Risk stratification with video capsule endoscopy leads to fewer hospital admissions in emergency department patients with low-risk to moderate-risk upper gastrointestinal bleed: A multicenter clinical trial.

OBJECTIVE: In US emergency departments (EDs), the physician has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Although many bleeding lesions are self-limited, the majority of these patients require emergency hospitalization for upper endoscopy (EGD). We conducted a clinical trial to determine if ED risk stratification with video capsule endoscopy (VCE) reduces hospitalization rates for low-risk to moderate-risk patients with suspected upper GI bleeding. METHODS: We conducted a randomized controlled trial at 3 urban academic EDs. Inclusion criteria included signs of upper GI bleeding and a Glasgow Blatchford score <6. Patients were randomly assigned to 1 of the following 2 treatment arms: (1) an experimental arm that included VCE risk stratification and brief ED observation versus (2) a standard care arm that included admission for inpatient EGD. The primary outcome was hospital admission. Patients were followed for 7 and 30 days to assess for rebleeding events and revisits to the hospital. RESULTS: The trial was terminated early as a result of low accrual. The trial was also terminated early because of a need to repurpose all staff to respond to the coronavirus disease 2019 pandemic. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital, and in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (P = 0.012). There was no difference in safety on day 7 and day 30 after the index ED visit. CONCLUSIONS: VCE is a potential strategy to decrease admissions for upper GI bleeding, though further study with a larger cohort is required before this approach can be recommended.

Improving Access to Self-Expanding Metal Stents for Patients With Esophageal Cancer in Eastern Africa: A Stepwise Implementation Strategy.

PURPOSE: The eastern corridor of Africa is affected by a high burden of esophageal cancer (EC), with > 90% of patients presenting with advanced disease. Self-expanding metal stents (SEMS) have been previously reported as safe and effective for palliation of malignant dysphagia in resource-limited settings; however, access is limited throughout Eastern Africa. METHODS: In response to demand for palliative interventions for patients with dysphagia because of EC, the African Esophageal Cancer Consortium (AfrECC) partnered with the Clinton Health Access Initiative to improve access to SEMS in Eastern Africa. We undertook a stepwise implementation approach to (1) identify barriers to SEMS access, (2) conduct a market analysis, (3) select an industry partner, (4) establish regulatory and procurement processes, (5) develop endoscopic training resources, (6) create a medical device registry, and (7) establish principles of accountability. RESULTS: Following an evaluation of market demand and potential SEMS manufacturers, Boston Scientific Corporation announced its commitment to launch an access program to provide esophageal SEMS to patients in Tanzania, Kenya, Malawi, and Zambia at a subsidized price. Parallel regulatory and procurement processes were established in each participating country. Endoscopy training courses were designed and conducted, using the Training-of-Trainers model. A device registry was created to centralize data for quality control and to monitor channels of SEMS distribution. Principles of accountability were developed to guide the sustainability of this endeavor. CONCLUSION: The AfrECC Stent Access Initiative is an example of a multisector partnership formed to provide an innovative solution to align regional needs with a supply chain for a high-priority medical device.

Outcomes of radiofrequency ablation by manual versus self-sizing circumferential balloon catheters for the treatment of dysplastic Barrett's esophagus: a multicenter comparative cohort study.

BACKGROUND AND AIMS: Radiofrequency ablation (RFA) is the preferred ablative modality for treating dysplastic Barrett's esophagus. The recently introduced self-sizing circumferential ablation catheter eliminates the need for a sizing balloon. Although it enhances efficiency, outcomes have not been compared with the previous manual-sizing catheter. We evaluated the comparative safety and efficacy of these 2 ablation systems in a large, multicenter cohort. METHODS: Patients undergoing RFA at 3 tertiary care centers from 2005 to 2018 were included. Circumferential RFA was performed in a standard fashion, followed by focal RFA as needed. Outcomes were compared between the self-sizing and manual-sizing groups. The primary outcome was the rate of adverse events, including strictures, perforation, and bleeding. Secondary outcomes were procedure time and treatment efficacy, as assessed by rates and time to complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM). RESULTS: Three hundred eighteen patients were included, 90 (28.3%) treated with the self-sizing catheter and 228 (71.7%) with the manual-sizing catheter. Twenty-one patients (6.6%) developed strictures (8 [8.9%] in the self-sizing group and 13 [5.7%] in the manual-sizing group, P = .32). Of the self-sizing strictures, 75% occurred at the 12J dose before widespread adoption of the current 10J treatment standard. One patient developed bleeding, and no perforations were encountered. Procedure time was significantly shorter in the self-sizing group. No significant differences were observed in rates of and time to CE-D and CE-IM. CONCLUSIONS: These findings suggest that both systems are comparable in safety and efficacy. The use of the self-sizing system may enhance the efficiency of RFA for treating dysplastic Barrett's esophagus.

Durability of radiofrequency ablation for treatment of esophageal squamous cell neoplasia: 5-year follow-up of a treated cohort in China.

BACKGROUND AND AIMS: Radiofrequency ablation (RFA) is an accepted treatment for flat Barrett's neoplasia. Less is known about RFA for esophageal squamous cell neoplasia (ESCN). Our group has reported several prospective studies of RFA for ESCN in China with promising results through 12 months of follow-up. In this cohort study we aimed to evaluate longer term outcomes after RFA for ESCN. METHODS: Patients with flat unstained lesions (USLs) on Lugol's endoscopy containing moderate-/high-grade intraepithelial neoplasia (MGIN/HGIN) or mucosal cancer were treated with RFA every 3 months until complete remission (CR; no MGIN or a worse histologic grade). Patients with CR at 12 months (CR12) were included for follow-up and underwent annual Lugol's endoscopy with biopsy sampling and re-RFA for flat USLs. The clinical course of patients with persistent ESCN at 12 months (treatment failures) is also reported. RESULTS: Among the 78 patients in CR12, 67 (86%) had sustained CR during a median of 48 months (interquartile range, 48-48) of follow-up and 5 endoscopies (interquartile range, 4-6). Recurrence occurred in 7 of 78 patients (9%; MGIN, n = 6; HGIN, n = 1); all lesions were managed with RFA. Four other patients (5%) had progression (to HGIN, n = 1; submucosal esophageal squamous cell carcinoma, n = 3). During follow-up protocol violations occurred in 46 of 78 patients (59%). Of the 12 treatment failures, progression occurred in 6. Overall, 2 patients developed subepithelial disease that was not visible after Lugol's endoscopy. Based on post-hoc analysis, the pink-color sign at baseline (a pink color change after Lugol's endoscopy) significantly predicted failure after RFA. CONCLUSIONS: RFA is relatively easy to apply and can efficiently treat large areas with ESCN. Despite protocol violations that may have interfered with the efficacy of RFA in 59% of patients, most patients with CR12 had sustained CR during follow-up. However, some patients progressed to advanced disease and 2 developed subepithelial disease, not visible after Lugol's endoscopy. Based on currently available data, we advise the restriction of the use of RFA for flat MGIN and HGIN without the pink-color sign on Lugol's chromoendoscopy. (Clinical trial registration number: NCT02047305.).

Intestinal metaplasia of the gastric cardia: findings in patients with versus without Barrett's esophagus.

BACKGROUND AND AIMS: There is controversy about finding intestinal metaplasia (IM) of the gastric cardia on biopsy. The most recent American College of Gastroenterology guideline comments that IM cardia is not more common in patients with Barrett's esophagus (BE). It provides limited guidance on whether the cardia should be treated when patients with BE undergo endoscopic eradication therapy (EET) and whether the cardia should undergo biopsy after ablation. The aims of our study were to determine the frequency in the proximal stomach of (1) histologic gastric cardia mucosa and (2) IM cardia. A third aim was to explore the frequency of advanced pathology (dysplasia and adenocarcinoma) in the cardia after patients with BE have undergone EET. METHODS: Consecutive patients undergoing esophagogastroduodenoscopy between January 2008 and December 2014 who had proximal stomach biopsies were included. Patients who had histologically confirmed BE were compared with those without BE. RESULTS: Four hundred sixty-two patients, 289 with BE and 173 without BE, were included. Histologically confirmed cardiac mucosa was found in 81.6% of all patients. This was more frequent in those with versus without BE (86% vs 75%; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.28-3.32; P = .003). IM cardia was more common in the BE group (17% vs 7%; OR, 2.67; 95% CI, 1.38-5.19; P = .004). Advanced pathology was more likely in the patients with BE who had undergone EET. CONCLUSIONS: Cardiac mucosa is present in most patients who undergo endoscopy for upper GI symptoms. IM cardia is more common in patients with BE than those without. Advanced histologic changes in the cardia were seen only in the subgroup of patients with BE who had undergone EET.

The African Esophageal Cancer Consortium: A Call to Action.

Esophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of cancer-related death; however, worldwide incidence and mortality rates do not reflect the geographic variations in the occurrence of this disease. In recent years, increased attention has been focused on the high incidence of esophageal squamous cell carcinoma (ESCC) throughout the eastern corridor of Africa, extending from Ethiopia to South Africa. Nascent investigations are underway at a number of sites throughout the region in an effort to improve our understanding of the etiology behind the high incidence of ESCC in this region. In 2017, these sites established the African Esophageal Cancer Consortium. Here, we summarize the priorities of this newly established consortium: to implement coordinated multisite investigations into etiology and identify targets for primary prevention; to address the impact of the clinical burden of ESCC via capacity building and shared resources in treatment and palliative care; and to heighten awareness of ESCC among physicians, at-risk populations, policy makers, and funding agencies.

Predictors of Progression in Barrett's Esophagus with Low-Grade Dysplasia: Results from a Multicenter Prospective BE Registry.

OBJECTIVES: Low-grade dysplasia (LGD) is a risk factor for progression in Barrett's esophagus (BE). Progression estimates however vary and predictors of progression are not well established. We aimed to assess predictors of progression in a multicenter BE-LGD cohort. METHODS: All subjects with LGD (diagnosed by a GI pathologist) in a prospective BE registry were identified. Progression was defined development of HGD/EAC more than 12 months after index date of LGD diagnosis. Clinical, endoscopic factors and impact of histologic review by an independent panel of two GI pathologists were assessed as predictors of progression. Cox proportional hazard models were used to assess their association with risk of progression. RESULTS: 244 BE-LGD subjects met inclusion criteria. Their mean age was 63.2 years. 205 (84%) were males. The median follow up was 4.8 years. Fifty six patients were diagnosed with HGD/EAC in less than 12 months, while 14 progressed to HGD/EAC after 12 months, with an overall annual risk of progression of 1.2%. 29% of LGD subjects were downgraded to non-dysplastic and the remaining re-confirmed as LGD or indefinite dysplasia. The risk of progression in the reconfirmed LGD group was eight fold higher (hazards ratio: 7.6, 95% CI: 1.5-139.4) in a propensity score stratified model. CONCLUSIONS: In this large BE-LGD cohort, progression risk increased substantially when an additional panel of two expert GI pathologists re-confirmed a LGD diagnosis. These BE subjects may be candidates for endoscopic therapy. LGD was a marker of prevalent HGD/EAC in 18% of patients.

A randomized trial comparing multiband mucosectomy and cap-assisted endoscopic resection for endoscopic piecemeal resection of early squamous neoplasia of the esophagus.

BACKGROUND AND AIM: Piecemeal endoscopic resection for esophageal high grade intraepithelial neoplasia (HGIN) or early squamous cell carcinoma (ESCC) is usually performed by cap-assisted endoscopic resection. This requires submucosal lifting and multiple snares. Multiband mucosectomy (MBM) uses a modified variceal band ligator without submucosal lifting. In high-risk areas where ESCC is common and endoscopic expertise is limited, MBM may be a better technique. We aimed to compare MBM to the cap-assisted technique for piecemeal endoscopic resection of esophageal ESCCs. METHODS: Patients with mucosal HGIN/ESCC (2 - 6 cm, maximum two-thirds of esophageal circumference) were included. Lesions, delineated by 1.25 % Lugol staining, were randomized to MBM or cap-assisted piecemeal resection. Endpoints were procedure time and costs, complete endoscopic resection, adverse events, and absence of HGIN/ESCC at 3-month and 12-month follow-up.  RESULTS: Endoscopic resection was performed in 84 patients (59 men, mean age 60) using MBM (n = 42) or the endoscopic resection cap (n = 42). There were no differences in baseline characteristics. Endoscopic complete resection was achieved in all lesions. Procedure time was significantly shorter with MBM (11 vs. 22 minutes, P < 0.0001). One perforation, seen after using the endoscopic resection cap, was treated conservatively. Total costs of disposables were lower for MBM (€200 vs. €251, P = 0.04). At 3-month and 12-month follow-ups none of the patients had HGIN/ESCC at the resection site. CONCLUSION: Piecemeal endoscopic resection of esophageal ESCC with MBM is faster and cheaper than with the endoscopic resection cap. Both techniques are highly effective and safe. MBM may have significant advantages over the endoscopic resection cap technique, especially in countries where ESCC is extremely common but limited endoscopic expertise and resources exist. (Netherlands trial register: NTR 3246.).

Kinematic analysis of wrist motion during simulated colonoscopy in first-year gastroenterology fellows.

BACKGROUND AND STUDY AIMS: Gastroenterology trainees acquire skill and proficiency in performing colonoscopies at different rates. The cause for heterogeneous competency among the trainees is unclear. Kinematic analysis of the wrist joint while performing colonoscopy can objectively assess the variation in wrist motion. Our objective was to test the hypothesis that the time spent by the trainees in extreme ranges of wrist motion will decrease as the trainees advance through the fellowship year. SUBJECTS AND METHODS: Five first-year gastroenterology fellows were prospectively studied at four intervals while performing simulated colonoscopies. The setting was an endoscopy simulation laboratory at a tertiary care center. Kinematic assessment of wrist motion was done using a magnetic position/orientation tracker held in place by a custom-made arm sleeve and hand glove. The main outcome measure was time spent performing each of four ranges of wrist motion (mid, center, extreme, and out) for each wrist degree of freedom (pronation/supination, flexion/extension, and adduction/abduction). RESULTS: There were no statistically significant differences in the time spent for wrist movements across the three degrees of freedom throughout the study period. However, fellows spent significantly less time in extreme range (1.47 ±â€Š0.34 min vs. 2.44 ±â€Š0.34 min, P = 0.004) and center range (1.02 ±â€Š0.34 min vs 1.9 ±â€Š0.34 min, P = 0.01) at the end of the study compared to the baseline evaluation. The study was limited by the small number of subjects and performance of colonoscopies on a simulator rather than live patients. CONCLUSIONS: Gastroenterology trainees alter the time spent at the extreme range of wrist motion as they advance through training. Endoscopy training during the first 10 months of fellowship may have beneficial effects on learning ergonomically correct motion patterns.

[Preliminary study on efficacy of radiofrequency ablation combined with endoscopic resection for eradicating widespread early non-flat type esophageal squamous cell carcinoma].

OBJECTIVE: To evaluate the efficacy of radiofrequency ablation(RFA) combined with endoscopic resection(ER) for eradicating widespread early non-flat type esophageal squamous cell carcinoma (ESCC) and precancerous lesions. METHODS: Retrospective analysis was performed on the clinical data of 4 patients with early non-flat type ESCC and precancerous lesions in January 2010 at the Cancer Institute and Hospital, Chinese Academy of Medical Sciences. Proportion of patients with histological complete response (CR) 3 months, 12 months to 5 years after operation and adverse events were observed. RESULTS: These 4 patients were all male, aged from 47 to 71 (mean age 62) years, including 2 of ESCC, 1 of HGIN, 1 of MGIN confirmed by pathology. USL length was 6-12 (mean 8.5) cm. Treatment area (TA) length was 8-14 (mean 10.5) cm. Three cases were 0-II a (mean length 2 cm), and 1 case 0-II c (mean length 4 cm). Lesions of 2 cases were complete cycle, and other 2 cases occupied 3/4 circumference. Four patients completed their operations successfully. Total operation time was 42-105 (mean 66.8) min, RFA time was 3-12 (mean 8.25) min, and ER time was 6-20 (10.25) min, without bleeding and perforation. The mean hospital stay was 3 days. Pathology examination showed that 2 cases were ESCC G2 (lesion length 12, 8 cm; non-flat type lesion length 3, 4 cm), 1 was HGIN (lesion length 12 cm; non-flat type lesion length 1 cm) and 1 was MGIN (lesion length 6 cm; non-flat type lesion length 2 cm). Three cases were CR 3 months, 1 to 5 years after operation. One case had HGIN at 3-month and MGIN at 1-year and 3-year during follow up, and was CR after treatment with HALO. Postoperative esophageal stenosis occurred in 4 cases. Among them, 2 cases were mild without treatment, and 2 were severe, who were relieved by endoscopic water sac dilation for 5-8 (mean 6.5) times. CONCLUSION: RFA combined with ER is effective and safe in the treatment of patients with early non-flat esophageal squamous cell carcinoma and precancerous lesions.

Presentation, Diagnosis, and Management of Esophageal Lichen Planus: A Series of Six Cases.

Lichen planus (LP) is an idiopathic disorder that presents with cutaneous and genital manifestations. Esophageal LP (ELP) was first described by Al-Shihabi and Jackson [J Laryngol Otol 1982;96:567-571] in 1982. Only approximately 80 cases have been documented in the literature since. It is a rare and underrecognized disorder, leading to a delay in diagnosis and a lack of standardized management. We describe the presentation, diagnosis, and management of 6 cases of ELP, at a tertiary institution, because we believe that an increasing awareness of this condition can help identify more cases and increase our understanding of this interesting condition.

Is it justified to ablate flat-type esophageal squamous cancer? An analysis of endoscopic submucosal dissection specimens of lesions meeting the selection criteria of radiofrequency studies.

BACKGROUND: Endoscopic radiofrequency ablation (RFA) appears to be a safe and effective treatment for flat-type noninvasive squamous neoplasia of the esophagus. However, if RFA is applied to lesions containing invasive cancer (esophageal squamous cell carcinoma [ESCC]), histological features associated with lymph node metastases may remain undetected. In addition, extension of neoplasia down the ducts of esophageal submucosal glands (SMGs) may create a sheltered "niche" beyond the reach of ablation. OBJECTIVE: To determine the RFA eligibility of flat-type ESCC. DESIGN: Retrospective analysis of prospectively collected data of ESCC patients. SETTING: National Cancer Center Hospital, Tokyo, Japan. PATIENTS: Patients with flat-type ESCC larger than 3 cm removed by endoscopic submucosal dissection (ESD). INTERVENTIONS: Three endoscopists involved in RFA studies in China reviewed endoscopic images to select lesions eligible for RFA. Corresponding ESD resection specimens were histologically examined. MAIN OUTCOME MEASUREMENTS: The presence of poor histological features (ie, invasion in m3 or deeper, poor tumor differentiation, or lymphovascular invasion) and the number of involved esophageal SMGs and ducts. RESULTS: Sixty-five lesions were included, 17 (26%) of which qualified as RFA eligible by RFA endoscopists. Interobserver agreement for this assessment was poor (κ = 0.09). Six of the 17 specimens (35%) showed relevant disease: 4 lesions invaded in the muscularis mucosae, 1 of which also showed lymphovascular invasion; 2 lesions showed extension of neoplasia into SMGs. LIMITATIONS: Limited number of cases. RFA eligibility status was based on analysis of still images. CONCLUSIONS: One third of flat-type ESCC, deemed eligible for RFA, demonstrated histological features that are considered (relative) contraindications to endoscopic treatment. Because it appears difficult for endoscopists to identify low-risk ESCC, conservative use of RFA for flat-type ESCC is advocated until long-term follow-up data are available.

Esophageal peristaltic defects in adults with functional dysphagia.

Functional dysphagia (FD) is characterized by the presence of dysphagia without evidence of mechanical esophageal obstruction, GERD, and histopathology-based esophageal motor disorders. Dysphagia is common in older patients; however, there is a paucity of information regarding the type and frequency of peristaltic abnormalities compared to younger patients. Based on recently validated criteria for classification of weak peristalsis using high-resolution manometry (HRM), we hypothesized that older patients with FD would have more peristaltic defects detected by HRM compared to younger FD patients. A retrospective review of our motility database yielded 65 patients that met inclusion criteria. Patients were divided into two groups based on age (younger: <70 years; older: ≥70 years). Patients were interviewed, completed a quality-of-life questionnaire, and underwent solid-state HRM. The two groups differed in age but in no other demographic characteristics, severity of dysphagia, or quality of life. Dyspeptic symptoms, including nausea (p < 0.001), early satiety (p = 0.01), bloating (p = 0.02), and belching (p = 0.01), were also more prevalent in younger FD patients. Older age was associated with weak peristalsis involving frequent failed peristalsis, small proximal peristaltic defects (2-5 cm), and large proximal peristaltic defects (>5 cm) (p < 0.001). The mean contraction amplitude was also lower in the older group (p < 0.05). These data support the hypothesis that older patients with FD have a higher frequency of peristaltic abnormalities on HRM compared to younger patients. Older age was associated with increased frequency of weak peristalsis with small and large peristaltic defects.

Self-dilation as a treatment for resistant, benign esophageal strictures.

GOALS AND BACKGROUND: Simple benign strictures may be relieved with one to three dilation sessions. Resistant benign strictures are anatomically complex and resistant to therapy. We sought to determine the efficacy and safety of esophageal self-dilation with bougie dilators in the largest series to date. STUDY: A retrospective chart review was performed to identify patients who underwent esophageal self-dilation at two tertiary referral centers (Mayo Clinic, Scottsdale, Arizona and Mayo Clinic Rochester, Minnesota) between January 1, 2003 and June 30, 2012. Demographic details and clinical information regarding relief of dysphagia, complications, and frequency of endoscopic and self-dilation were abstracted. RESULTS: Of the 32 patients who began self-dilation for nonmalignant strictures, 30 [22 men; median (range) age, 62 years (22-86 years)] were included in the study. Median (range) follow-up was 37 months (14-281 months). Stricture etiology included radiation therapy (n = 8), anastomotic stricture (n = 9), eosinophilic esophagitis (n = 4), caustic ingestion (n = 3), photodynamic therapy (n = 2), granulation tissue (n = 2), peptic stricture (n = 1) and one patient had radiation therapy and peptic stricture. The average number (range) of physician performed dilations before self-dilation was 12 (4-55). Esophageal self-dilation was successful in treating 90 % of patients. Dysphagia score (2 vs. 1; P < 0.001), stricture diameter (median; 5 vs. 12 mm; P < 0.001) and weight (median; 73 vs. 77 kg; P < 0.001) were significantly different between EDG dilation versus self-dilation. CONCLUSIONS: Esophageal self-dilation is a safe, effective treatment for resistant, benign esophageal strictures. This management strategy should be strongly considered in this patient population.

Emergency physicians accurately interpret video capsule endoscopy findings in suspected upper gastrointestinal hemorrhage: a video survey.

BACKGROUND: Acute upper gastrointestinal (GI) hemorrhage is a common emergency department (ED) presentation whose severity ranges from benign to life-threatening and the best tool to risk stratify the disease is an upper endoscopy, either by scope or by capsule, a procedure performed almost exclusively by gastroenterologists. Unfortunately, on-call gastroenterology specialists are often unavailable, and emergency physicians (EPs) currently lack an alternative method to endoscopically visualize a suspected acute upper GI hemorrhage. Recent reports have shown that video capsule endoscopy is well tolerated by ED patients and has similar sensitivity and specificity to endoscopy for upper GI hemorrhage. OBJECTIVES: The study objective was to determine if EPs can detect upper GI bleeding on capsule endoscopy after a brief training session. METHODS: A survey study was designed to demonstrate video examples of capsule endoscopy to EPs and determine if they could detect upper GI bleeding after a brief training session. All videos were generated from a prior ED-based study on patients with suspected acute upper GI hemorrhage. The training session consisted of less than 10 minutes of background information and capsule endoscopy video examples. EPs were recruited at the American College of Emergency Physicians Scientific Assembly in Denver, Colorado, from October 8, 2012, to October 10, 2012. Inclusion criteria included being an ED resident or attending physician and the exclusion criteria included any formal endoscopy training. The authors analyzed the agreement between the EPs and expert adjudicated capsule endoscopy readings for each capsule endoscopy video. For the outcome categories of blood (fresh or coffee grounds type) or no blood detected, the sensitivity and specificity were calculated. RESULTS: A total of 126 EPs were enrolled. Compared to expert gastroenterology-adjudicated interpretation, the sensitivity to detect blood was 0.94 (95% confidence interval [CI] = 0.91 to 0.96) and specificity was 0.87 (95% CI = 0.80 to 0.92). CONCLUSIONS: After brief training, EPs can accurately interpret video capsule endoscopy findings of presence of gross blood or no blood with high sensitivity and specificity.