We investigated whether use of a stiffening wire increased insertion depth during double-balloon enteroscopy (DBE).

A total of 54 patients were randomized to the stiffening wire or the control group after reaching the maximum insertion depth using a conventional technique. Further advancement was then attempted. The primary outcome was the distance gained after randomization. Secondary outcomes included total insertion depth, diagnostic and intervention rates, pain scores, and adverse events.

The median insertion distance after randomization was higher in the stiffening wire group compared with the control group (135 vs 19 cm; P < .001), as was the total insertion depth (502 vs 391 cm; P = .015). There were no differences in diagnostic or intervention rates or pain scores. Two adverse events occurred in the stiffening wire arm but were unrelated to the wire.

The stiffening wire increased insertion depth and should be used when an abnormality cannot be reached with a conventional technique. (Clinical trial registration number: NCT02720848.).

Although the type and prevalence of small-bowel lesions in patients with liver cirrhosis have been reported, the clinical significance of their endoscopic features is unclear. We aimed to clarify their association with small-bowel bleeding in liver cirrhosis patients with suspected small-bowel bleeding.

We retrospectively included 165 patients with liver cirrhosis (96 men; median age, 73 years) who underwent capsule endoscopy at our institution: 32 without portal hypertensive enteropathy (Grade 0), 101 with inflammatory-like abnormalities (Grade 1), and 32 with vascular lesions (Grade 2). The main outcome measures were the rates of small-bowel bleeding at the initial bleeding episode and rebleeding. Factors associated with Grade 2 portal hypertensive enteropathy were examined.

At the time of initial bleeding, 66% of patients with Grade 2 portal hypertensive enteropathy had small-bowel bleeding, compared with only 3% of those with Grades 0 or 1 portal hypertensive enteropathy. Furthermore, the cumulative rebleeding rate from small-bowel lesions 1 year after the initial bleeding was 33% in patients with Grade 2, compared to 0% in those with Grades 0 and 1. Colorectal angioectasia, Child-Pugh Grade C cirrhosis, and a history of blood transfusion were independent predictors of small-bowel vascular lesions.

Our results suggest that patients with colorectal angioectasia, Child-Pugh Grade C cirrhosis, or a history of blood transfusion have a high risk of small-bowel bleeding and should, therefore, be examined via capsule endoscopy.

There is a lack of effective means for precise drug delivery of gastrointestinal diseases. Herein we report a novel magnetically controlled drug delivering capsule endoscope (MDCE) to achieve precision drug delivery for gastrointestinal diseases. MDCE integrates a drug delivery system into conventional capsule endoscope. It can carry 0.5 ml of liquid medication, which can be sprayed onto the target area using an electric pump upon detecting lesions by convolutional neural network (CNN)-model. Additionally, with the aid of an external magnet, the operator can adjust the posture and drug delivery direction of the capsule endoscope to enhance the accuracy of drug release. This adjustment process is monitored in real-time through the camera at the front of the capsule endoscope. To validate the clinical efficacy of the MDCE, we established porcine intestinal epithelial injury and bleeding models, and we demonstrated that MDCE could accurately deliver drugs under magnetic control through direct visualization. MDCE could significantly reduce injury area by delivering organoids to porcine injury sites after 7 days compared to the control group (48 mm2vs. 21 mm2, p = 0.018). MDCE could significantly reduce bleeding time by spraying norepinephrine to porcine intestinal bleeding site compared to the control group (731 s vs. 418 s, p = 0.007). These demonstrate that MDCE could actively accurately release drugs under magnetic control through direct visualization in a non-invasive manner. This opens a new chapter for the precision treatment of gastrointestinal diseases and provides a novel approach for oral drug administration for systemic diseases.

Currently, the factors influencing small bowel bleeding caused by nonsteroidal anti-inflammatory drugs (NSAIDs) remain unclear.

This study aimed to assess NSAID-associated small bowel bleeding and evaluate the impact of other drugs on it through a pharmacovigilance study, thereby providing valuable insights for clinical practice.

Data on NSAID-associated small bowel bleeding were retrospectively extracted from two public adverse drug reaction databases-the Food and Drug Administration's (FDA) Adverse Event Reporting System (FAERS) and the Japan Pharmaceuticals and Medical Devices Agency's Adverse Drug Event Reporting (JADER)-from 2004 to 2023 for further analysis.

The reporting odds ratio (ROR), a pharmacovigilance technique, was employed to identify signals of adverse reactions, and the Chi-square test was utilized to assess differences between groups.

Multiple NSAIDs associated with small bowel bleeding were identified in both databases. In the drug combination analysis, no significant differences in the risk of small bowel bleeding were found between NSAIDs combined with proton pump inhibitors (PPIs) and NSAIDs alone in FAERS (all p > 0.05). Decreasing risks were found when multiple NSAIDs were combined with rebamipide or probiotics compared to NSAIDs alone in JADER (p < 0.05 and ROR  < 1). In subgroup analyses of age and sex, older adults and males who used aspirin showed higher risk signals in both databases (all p < 0.05 and ROR  > 1).

PPIs did not show a significant impact on NSAIDs-associated small bowel bleeding, while rebamipide and probiotics may exhibited a preventive effect against NSAIDs-associated small bowel bleeding. Older adults and males constituted risk factors for aspirin-associated small bowel bleeding.

A jejunal gastrointestinal stromal tumor (GIST) is a rare malignant mesenchymal neoplasm of the gastrointestinal tract that arises from the interstitial cells of Cajal. Massive and recurrent bleeding due to jejunal GIST is a diagnostic challenge which may lead to delays in treatment. GISTs as the source of bleeding are already rare. This case is further characterized by endoscopic visualization and clipping of a site of bleeding before eventual surgical resection for recurrent bleeding.

This review discusses the ways in which the health care provider (or more broadly, the provision of medical care) can cause harm to the bowel and highlights the appearance of such untoward events on imaging. The etiologies are myriad, and as such, the radiologist must remain vigilant in identifying the presence of suspected and unsuspected injuries. Specific attention is given to complications from medication and external radiation therapy, as these interventions and their timing are often not known by the radiologist.

A 21-year-old Palestinian woman experienced recurrent hematemesis and melena over 7 months, requiring multiple hospital admissions and blood transfusions. Despite extensive investigations, the bleeding source remained undetermined until a posterior nasal bleed was suspected. Flexible rhinoscopy revealed a dilated sphenopalatine artery, and she was successfully treated with endovascular intervention. It is important for the Gastroenterologists to consider nasal endoscopy for patients with unexplained UGIB.

Obscure gastrointestinal bleeding (OGIB), defined in 2010, involves bleeding from the GI tract that remains unexplained after standard diagnostic procedures. OGIB, which accounts for about 5% of all GI bleeds, poses diagnostic and management challenges, particularly due to the anatomical features of the small intestine. Advances in capsule endoscopy (CE) and balloon-assisted endoscopy have improved the diagnostic and therapeutic landscape for small intestinal lesions.

To determine the recurrence rate and identify risk factors for recurrence following diagnostic and therapeutic interventions using CE and balloon-assisted endoscopy in patients with OGIB.

A retrospective cohort study at Gifu University Hospital analyzed CE procedures for patients with OGIB from 2008 to 2022. Patients underwent CE with subsequent treatments based on the findings. Statistical analyses, including Kaplan-Meier and Cox proportional hazards models, were used to estimate cumulative recurrence rates and identify recurrence risk factors.

Out of 417 patients, 65.2% had positive CE findings, leading to therapeutic interventions in 16.3% of cases. The cumulative recurrence rates at 12, 24, and 36 months were 4.3%, 9.0%, and 13.9%, respectively. Liver cirrhosis (hazard rate: 4.15, 95% confidence interval 1.88-9.18, p < 0.01) was identified as a significant risk factor for recurrence.

A significant recurrence rate in OGIB patients, with liver cirrhosis being a major risk factor. Despite diagnostic and therapeutic advances, a comprehensive approach including careful follow-up and consideration of risk factors is essential for management.

We aimed to evaluate the usefulness and acceptability of CapsoCam Plus (CapsoCam) in Japanese patients.

This retrospective single-center study enrolled 930 patients with suspected small-bowel bleeding (SSBB) who underwent capsule endoscopy. Thirty-three patients using CapsoCam and PillCam SB3 (SB3) were matched using propensity score matching. The diagnostic yield and the acceptability of CapsoCam were evaluated.

There was no SSBB case where capsule endoscopy was performed within 48 h of bleeding. CapsoCam had a significantly higher observation rate of the entire small bowel (97% vs. 73%, p = 0.006) and Vater's papilla (82% vs. 15%, p < 0.001) than SB3. The reading time of CapsoCam was significantly longer than that of SB3 (30 vs. 25 min, p < 0.001), and CapsoCam's time from the capsule endoscopy swallowing to read completion was longer than that of SB3 (37 vs. 12 h, p < 0.001). The two groups showed no difference in the capsule endoscopy findings according to the P classification. Notably, 85% of the patients using CapsoCam reported examination distress as "not at all" or "almost not," and 94% reported swallowing difficulty as "very easy" or "easy."

CapsoCam took time to read; however, it is a well-tolerated examination with a high observation rate of Vater's papilla and entire small-bowel mucosa. Detectability of bleeding sources was comparable in both modalities for cases of occult SSBB and overt SSBB more than 48 h after bleeding. CapsoCam is a useful modality for patients with SSBB.

Deep enteroscopy, encompassing push enteroscopy (PE) and balloon-assisted enteroscopy (BAE), has revolutionized the diagnosis and treatment of pediatric small bowel disorders. This review examines the evolving role of these techniques in managing conditions such as obscure gastrointestinal bleeding, Crohn's disease, polyposis syndromes, strictures, and small bowel tumors. While PE is effective for both diagnostic and therapeutic interventions in the proximal small bowel, its limited insertion depth has driven the adoption of BAE techniques. These include single-balloon enteroscopy (SBE) and double-balloon enteroscopy (DBE), which provide deeper and more comprehensive access. Both BAE modalities offer greater insertion depth and stability, enabling advanced therapeutic interventions such as polypectomy, stricture dilation, and hemostasis. Pediatric-specific data demonstrate high diagnostic yields for BAE, with comparable outcomes between SBE and DBE. These techniques have proven safe across diverse indications, though younger children may experience slightly higher complication rates due to anatomical considerations. Despite these advancements, challenges persist, including a limited evidence base in pediatrics, barriers to training, and the need for standardized protocols. Additionally, emerging innovations such as artificial intelligence offer opportunities to enhance diagnostic accuracy and procedural efficiency. Comparative analyses of PE, BAE, and capsule endoscopy are necessary to refine procedural selection and optimize outcomes in pediatric patients. Furthermore, structured pediatric training programs and simulation-based learning could address competency gaps, ensuring safe and effective application of these techniques. By addressing current research gaps, embracing technological advancements, and tailoring approaches to pediatric populations, deep enteroscopy can continue to transform the management of small bowel disorders in children.

Digestive bleeding is an important cause of hospital admission; however, the mortality rate in these patients has not been reduced. Digestive bleeding has a multiple etiology; specifically, bleeding from the small intestine accounts for 5 to 10% of gastrointestinal hemorrhages, of which between 0.06% and 5% of cases are caused by diverticula of the small intestine. Most cases are asymptomatic; however, the symptomatic form is highly variable and can present with multiple complications, such as massive bleeding. Therefore, the objective of this study was to explore the approach to jejunal diverticular disease (JDD) with gastrointestinal bleeding.

A 48-year-old male patient presented with massive digestive bleeding of unknown origin, initially treated with angiography and embolization, with a satisfactory outcome. However, six days after discharge, the patient experienced new massive bleeding that required an urgent exploratory laparotomy, during which jejunal diverticular disease (JDD) of the small intestine was identified.

Diverticula of the small intestine are usually asymptomatic, and complications are rare; however, they can affect the patient's survival. Therefore, an appropriate approach, accurate and timely diagnosis, and a multidisciplinary management strategy are required to offer the best therapeutic options for the patient.

The identification of gastrointestinal bleeding holds significant importance in wireless capsule endoscopy examinations, primarily because bleeding is the most prevalent anomaly within the gastrointestinal tract. Moreover, gastrointestinal bleeding serves as a crucial indicator or manifestation of various other gastrointestinal disorders, including ulcers, polyps, tumors, and Crohn's disease. Gastrointestinal bleeding may be classified into two categories: active bleeding, which refers to the presence of continuing bleeding, and inactive bleeding, which can potentially manifest in any region of the gastrointestinal system. Currently, medical professionals diagnose gastrointestinal bleeding mostly by examining complete wireless capsule endoscopy images. This approach is known to be demanding in terms of labor and time.

This research used white-light images (WLIs) obtained from 100 patients using the PillCam™ SB 3 capsule endoscope to identify and label the areas of bleeding seen in the WLIs.

A total of 152 photographs depicting bleeding and 182 images depicting non-bleeding were selected for analysis. In addition, hyperspectral imaging was used to transform WLI into hyperspectral images using spectral reconstruction through band selection. These images were then categorized into WLIs and hyperspectral images. The training set consisted of seven datasets, each including six spectra. These datasets were used to train the Visual Geometry Group-16 (VGG-16) model, which was developed using a convolutional neural network. Subsequently, the model was tested, and its diagnostic accuracy was assessed.

The accuracy rates for the respective measures are 83.1%, 65.8%, 66.2%, 72.2%, 73.7%, and 88%. The respective precision values are 78.5%, 47.5%, 30.6%, 59.5%, 77.7%, and 80.2%. The recall rates for the relevant data points are 83.3%, 67.9%, 86%, 74.2%, 68.6%, and 92.4%. The initial dataset comprises an image captured under white-light conditions, whereas the final dataset is the most refined spectral picture data.

The findings suggest that employing spectral imaging within the wavelength range of 405 to 415 nm can enhance the accuracy of detecting small intestinal bleeding.

Angiosarcoma is a rare, soft tissue tumor arising from lymphatic and vascular endothelial cells with high malignancy potential. While commonly observed in cutaneous and subcutaneous tissues, gastrointestinal subtypes are exceedingly rare. A 47-year-old male initially presented for the management of extensive burn injuries sustained in a motor vehicle collision. Throughout an extended hospital stay, he developed melanotic stools and progressive microcytic anemia. Following institutional burn protocol, the patient received multiple blood transfusions. Physical examination revealed a toxic appearance with abdominal distention. A push enteroscopy identified an ulcerated mass in the proximal jejunum. Surgical resection of the mass was performed, and pathological analysis confirmed the diagnosis of gastrointestinal angiosarcoma. The study concludes that patients presenting with unidentifiable melena and anemia after imaging and routine scopes should be considered for having a gastrointestinal lesion, including a gastrointestinal angiosarcoma, despite its rarity. Early recognition of such conditions may facilitate timely diagnosis and intervention, potentially improving survival outcomes. Furthermore, in the complexity of this case in relation to other existing medical conditions and traumatic injuries, weighing risk and benefit to tailor treatment including utilization of chemotherapy and radiation should be individualized.

The diagnosis and management of small bowel bleeding (SBB) can be a clinical challenge. Advances in video capsule endoscopy, balloon-assisted enteroscopy, and multiphasic computed tomography allow for localization and therapeutic intervention. Etiologies of SBB including vascular, neoplastic, and inflammatory conditions are associated with age and comorbidities. The present review highlights terminologies that describe SBB, provides a differential diagnosis for bleeding etiologies, and summarizes a clinical approach to managing this condition.

Fewer studies have been conducted on the diagnostic value of capsule endoscopy, CT enterography and enteroscopy in suspected small bowel bleeding. This study aimed at analyzing the diagnostic and clinical value of capsule endoscopy, CT enterography and enteroscopy for suspected small bowel bleeding.

This retrospective study compared the diagnostic rate and consistency of findings among groups. In addition, diagnostic rates were compared between combined enteroscopy versus uncombined enteroscopy associated with capsule endoscopy or CT enterography, as well as the influencing factors of diagnostic outcomes. The complete enteroscopy rates and diagnostic rates were analyzed for the one-day enteroscopy group and the non-one-day enteroscopy group.

There was no significant difference in diagnostic rates between capsule endoscopy (n = 70) and CT enterography (n = 122) (χ2 = 3.334; p = 0.068), while the diagnostic rate of enteroscopy (n = 396) is higher than capsule endoscopy (χ2 = 10.064; p = 0.002) and CT enterography (χ2 = 42.661; p < 0.001). Diagnostic rates were much higher in patients with a successful completion of docking inspection (n = 64) than in undocked patients (n = 60) (85.9% vs 46.7%; p < 0.001), even though these patients still had combined capsule endoscopy or CT enterography. The complete enteroscopy rates (χ2 = 0.364; P = 0.546) and diagnostic rates (χ2 = 2.511; P = 0.113) of enteroscopy in the one-day group (n = 55) were not significantly different from those in the non-one-day group (n = 25).

Enteroscopy is the more reliable method of diagnosing suspected small bowel bleeding among enteroscopy, capsule endoscopy and CT enterography. Moreover, uncompleted enteroscopy combined with capsule endoscopy or CT enterography may not yet be a substitute for successful completion of docking enteroscopy in clinical practice.

This case emphasises the difficulties in diagnosing a patient with brisk active small bowel bleeding and the differential diagnostic process of identifying tumour types preoperatively using imaging information. This case also underscores the importance of the surgical approach in different scenarios. Despite advancements in small bowel imaging, identifying the source and causes of small bowel bleeding remains challenging, particularly in life-threatening situations. Jejunal gastrointestinal stromal tumour (GIST) is a rare neoplasm of the gastrointestinal tract with small bowel GISTs commonly presenting with GI bleeding. However, brisk or massive bleeding is infrequently reported and poses a significant preoperative diagnostic challenge. Early diagnosis and prompt intervention are essential and can lead to excellent outcomes. Well-planned surgical intervention during emergency operations for gastrointestinal bleeding is integral to effective management.

Glasgow-Blachford (GBS) and Rockall scores are recognized tools to prioritize patients with upper gastrointestinal bleeding. Their utility in predicting findings on capsule endoscopy (CE) in patients with overt small bowel bleeding (OSBB) remains unclear. The aim was to assess use of these scores in predicting relevant findings on CE and outcome among patients with suspected OSBB.

A retrospective analysis was performed from January 2019 to June 2022. Clinical parameters and scores were collected at presentation and at 24 hours. Univariate analysis used simple logistic regression, chi-squared test or Mann-Whitney as needed. ROC analysis was performed selecting the optimal cut-off point maximized by the Youden index.

Seventy-nine patients were included, 62% of whom had relevant findings. The predictor showing the highest discrimination ability was the initial GBS (area under the curve [AUC] 0.625; 95% confidence interval [CI] 0.49-0.76). The optimal cut-off point was at least 4, with sensitivity 98%, specificity 30%, and accuracy 72%. Multivariable regression analysis showed inpatient status on CE (odds ratio [OR] 117.27; 95% CI 11.32-4492.93; P = 0.001), shorter time to CE (OR 1.02; CI 1.01-1.04; P = 0.018), higher initial GBS (OR 1.22; CI 1.06-1.43; P = 0.009), and higher GBS within 24 hours (OR 1.19; CI 1.04-1.37; P = 0.013) were predictive factors for relevant findings on CE, with a model AUC 0.802, sensitivity 91.8%, and specificity 63.3%.

GBS and Rockall scores were useful in predicting relevant findings on CE in this cohort of patients with suspected OSBB. In patients with GBS 5 or higher, early CE during the same admission is warranted.

Capsule endoscopy has been proven as an efficient and accurate tool in the diagnosing and monitoring patients with inflammatory bowel disease, especially Crohn's disease (CD). The current European Crohn's and Colitis Organization guidelines recommend small bowel disease assessment in newly diagnosed CD, wherein small bowel capsule endoscopy (SBCE) is of prime importance. SBCE plays an essential role in assessing mucosal healing in patients with CD, serving as a monitoring tool in a treat to target strategy, and is capable of identifying high-risk patients for future flares.

The endoscopic evaluation and management of small intestinal diseases continue to evolve and expand. The advent of small bowel wireless capsule endoscopy and deep enteroscopy with either a double- or single-balloon enteroscope now allows complete endoscopic visualization of the entire small intestine and enables access for endoscopic interventions such as biopsies or hemostasis for most of the small bowel. New endoscopic techniques are available to treat proximal malignant small bowel obstruction, including intraluminal stents and endoscopic gastrojejunal stents. Emerging technologies also aim to improve weight loss and diabetes management via small bowel endoscopic interventions.

Small bowel bleeding (SBB) is the main indication for videocapsule endoscopy (VCE); the diagnostic yield (DY) could be influenced by antithrombotic therapies. We explored the effects of these therapies on SBB.

Consecutive patients from two centers (Milan, Italy and Sheffield, UK) who underwent VCE between March 2001 and July 2020 were considered. Demographic data, clinical parameters, drug therapy, and technical characteristics of the procedure were collected. VCE findings and DY were evaluated.

In total, 957 patients (1,052 VCEs) underwent VCE for SBB (DY 50.6%, no retention); 27 patients (27 VCEs) received direct oral anticoagulants, 87 (88 VCEs) received other anticoagulants, 115 (135 VCEs) received antiplatelet therapy, 198 (218 VCEs) received monotherapy, and 31 (32 VCEs) received combined therapy. There were no differences in the completion rate, findings, and DYs between each subgroup or between monotherapy and combined therapy. The overt bleeding rate was similar in all groups, even when comparing antithrombotic users versus those not on therapy (p=0.59) or monotherapy versus combined therapy (p=0.34).

VCE is safe and has a high clinical impact on SBB. Antithrombotic therapies did not affect DY or overt bleeding rate and, consequently, can be considered safe in terms of SBB risk.

Anaemia occurs due to an imbalance between erythrocyte production and loss. This imbalance can be due to ineffective erythropoiesis, blood loss or haemolysis. Whilst there are many causes for anaemia, iron deficiency anaemia (IDA) remains the predominant cause worldwide.

There have been many updated guidelines on the management of IDA in the past few years. As the reasons for IDA are many, evaluation requires thorough analysis and focused investigations. As an asymptomatic disease in the early stages, IDA can lead to many mistakes in its management. This review highlights potential mistakes in assessing and managing IDA and recommendations to avoid them.

The effective management of IDA necessitates a comprehensive and multidisciplinary approach. By recognising and addressing the common mistakes highlighted in this narrative review, healthcare professionals can improve patient outcomes, minimise complications, and enhance the overall quality of care.

Acute severe lower gastrointestinal bleeding is a rare but potentially fatal complication of Crohn's disease (CD), affecting between 0.6% and 5.5% of CD patients during their lifelong disease course. Managing bleeding episodes effectively hinges on vital resuscitation. Endoscopic evaluation and computed tomography play crucial roles in accurate identification and intervention. Fortunately, most bleeding episodes can be successfully managed through appropriate conservative treatment. Medical therapies, particularly infliximab, aim to induce and maintain mucosal healing and serve as the leading treatment approach. Minimally invasive procedures, such as endoscopic hemostasis and angio-embolization, can achieve immediate hemostasis. Surgical treatment is only considered a last resort when conservative therapies fail. Despite achieving hemostasis, the risk of rebleeding ranges from 19.0% to 50.5%. The objective of this review is to provide a comprehensive and updated overview of the clinical manifestations, diagnostic methods, therapeutic approaches, and prognostic outcomes associated with acute severe gastrointestinal bleeding in CD. Furthermore, we aimed to propose a management algorithm to assist clinicians in the effective management of this condition.

Background The utility of small bowel capsule endoscopy (SBCE) in the inpatient setting is controversial due to retention rates and costs. Aim This study aims to evaluate whether using SBCE significantly improved the identification of potential bleeding sites or reduced the risk of 30-day readmission for overt or occult gastrointestinal bleeding. Methods This was a single-center retrospective cohort study involving inpatients who underwent SBCE at a suburban tertiary care hospital from January 1, 2012, to January 1, 2022, for suspected small bowel bleeding. There was no control group used in this observational study. We used chi-square testing to determine the significance among our categorical variables and t-tests to compare means for our numerical variables. We also did multivariable logistic regression to analyze risk factors for increased hospital stay. All statistical analysis was done in R (R Core Team, 2020, R Foundation for Statistical Computing, Vienna, Austria). Results We identified 514 inpatients who underwent SBCE from January 1, 2012, to January 1, 2022, including 300 (58.4%) men and 214 (41.6%) women. Most (305/514, 59.3%) had no notable findings on SBCE, but 209/514 (40.7%) subsequently underwent endoscopic procedures, and a bleeding site was identified and treated in 168/209 (80.4%). Undergoing a subsequent procedure significantly increased the average number of days between capsule deployment and discharge (9.6 vs. 4.9 days, p < 0.005) without significantly reducing the risk for 30-day readmission (OR 1.33, 95% CI 0.9-1.9, p = 0.2). Among the 209 patients who had a subsequent procedure, identifying and treating a bleeding site did not significantly change readmission rates (OR 1.35, 95% CI 0.6-3.1, p = 0.5) compared to patients who did not have a procedure. Conclusion We did not find that inpatient SBCE significantly affected 30-day readmission rates even if an endoscopic procedure was subsequently done or a potential bleeding site was treated.

This document summarizes the relevant literature for the selection of the initial imaging in five clinical scenarios in patients with suspected or known nonvariceal upper gastrointestinal bleeding (UGIB). These clinical scenarios include suspected nonvariceal UGIB without endoscopy performed; endoscopically confirmed nonvariceal UGIB with clear source but treatment not possible or continued bleeding after endoscopic treatment; endoscopically confirmed nonvariceal UGIB without a confirmed source; suspected nonvariceal UGIB with negative endoscopy; and postsurgical or post-traumatic nonvariceal UGIB when endoscopy is contraindicated. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of nonvariceal UGIB. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Acute lower gastrointestinal bleeding is a common emergency in gastroenterology. Currently, there is insufficient information to predict adverse outcomes in patients with acute lower gastrointestinal bleeding. Our study aimed to compare the effectiveness of the clinical risk scores currently utilized and their ability to predict significant outcomes in lower gastrointestinal bleeding.

We conducted a prognostic study of patients hospitalized for acute lower gastrointestinal bleeding who underwent colonoscopy or angiography at a single-center hospital between January 2015 and October 2023. Adverse outcomes associated with ALGIB included rebleeding, blood transfusion, hemostatic interventions, and in-hospital death. We calculated three risk scores at admission (Oakland, Birmingham, SALGIB). We measured the accuracy of these scores using the area under the receiver operating characteristic curve (AUC) and compared them with DeLong's test.

222 patients with confirmed lower gastrointestinal bleeding (aged 64 years, 53-75) were finally included. The most common diagnoses were colorectal cancer (28 %) and hemorrhoids (14 %). The Oakland score, Birmingham score, and SALGIB score displayed comparable performance in predicting any adverse outcome (AUC = 0.54, 0.53, 0.55). However, none of the scores were able to sufficiently discriminate rebleeding, blood transfusion, or hemostatic intervention. Using the Youden index, cutoff points for predicting undesired results were identified for the Oakland score at 13, Birmingham score at 3, and SALGIB score at 2.

None of the three scores demonstrated satisfactory discrimination for adverse outcomes. Therefore, it is necessary to develop novel risk stratification scores with higher performance to improve risk stratification in acute lower gastrointestinal bleeding.

Deciding which patients with suspected small bowel bleeding (SSB) would benefit most from small bowel capsule endoscopy (SBCE) is challenging. Our aim was to perform an external validation of the recently developed SSB Capsule Diagnostic (Dx) score that includes 3 variables (hospital admission with overt bleeding, hemoglobin <6.4 g/dL and age <54 years) and has been shown to be potentially useful in limiting the use of SBCE in SSB low-risk patients.

Retrospectively included all adult patients submitted to SBCE for SSB between November 2007 and December 2019. Patients' demographic, clinical and laboratorial data at the time of SBCE were recorded. Small bowel lesions were classified according to Saurin classification. The SSB Capsule Dx score was calculated, and its calibration and discrimination ability were assessed.

We assessed 473 SBCEs for SSB. Patients' mean age was 61.2 ± 17.9 years and 65.8% were female. P2 lesions were present in 36.2% of SBCEs. There was a significant association between the score and P2 lesions (p < 0.001). Mean score was -0.21 ± 0.87 having a fair accuracy toward the outcome (C-statistic 0.700; 95% confidence interval, 0.652-0.749; p < 0.001). A cutoff value of 0 was found to have a high sensitivity (86.0%) and negative predictive value (84.9%) for the diagnosis of P2 lesions at SBCE.

Patients with a SSB Capsule Dx score <0 are unlikely to have a significant lesion on SBCE, thus its routine use in the clinical practice may be useful in the identification of low-risk SSB patients.

Background: Small bowel capsule endoscopy (SBCE) is an established non-invasive diagnostic modality for a variety of small bowel pathologies and has a significant role in altering the treatment course. The diagnostic yield of SBCE in the published literature varies widely between 45 and 75%. Furthermore, it is unclear if any patient-related factors predict higher diagnostic yield. The aim of this study is to report the diagnostic yield of SBCE for suspected small bowel disease and identify any predictive factors for identifying significant pathology on SBCE. Method: A retrospective study was conducted at Mubarak Al-Kabeer Hospital in Kuwait for patients who underwent SBCE between October 2013 and February 2022. All patients underwent upper and lower endoscopy prior to referral for SBCE. Patients' medical records were reviewed to determine SBCE indications, results, and complications. The significance of the SBCE finding was classified according to the Saurin system. A logistic regression was performed to characterize baseline predictors for identifying significant pathology on SBCE. Results: Overall, 210 patients underwent SBCE and were included in the analysis. The mean age was 57.9 years (SD 18.5), and 129 (61.4%) were males. The most common indication for SBCE was obscure occult gastrointestinal bleed (75.7%), obscure overt gastrointestinal bleed (28.6%), and investigating gastrointestinal symptoms (7.6%). Adequate bowel preparation was achieved in most patients (88.1%), imaging of the entire small bowel was achieved in 194 patients (92.4%), and no adverse events were recorded. The overall diagnostic yield of SBCE for small bowel disease was 68.1%. The most common findings were vascular lesions in the small bowel (40.0%), small bowel ulcers (22.9%), and erosions (22.9%). On multivariate regression analysis, melena at baseline was significantly associated with increased odds of identifying high-risk lesions (Saurin class P2) (OR 2.1, 95%CI 1.03-4.30, p = 0.04). Conclusions: SBCE is an effective and safe tool for investigating small bowel pathology with a diagnostic yield of 68.1% in carefully selected patients undergoing such a test. Melena at baseline is the strongest predictor of identifying high-risk lesions, and patients with which should be prioritized for SBCE.

Heyde syndrome, marked by aortic stenosis, gastrointestinal bleeding from angiodysplasia, and acquired von Willebrand syndrome, is often underreported. Shear stress from a narrowed aortic valve degrades von Willebrand factor multimers, leading to angiodysplasia formation and von Willebrand factor deficiency. This case report aims to raise clinician awareness of Heyde syndrome, its complexity, and the need for a multidisciplinary approach. We present a 75-year-old man with aortic stenosis, gastrointestinal bleeding from angiodysplasia, and acquired von Willebrand syndrome type 2A. The patient was successfully treated with argon plasma coagulation and blood transfusions. He declined further treatment for aortic stenosis but was in good overall health with improved laboratory results during follow-up. Additionally, we provide a comprehensive review of the molecular mechanisms involved in the development of this syndrome, discuss current diagnostic and treatment approaches, and offer future perspectives for further research on this topic.

A 79 year old female individual presented to the hospital and complained of 1 month melena and anemia due to chronic gastrointestinal bleeding because of cavernous hemangiomatosis of the small bowel. After undergoing an initial video laparoscopic jejunal-ileal resection surgery 7 days after first hospitalization, given the persistence of anemia, she underwent laparotomic duodenojejunal resection surgery again 2 months later. Multiple cavernous hemangiomatosis is a rare vascular disease (7-10% of all benign small bowel tumors), and it often manifests with bleeding, which may be occult or massive; more rarely, it manifests with intestinal occlusion or perforation. Diagnoses often require the use of multiple radiological and endoscopic methods; video capsule endoscopy has significantly increased the diagnostic rate. The gold standard of treatment is surgical resection, whenever possible, balancing the need for radicality with the possible metabolic consequences of massive small intestine resections.

Background: Small bowel bleeding (SB) comprises 5%-10% of gastrointestinal (GI) bleeding cases. This article describes the staged retrograde intraoperative enteroscopy (SRIE) surgical technique for the etiological diagnosis and treatment of small bowel bleeding. Methods: SRIE was performed on patients with persistent SB at a quaternary university hospital in Brazil from 2020 to 2023. The technique is described in 5 steps, alongside visual aids, including images and a depicting a portion of the procedure. Patients presenting with confirmed coagulopathies, pregnancy, or unwillingness for surgery were excluded. Surgical procedures were performed after informed consent. Case Series: Four participants were submitted to SRIE, including 2 females (64 and 83 years old), and 2 males (46 and 57 years old). Three out of four (75%) of the patients received a confirmed diagnosis of GI bleeding, attributed to angioectasia, acquired von Willebrand disease, and vitamin K deficiency. SRIE was conducted via enterotomy, involving a subsequent insufflation-inspection-deflation of 10 to 10 cm segments of the small bowel (Steps 1 to 5). The procedure was successfully executed in all four patients without complications, allowing confirmation of the etiological diagnosis of SB or exclusion of anatomical causes of hemorrhage. Conclusions: SRIE is a valuable but invasive tool for assessing SB hemorrhage when conventional imaging falls short. When performed systematically and standardized, it allows accurate visualization of SB using a standard endoscope.

Objective: Integrating artificial intelligence (AI) solutions into clinical practice, particularly in the field of video capsule endoscopy (VCE), necessitates the execution of rigorous clinical studies. Methods: This work introduces a novel software platform tailored to facilitate the conduct of multi-reader multi-case clinical studies in VCE. The platform, developed as a web application, prioritizes remote accessibility to accommodate multi-center studies. Notably, considerable attention was devoted to user interface and user experience design elements to ensure a seamless and engaging interface. To evaluate the usability of the platform, a pilot study is conducted. Results: The results indicate a high level of usability and acceptance among users, providing valuable insights into the expectations and preferences of gastroenterologists navigating AI-driven VCE solutions. Conclusion: This research lays a foundation for future advancements in AI integration within clinical VCE practice.

Obscure gastrointestinal bleed (OGIB), now called small bowel bleed (SBB), comprises 5% to 10% of all gastrointestinal (GI) bleed episodes and capsule endoscopy (CE) is a tool for its evaluation. Studies on CE in a large sample of SBB patients from the tropics are limited.

We did a retrospective analysis of a prospectively maintained database of patients with SBB undergoing CE using PillCam or MiroCam CE.

Of 350 patients (age 52.4 ± 17.4 years; 248 [70.9%] male) undergoing CE, 243 (69.4%) and 107 (30.6%) had overt and occult SBB, respectively. CE detected lesions in 244 (69.7%) patients (single lesion in 172 [49.1%]; multiple in 72 [20.6%]). The single lesions included vascular malformations (52, 14.9%), ulcer/erosion (47, 13.4%), tumor (24, 6.9%), hookworm (19, 5.4%), stricture (15, 4.3%), hemobilia (1, 0.3%) and blood without identifiable lesion (9, 2.6%). Of 72 with multiple lesions, ulcer with stricture was the commonest finding (n = 43, 12.3%). No abnormality was detected in 106 (30.3%) patients. The frequency of lesion detection was comparable among patients with overt and occult SBB (173/243, 71.2% vs. 71/107, 66.3%, respectively; p = 0.4). Younger patients (0 to 39 years) more often had multiple lesions on CE than the older (≥ 40 years) ones (26/76, 34.2% vs. 46/228, 20.2%, respectively; p = 0.001).

CE has a high diagnostic yield in SBB in the tropics, regardless of the type of bleed or of CE brand and the duration of recording. Multiple lesions associated with SBB are commoner among younger (< 40 years) patients.

Heyde syndrome is the cooccurrence of aortic stenosis and gastrointestinal bleeding secondary to vascular lesions, including angiodysplasias. Several studies have demonstrated cessation of gastrointestinal bleeding after transcatheter aortic valve implantation (TAVI), but the etiology and effects on vascular lesions are largely unknown.

To examine the associations of TAVI with gastrointestinal vascular lesions and identify factors associated with recovery among patients with iron deficiency anemia and severe aortic stenosis.

In this prospective, single-center cohort study, patients with iron deficiency anemia on the TAVI waiting list from September 2020 to February 2022 were assessed by capsule endoscopy. Those with vascular lesions were reassessed 6 months after TAVI. Endoscopic images were anonymized and evaluated by 2 independent researchers. Data were analyzed from September 2022 to August 2024.

TAVI.

The primary outcome was the mean difference in the number of vascular lesions before vs after TAVI.

A total of 24 patients (mean [SD] age, 77.4 [7.1] years; 18 [75.0%] male) underwent capsule endoscopy, and vascular lesions were present in 18 patients (75.0%). TAVI was performed in 15 of 18 patients with vascular lesions, of whom 11 agreed to a second capsule endoscopy. The mean (SD) number of vascular lesions across the gastrointestinal tract decreased from 6.4 (5.6) lesions before TAVI to 2.0 (2.1) lesions 6 months after TAVI (P = .04). The number of vascular lesions decreased in 9 of 11 patients (81.8%), including 6 patients (54.5%) who no longer had typical angiodysplasias. Resolution of angiodysplasias was less frequent in patients who had multiple valvular heart disease before TAVI (0 of 3 patients) vs those without multiple valvular heart disease (6 of 8 patients [75.0%]) and in patients with significant paravalvular leakage after TAVI (2 of 5 patients [40.0%]) vs those without significant leakage (4 of 6 patients [66.7%]).

In this cohort study of 24 patients with iron deficiency anemia and severe aortic stenosis, angiodysplasias were present in 75.0% of patients. TAVI was associated with reduced size and number of angiodysplasias in these patients. These findings suggest that TAVI not only improves aortic stenosis but may also reduce gastrointestinal bleeding by resolving vascular lesions, offering a dual benefit for patients with Heyde syndrome.

Gastrointestinal angiodysplasia (GIA) is a common, acquired, vascular abnormality of the digestive tract, and a frequent cause of bleeding. Refractory GIA criteria usually include recurrent bleeding, transfusions and/or repeat endoscopy. Pharmacological and interventional treatments have been the subject of recent high-quality publications. This review provides an overview of the latest updates on non-endoscopic management of refractory GIA. Aortic valve replacement has shown its efficacy in Heyde syndrome and should be considered if indicated. Anti-angiogenic drugs, such as Octreotide and Thalidomide, are efficient treatments of refractory GIA-related bleeding. Somatostatin analogs should, based on efficacy and tolerance profile, be considered first. In the future, a better understanding of the physiopathology of GIA might help develop new-targeted therapies.

Capsule endoscopy (CE) is useful for managing patients with suspected small bowel diseases. However, the effect of prolonged CE examination time on CE performance is unknown.

To evaluate the completeness and diagnostic yield of prolonged CE imaging in patients with suspected small bowel bleeding.

We reviewed consecutive records of adult CE examinations via an overnight protocol from Jan 2016 to Dec 2020 at a tertiary center in Taiwan. We subcategorized the CE records by recording length into within 8 h, within 12 h and throughout the whole procedure and compared the completion rate and diagnostic yield between the groups. Cochran's Q test was used for statistical analysis.

A total of 88 patients were enrolled with 78.4% inpatients (median age 72 years). The small bowel evaluation completion rate was 93.2%, which was significantly greater than the 79.5% rate within 12 h (p = 0.025) and the 58% rate within 8 h (p < 0.001). The diagnostic yield was 83% in the whole-course overnight study, which was significantly greater than the 71.6% diagnostic yield within 8 h (p < 0.001) and similar to the 81.8% diagnostic yield within 12 h.

Prolonged overnight CE examination can improve the completion rate and diagnostic yield and should be considered for routine clinical practice.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of the different endoscopic management approaches for gastrointestinal angiodysplasia in symptomatic adults.