Capsule Endoscopy in the Assessment of Obscure Gastrointestinal Bleeding: An Evidence-Based Analysis.

BACKGROUND: Obscure gastrointestinal bleeding (OGIB) is defined as persistent or recurrent bleeding associated with negative findings on upper and lower gastrointestinal (GI) endoscopic evaluations. The diagnosis and management of patients with OGIB is particularly challenging because of the length and complex loops of the small intestine. Capsule endoscopy (CE) is 1 diagnostic modality that is used to determine the etiology of bleeding. OBJECTIVES: The objective of this analysis was to review the diagnostic accuracy, safety, and impact on health outcomes of CE in patients with OGIB in comparison with other diagnostic modalities. DATA SOURCES: A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published between 2007 and 2013. REVIEW METHODS: Data on diagnostic accuracy, safety, and impact on health outcomes were abstracted from included studies. Quality of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS: The search yielded 1,189 citations, and 24 studies were included. Eight studies reported diagnostic accuracy comparing CE with other diagnostic modalities. Capsule endoscopy has a higher sensitivity and lower specificity than magnetic resonance enteroclysis, computed tomography, and push enteroscopy. Capsule endoscopy has a good safety profile with few adverse events, although comparative safety data with other diagnostic modalities are limited. Capsule endoscopy is associated with no difference in patient health-related outcomes such as rebleeding or follow-up treatment compared with push enteroscopy, small-bowel follow-through, and angiography. LIMITATIONS: There was significant heterogeneity in estimates of diagnostic accuracy, which prohibited a statistical summary of findings. The analysis was also limited by the fact that there is no established reference standard to which the diagnostic accuracy of CE can be compared. CONCLUSIONS: There is very-low-quality evidence that CE has a higher sensitivity but a lower specificity than other diagnostic modalities. Capsule endoscopy has few adverse events, with capsule retention being the most serious complication. Capsule endoscopy is perceived by patients as less painful and less burdensome compared with other modalities. There is low-quality evidence that patients who undergo CE have similar rates of rebleeding, further therapeutic interventions, and hospitalization compared with other diagnostic modalities.

Hospitalizations and testing in gastroparesis.

BACKGROUND AND AIM: Gastroparesis significantly impairs the quality of life in affected individuals and may lead to repeat hospitalizations due to refractory symptoms. We hypothesized that pain is a key reason for emergency encounters and diagnostic testing. METHODS: Using the ICD9 code 536.3, electronic medical records were analyzed retrospectively. Multivariate regression was used to determine predictors of hospital stays and use of diagnostic testing. RESULTS: In total, 326 patients (80% women, age: 44.1 ± 0.8 years) were identified. During 504 patient-years of follow up, patients were hospitalized on average slightly more than once annually for about 8 days and underwent 320 endoscopies, 366 computed tomography scans, 390 abdominal X-rays, 90 upper gastrointestinal contrast studies and 163 gastric emptying studies; 37 patients exceeded an annual radiation exposure of 20 mSv at least once. The majority of tests were confirmatory, with results not altering treatment. Vomiting and pain were the most common cause for emergency encounters and diagnostic testing. Age and comorbidity, but not opioid use (present in 25%) or the presence of chronic pain disorders (present in 32%) correlated with increased hospital days. CONCLUSIONS: While surrogate markers of pain do not predict repeat hospitalizations, pain was the primary reason for emergency encounters and frequent diagnostic testing. Repeated testing had a limited impact on treatment and outcome, but certainly contributes to the cost and even risk of care. Concerted efforts are needed to not only improve the care and quality of life of patients with gastroparesis, but also to reduce the number of potentially unnecessary or even harmful interventions.

Use of the entero-test, a novel approach for the noninvasive capture of biliary metabolites in dogs.

Preclinical information on the biliary metabolites of a drug candidate is typically obtained through the collection of bile after surgical cannulation of the bile duct. In this study, we describe a novel approach using the Entero-Test, a simple device that facilitates the noninvasive sampling of duodenal bile. The Entero-Test was used to collect bile from six fasted dogs that had been dosed either orally with simvastatin (SV) or intravenously with simvastatin hydroxy acid (SVA), compounds that have been previously reported to undergo extensive metabolism and biliary secretion in the dog. The devices, consisting of a weighted gelatin capsule containing 90 cm of a highly absorbent nylon string, were swallowed by each dog with the proximal end of the string taped to the animal's face. Once the weighted string had reached the duodenum, gallbladder contraction was stimulated to release bile. Each bile-stained string was then retrieved via the mouth and, after solvent extraction, samples were analyzed for drug-related material by ultraperformance liquid chromatography-mass spectrometry and NMR spectroscopy. Numerous metabolites of SV and SVA were observed, and, in general, the major metabolites have been reported previously from studies with bile duct-cannulated animals dosed with [14C]SV or [14C]SVA. The results from this study demonstrate the utility of deploying the Entero-Test in absorption, distribution, metabolism, and elimination studies to provide information on the nature of biliary metabolites, which, on occasion, may be sufficient to negate the need for more invasive sampling techniques. The benefits and limitations of the technique are discussed.

Iatrogenic colorectal perforation induced by anorectal manometry: report of two cases after restorative proctectomy for distal rectal cancer.

There are no reports regarding perforation of the colorectum induced by anorectal manometry. We report two cases of colorectal perforation that occurred during manometry in the patients undergoing restorative proctectomy for distal rectal cancer. In the first patient, computed tomography showed an extraperitoneal perforation in the pelvic cavity and a rupture of the rectal wall. A localized perforation into the retroperitoneum was managed conservatively. In the second patient, a 3 cm linear colon rupture was detected above the anastomotic site. A primary closure of the perforated colon and proximal ileostomy were conducted, but the patient died 2 wk later. We hypothesize that the perforation induced by anorectal manometry may be associated with the relative weakening of the proximal bowel wall due to anastomosis, decreased compliance, and abnormal rectal sensation. We suggest that measurement of the maximum tolerable volume should not be routinely performed after restorative proctectomy for distal rectal cancer.

Diagnosis of food allergy in children: toward a standardization of food challenge.

Adverse reactions to food represent a common complaint in childhood; however, only a small proportion of children have proven clinically relevant food allergy. The foods most commonly involved in food allergy are cow's milk, hen's eggs, peanuts, tree nuts, seeds, soy, wheat, fish, and crustaceans. The diagnostic workup of suspected food allergy includes the patient's history, skin prick testing, the measurement of food-specific immunoglobulin E antibodies, and, more recently, the atopy patch test. Because none of these parameters can accurately predict tolerance, the gold standard for diagnosing food allergy is still the double-blind, placebo-controlled food challenge. Although numerous efforts have been made to standardize the procedure, there is a need for improvement. This review presents the current status of the indication and performance of controlled oral food challenges in children with suspected food-related symptoms. It covers aspects of indications and contraindications, blinding, diet before the challenge, the practical performance, the handling of medication, the interpretation of test results, suitable locations for testing, safety considerations, and the procedure after a period of avoidance. Efforts to standardize oral food challenges to achieve the best possible decision on a diet are important to avoid an unnecessary diet that may be harmful to the child.

Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis.

UNLABELLED: Measurement of hepatic venous pressure gradient (HVPG) is a standard method for the assessment of portal pressure and correlates with the occurrence of its complications. Liver stiffness measurement (LSM) has been proposed as a noninvasive technique for the prediction of the complications of cirrhosis. In this study, we evaluated the ability of LSM to predict severe portal hypertension compared with that of HVPG in 61 consecutive patients with HCV-related chronic liver disease. A strong relationship between LSM and HVPG measurements was found in the overall population (r=0.81, P<0.0001). However, although the correlation was excellent for HVPG values less than 10 or 12 mm Hg (r=0.81, P=0.0003 and r=0.91, P<0.0001, respectively), linear regression analysis was not optimal for HVPG values>or=10 mm Hg (r2=0.35, P<0.0001) or>or=12 mm Hg (r2=0.17, P=0.02). The AUROC for the prediction of HVPG>or=10 and >or=12 mm Hg were 0.99 and 0.92, respectively and at LSM cutoff values of 13.6 kPa and 17.6 kPa, sensitivity was 97% and 94%, respectively. In patients with cirrhosis, LSM positively correlated with the presence of esophageal varices (P=0.002), although no correlation between LSM and esophageal varices size was detected. The area under the ROC for the prediction of EV was 0.76 and at a LSM cutoff value of 17.6 kPa sensitivity was 90%. CONCLUSION: LSM represents a non-invasive tool for the identification of chronic liver disease patients with clinically significant or severe portal hypertension and could be employed for screening patients to be subjected to standard investigations including upper GI endoscopy and hemodynamic studies.