Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit

Background and study aims: Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients. Patients and methods: We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016. Results: This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration. Conclusions: This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill

A Reconsideration of the Diagnosis and Management of Gastrointestinal Bleeding Based on its Epidemiology and Outcomes Analysis

Background: Traditionally, gastrointestinal bleeding (GIB) has been divided into upper and lower GIB with little consideration of the small bowel as a source. Furthermore, melena is generally included in the upper category, despite its poor localization value. We analyzed 341 consecutive GIB patients to see if those presenting with melena/hematocheiza have less efficient evaluations then when compared to those presenting with hematemesis. Methods: A retrospective analysis was performed for 341 consecutive patients admitted to our ED with GIB over a year. Cohorts were separated based on presenting symptom to the ED, hematemesis (G1) and non-hematemesis (G2). Data obtained included demographics, diagnosis, number and type of procedure, diagnostic yield of each procedure, hours to diagnosis, ICU days, and total hospital days. Results: G1 (n=105, 62%M) was younger than G2 (n=231, 53%M) with a mean age of 54 vs. 66, p≤0.001. 78% and 98% of patients were admitted to the hospital in G1 and G2 respectively (p=0.02). Median time to diagnosis was 14.0 hours and 20.0 hours for G1 and G2 respectively (p≤0.001). Median number of days in the ICU was 3.0 in both groups, and median number of hospital days was 3.0 for G1 vs. 4.0 for G2 (p=0.267). In G1, the 1st procedure was diagnostic 69% of the time vs 54% for G2 (p=0.07). The overall diagnostic yield for EGDs in G1 was 58% vs. 51% in G2 (p=0.279). Colonoscopies overall were diagnostic 39% of the time in G2 and, interestingly, VCEs were the most diagnostic, yielding a diagnosis 74% of the time in G2 (n= 34). Unexpectedly, those admitted in G1 had a confirmed diagnosis only 61% of the time compared to 62% in G2. Conclusion: Our data suggests that a portion of patients presenting with non-hematemesis (G2) are inefficiently managed and a search for an alternative strategy is warranted. Early deployment of VCE may be a more efficient and economic option, although prospective evaluation of this concept is needed

A Year of Gastrointestinal Bleeding: An Epidemiologic Study

Background: For decades the diagnosis and management of gastrointestinal bleeding (GIB) has been based largely on endoscopy. Studying a large cohort of patients presenting to the ED we may find cost-effective alternatives in the management of GIB. We analyzed the epidemiology and initial disposition of all patients who presented to our ED from the perspective of hematemesis versus non-hematemesis, to identify patterns among each cohort’s presentations to aid in this. Methods: Retrospective analysis of medical records for 338 patients presenting to the UMass ED. Two cohorts were identified: those with hematemesis (G1) or non-hematemesis (G2). Results: 105 patients presented to the ED with hematemesis (G1), 233 patients presented with non-hematemesis GIB (G2). G1 was younger than G2 (54.4 years vs. 65.6 years, p\u3c0.001). There were more males in G1 vs. G2 (61% vs. 53%, p=0.154). Comorbities in G1 were liver disease (21%), alcohol abuse (20%), and diabetes (11%). Comorbities in G2 were coronary artery disease (22%), atrial fibrillation (13.7%), and diverticulosis (8%). More patients in G2 than G1 used Coumadin (23% vs. 7%, p\u3c0.001), anti-platelet agents (12% and 3%, p\u3c0.004), and NSAIDs (40% and 32%y, p=0.203). Admission hematocrit was greater in G1 compared to G2 (34.1 vs. 30.0, p\u3c0.001). INR was greater in G2 compared to G1 (1.7 vs. 1.3, p=0.03). BUN was greater in G2 compared to G1 (30.2 vs. 23.6, p=0.021). More patients in G2 were admitted compared to G1 (89.6% vs. 78.1%, p=0.019). More were admitted to the ICU in G1 compared to G2 (46% vs. 38%, p=0.237).Discussion: This study uses a novel approach that elicits different patterns than the traditional delineation of upper versus lower GIB. These results may lead to new decision-making in patients presenting with GIB, allowing for new diagnostic and management paradigms, resulting in cost-effective care

Settings of a novel electrosurgical generator to enable efficient and safe submucosal endoscopic procedures

Introduction: A novel electrosurgical generator unit (ESU), ConMed Beamer, was recently introduced to facilitate endoscopic submucosal dissection (ESD) by employing Automatic Cutting Effect (ACE) technology. Its use in submucosal endoscopy has yet to be investigated. Background and study aims: The aim of this study was to evaluate the feasibility and safety of performing ESD and per-oral endoscopic myotomy (POEM) using novel settings generated with ConMed Beamer ESU. Patients and methods: Single-center prospective study of 59 consecutive patients undergoing ESD/POEM at a tertiary referral center. ESU settings were initially generated by testing in live animal models prior to first in-human study. The primary outcome was technical success. Secondary outcomes were procedure times, rate of en bloc/R0 resection, rate of adverse events. Results: 44 (50 polyps) and 15 patients underwent ESD and POEM, respectively. En bloc resection, R0 resection, and curative resection rates were 90%, 77.1%, and 70.8%, respectively. Mean maximal length of the lesion was 3.07 cm +/- 1.43 with an average dissection speed of 14.2 cm2/hour +/- 11.1. Technical success was achieved in 100% of POEM patients. Mean time (minutes) to complete the POEM procedure was 50.1 min +/- 12.4. Two major adverse events occurred amongst all patients (3.4%). All intraprocedural bleeding events were controlled using the ConMed Beamer ESU. Conclusion: ConMed Beamer ESU settings generated from this study were proven safe and effective in a prospective cohort of patients who underwent submucosal endoscopic procedures. This novel ESU can be added to the armamentarium of ESD capable generators

A randomized controlled trial comparing efficacy of early video capsule endoscopy with standard of care in the approach to non-hematemesis gastrointestinal bleeding (with videos)

OBJECTIVE: Patients presenting with non-hematemesis GI bleeding represent a diagnostic challenge for physicians. We performed a randomized controlled trial to assess the benefits of deployment of a video capsule soon after admission in the management of patients presenting with melena, hematochezia, or severe anemia compared with standard of care management. DESIGN: Patients admitted with non-hematemesis GI bleeding were randomized and placed into one of 2 study groups. In the experimental group patients ingested a video capsule soon after admission to the hospital. These capsule patients had further endoscopic workup based on the findings from the capsule. Patients in the control group underwent endoscopic evaluation (ie, upper endoscopy, capsule endoscopy, and/or colonoscopy) to identify the source of bleeding as directed by the attending gastroenterologist\u27s interpretation of their clinical presentation. The primary endpoint for this study was the rate of localization of bleeding during hospitalization. RESULTS: Eighty-seven patients were included in this study, 45 were randomized to the Standard of Care arm and 42 were randomized to the Early Capsule arm. A bleeding source was localized in 64.3% of the patients in the Early Capsule arm and in 31.1% of the patients in the Standard of Care arm (p \u3c 0.01). The likelihood of endoscopic localization of bleeding over time was greater for patients receiving early capsule endoscopy compared with those in the standard of care arm (adjusted hazard ratio, 2.77; 95% confidence interval, 1.36 - 5.64). CONCLUSION: For patients admitted to the hospital for non-hematemesis GI bleeding, early capsule endoscopy is a safe and effective alternative for the detection of the source of bleeding