 12 SBSLs (four gastrointestinal stromal tumors, two neuroendocrine tumors, four lipomas and two polypoid lymphangiectasias) and 18 innocent bulges. SPICE scores ranged from 0 to 4, allowing the distinction between SBSLs and innocent bulges (p < 0.001). SPICE > 2 had a 66.7% sensitivity, 100.0% specificity, 100.0% positive predictive value and 78.3% negative predictive value, and the area under the curve was 0.88 (95% CI, 0.73-1.00; p < 0.001) for the diagnosis of SBSL. CONCLUSIONS: Our data support SPICE, namely a score > 2, as a predictive method of SBSLs. Taking into account its simplicity, it may be very useful in the distinction between SBSLs and innocent bulges on SBCE.

The Baveno VI criteria for predicting esophageal varices: validation in real life practice.

BACKGROUND AND AIMS: According to the Baveno VI consensus, patients with liver stiffness < 20 kPa and a platelet count > 150,000 ul have very low risk of clinically significant varices and do not need a screening endoscopy. The aim of this study was to evaluate non-invasive methods as predictors of esophageal varices according to the Baveno VI recommendations, in real life clinical practice. METHODS: Retrospective evaluation of patients with chronic liver disease who underwent transient elastography between January 2013 and December 2015. RESULTS: One hundred and four patients were included in the study, the median age was 56.8 years and 69.2% were male. The etiology of liver disease was hepatitis C in 80% of patients (including 20% with HIV co-infection), alcohol in 12%, hepatitis B in 4% and other causes in 5%. Varices were present in 25% of patients. A liver stiffness < 20 kPa had a sensitivity of 92.3% and a specificity of 84.6%. When considering high risk varices (small with red wales or large varices), a liver stiffness < 20 kPa had 100% sensitivity. A platelet count > 150,000/l had a sensitivity of 84.6% and a specificity of 64.1%. Four patients with a platelet count (PLT) > 150,000/l had esophageal varices. When both criteria were applied to the patient cohort, according to the Baveno VI consensus, the sensitivity was 100% and the specificity, 61.5%. CONCLUSION: In this study, the Baveno VI criteria had 100% sensitivity but a relatively low specificity for the non-invasive diagnosis of esophageal varices. In clinical practice, all patients with varices are identified but many patients have a subsequent negative endoscopy.

A typical but seldom recognized foreign body in the esophagus of a laryngectomized patient.

A 57-year-old man with a past medical history of total laryngectomy for squamous cell carcinoma of the larynx was admitted to our institution 5 months after the procedure, for surgical resection of a local recurrence of the tumor. In the postoperative period, endoscopically guided placement of a nasogastric tube was scheduled, after previous failed attempts. Upper gastrointestinal endoscopy revealed an anastomotic dehiscence, 13 cm distal to the incisors, and a foreign body penetrating through the esophageal wall, 20cm distal to the incisors. We were unable to identify the foreign body with certainty but, after consulting with the assistant otorhinolaryngologist, we realized that it was a voice prosthesis.

Validation of the computed assessment of cleansing score with the Mirocam® system.

BACKGROUND AND AIMS: A computed assessment of cleansing (CAC) score was developed to objectively evaluate small-bowel cleansing in the PillCam® capsule endoscopy (CE) system and to overcome the subjectivity and complexity of previous scoring systems. Our study aimed to adapt the CAC score to the Mirocam® system, evaluate its reliability with the Mirocam® CE system and compare it with three validated subjective grading scales. PATIENTS AND METHODS: Thirty CE were prospectively and independently reviewed by two authors who classified the degree of small-bowel cleanliness according to a quantitative index, a qualitative evaluation and an overall adequacy assessment. The authors were blinded for the CAC score of each CE, which was calculated as ([mean intensity of the red channel]/[mean intensity of the green channel] - 1) x 10. The mean intensities of the red and green channels of the small-bowel segment of the "Map View" bar in the Miroview Client® were determined using the histogram option of two photo-editing software. RESULTS: There was a strong agreement between both CE readers for each of the three subjective scales used. The reproducibility of the CAC score was excellent and identical results were obtained with the two photo-editing software. Regarding the comparison between the CAC score and the subjective scales, there was a moderate-to-good agreement with the quantitative index, qualitative evaluation and overall adequacy assessment. CONCLUSIONS: CAC score represents an objective and feasible score in the assessment of small-bowel cleansing in the Mirocam® CE system, and could be used per se or as part of a more comprehensive score.

Ultrasound-assisted technique for challenging jejunostomy balloon-tube replacements.

The authors present a case of a 38-year-old man with a 4-hour history of accidental removal of a jejunostomy balloon-tube replacement (PEG-18-BRT-S, Cook Medical Inc., Bloomington, USA). The patient had undergone a direct percutaneous endoscopic jejunostomy (DPEJ) ten months ago, before chemoradiotherapy treatment for an esophageal squamous-cell carcinoma (uT3N2cM0). His past medical condition included alcoholic liver disease and distal gastrectomy from a life-threatening duodenal bleeding ulcer.

What is the long-term outcome of a negative capsule endoscopy in patients with obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: There are contradictory findings regarding long-term outcome in patients with obscure gastrointestinal bleeding and negative capsule endoscopy. Factors associated with rebleeding after a negative videocapsule are not entirely known. OBJECTIVE: The aim of this study was to compare the rebleeding rate between negative and positive capsule endoscopy patients and to identify predictive factors for rebleeding in patients with negative findings. MATERIAL AND METHODS: Consecutive patients with obscure gastrointestinal bleeding referred to a single center over a period of 5 years were identified. After exclusion of patients with a follow time < 6 months, 173 patients were included. Clinical information was retrospectively collected from medical records. Rebleeding was defined as evidence of melena/hematochezia, a drop in hemoglobin of ≥ 2 g/dL, or the need for transfusion 30 days after the index episode. RESULTS: The mean age was 61.7 years and 60% were female. The median follow up time was 27 months. Most patients were referred for occult gastrointestinal bleeding (67.1%) while 32.9% were referred for overt bleeding. More than 50% of the patients had negative capsule endoscopy. The rebleeding rate in negative capsule endoscopy is 16%, with a mean follow-up time of 25.8 months and is significantly lower than positive capsule endoscopy (16% vs. 30.2%, p = 0.02). Rebleeding after negative capsule endoscopy is higher in patients who need more transfusions of packet red blood cells before capsule endoscopy (3.0 vs. 0.9, p = 0.024) and have overt bleeding (46% vs. 13.9%, p = 0.03). In 53% of these patients, rebleeding occurs > 12 months after a negative capsule endoscopy. CONCLUSIONS: Patients with obscure gastrointestinal bleeding and a negative capsule endoscopy had a significantly lower rebleeding rate and can be safely followed. However, a higher transfusion of red blood cells previous to capsule endoscopy and an overt bleeding are associated with a higher rebleeding. So, it is reasonable to consider that these patients may benefit of at least one year of follow-up.

What is the long term safety of a negative capsule endoscopy in patients with obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: There are contradictory findings regarding long-term outcome in patients with obscure gastrointestinal bleeding and negative capsule endoscopy. Factors associated with rebleeding after a negative videocapsule are not entirely known. OBJECTIVE: The aim of this study was to compare the rebleeding rate between negative and positive capsule endoscopy patients and to identify predictive factors for rebleeding in patients with negative findings. MATERIAL AND METHODS: Consecutive patients with obscure gastrointestinal bleeding referred to a single center over a period of 5 years were identified. After exclusion of patients with a follow time < 6 months, 173 patients were included. Clinical information was retrospectively collected from medical records. Rebleeding was defined as evidence of melena/hematochezia, a drop in hemoglobin of ≥ 2 g/dL, or the need for transfusion 30 days after the index episode. RESULTS: The mean age was 61.7 years and 60% were female. The median follow up time was 27 months. Most patients were referred for occult gastrointestinal bleeding (67.1%) while 32.9% were referred for overt bleeding. More than 50% of the patients had negative capsule endoscopy. The rebleeding rate in negative capsule endoscopy is 16%, with a mean follow-up time of 25.8 months and is significantly lower than positive capsule endoscopy (16% vs. 30.2%, p = 0.02). Rebleeding after negative capsule endoscopy is higher in patients who need more transfusions of packet red blood cells before capsule endoscopy (3.0 vs. 0.9, p = 0.024) and have overt bleeding (46% vs. 13.9%, p = 0.03). In 53% of these patients, rebleeding occurs > 12 months after a negative capsule endoscopy. CONCLUSIONS: Patients with obscure gastrointestinal bleeding and a negative capsule endoscopy had a significantly lower rebleeding rate and can be safely followed. However, a higher transfusion of red blood cells previous to capsule endoscopy and an overt bleeding are associated with a higher rebleeding. So, it is reasonable to consider that these patients may benefit of at least one year of follow-up.