Capsule Endoscopic Diagnosis Of Extra-Intestinal Bleeding

Introduction & Aims: Unlike cable endoscopy, which requires sedation and distension of the lumen for visualization, CE provides imaging of the gut without disturbing its physiological state. It is unclear whether CE, designed primarily for small intestinal imaging, will be useful in the diagnosis of bleeding lesions in the stomach or colon that were not apparent to the cable endoscopy. We report the role of CE in 50 patients (pts) with obscure GI bleeding in the diagnosis of extra-intestinal bleeding. Methods: CE reports & hospital charts of pts with obscure GI bleeding (2002-04) were reviewed to establish site of bleeding, etiology of bleeding, & CE indicators of bleeding & the outcome of these pts. Results: CE images of 50 pts (mean age: 67; range 39-90 years, M/F: 23/27) who underwent CE for diagnosis of obscure GI bleeding (overt n = 20; occult with Hb < 8 g/dl: n = 3, Hb 8-11 g/dl: n = 27) were reviewed. I. Bleeding Source was diagnosed in 15 of the 50 pts. In 4 pts the source of bleeding was present outside the small intestine: stomach (n = 3) & colon (n = 1). II. Etiology of Extra-intestinal Bleeding: a) Stomach: GAVE (n = 1), Dielaufoy's lesion (DL) (n = 2) c) Colon: Cecal AVM (n = 1). III. CE Findings Suspicious for Extra-intestinal Bleeding: Flecks of heme or blood clots in the stomach (n = 2), fresh blood in the duodenum with normal stomach (n = 1), blood in the cecum without any blood in the small intestine provided clues for extra-intestinal source of bleeding. IV. Specific Diagnosis: i. GAVE: At EGD, it was initially misdiagnosed as hemorrhagic gastritis. Capillary blanching & refilling along with active bleeding from the pylorus as the CE exited the stomach confirmed the diagnosis of GAVE. ii. Gastric DL: Of the two pts, in one CE identified the lesion. In the other, presence of old blood in the duodenum lead to suspicion of a gastric source of bleeding on repeat endoscopy actively bleeding DL was identified. iii. Cecal AVMs: Bleeding from the cecum was identified on a 3rd CE; cecal AVMs were identified at colonoscopy (narcotics were avoided for sedation) after injection of nalaxone. V. Outcome: Endoscopic therapy controlled bleeding and there was no recurrence of bleeding during a follow-up of 6-12 moths. Conclusions: Capsule endoscopy is useful in the diagnosis of extra-intestinal bleeding and search for lesions should not be limited to the small intestine alone during capsule endoscopic review. Introduction & Aims: Unlike cable endoscopy, which requires sedation and distension of the lumen for visualization, CE provides imaging of the gut without disturbing its physiological state. It is unclear whether CE, designed primarily for small intestinal imaging, will be useful in the diagnosis of bleeding lesions in the stomach or colon that were not apparent to the cable endoscopy. We report the role of CE in 50 patients (pts) with obscure GI bleeding in the diagnosis of extra-intestinal bleeding. Methods: CE reports & hospital charts of pts with obscure GI bleeding (2002-04) were reviewed to establish site of bleeding, etiology of bleeding, & CE indicators of bleeding & the outcome of these pts. Results: CE images of 50 pts (mean age: 67; range 39-90 years, M/F: 23/27) who underwent CE for diagnosis of obscure GI bleeding (overt n = 20; occult with Hb < 8 g/dl: n = 3, Hb 8-11 g/dl: n = 27) were reviewed. I. Bleeding Source was diagnosed in 15 of the 50 pts. In 4 pts the source of bleeding was present outside the small intestine: stomach (n = 3) & colon (n = 1). II. Etiology of Extra-intestinal Bleeding: a) Stomach: GAVE (n = 1), Dielaufoy's lesion (DL) (n = 2) c) Colon: Cecal AVM (n = 1). III. CE Findings Suspicious for Extra-intestinal Bleeding: Flecks of heme or blood clots in the stomach (n = 2), fresh blood in the duodenum with normal stomach (n = 1), blood in the cecum without any blood in the small intestine provided clues for extra-intestinal source of bleeding. IV. Specific Diagnosis: i. GAVE: At EGD, it was initially misdiagnosed as hemorrhagic gastritis. Capillary blanching & refilling along with active bleeding from the pylorus as the CE exited the stomach confirmed the diagnosis of GAVE. ii. Gastric DL: Of the two pts, in one CE identified the lesion. In the other, presence of old blood in the duodenum lead to suspicion of a gastric source of bleeding on repeat endoscopy actively bleeding DL was identified. iii. Cecal AVMs: Bleeding from the cecum was identified on a 3rd CE; cecal AVMs were identified at colonoscopy (narcotics were avoided for sedation) after injection of nalaxone. V. Outcome: Endoscopic therapy controlled bleeding and there was no recurrence of bleeding during a follow-up of 6-12 moths. Conclusions: Capsule endoscopy is useful in the diagnosis of extra-intestinal bleeding and search for lesions should not be limited to the small intestine alone during capsule endoscopic review.