Advertisement
Gastrointestinal Endoscopy
Advanced searchSave search
Editorial| Volume 68, ISSUE 6, P1128-1130, December 2008

Obscure GI bleeding: is capsule endoscopy sufficient?

DOI:https://doi.org/10.1016/j.gie.2008.08.008
Obscure GI bleeding: is capsule endoscopy sufficient?
Previous ArticleNegative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates
Next ArticleStool consistency and stool frequency are excellent clinical markers for adequate colon preparation after polyethylene glycol 3350 cleansing protocol: a prospective clinical study in children

      Abbreviations:

      CE (capsule endoscopy), CTE (CT enteroclysis), DBE (double-balloon enteroscopy), OGIB (obscure GI bleeding)
      As a first-line investigation, we recommend capsule endoscopy over double-balloon endoscopy in view of its noninvasiveness, higher chance to visualize the entire small intestine, and similar diagnostic yield of both investigations.
      For decades, investigation of obscure GI bleeding (OGIB) has often caused frustration in both patients and clinicians. Noninvasive tests, such as small-bowel follow-through, radioisotope-labeled red blood cell scan, and push enteroscopy, have had suboptimal diagnostic yields in the range of 20% to 40%.
      • Rex D.K.
      • Lappas J.C.
      • Maglinte D.D.
      • et al.
      Enteroclysis in the evaluation of suspected small intestinal bleeding.
      Gastroenterology. 1989; 97: 58-60
      , 
      • Olds G.D.
      • Cooper G.S.
      • Chak A.
      • et al.
      The yield of bleeding scans in acute lower gastrointestinal hemorrhage.
      J Clin Gastroenterol. 2005; 39: 273-277
      , 
      • Zaman A.
      • Katon P.M.
      Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a stand endoscope.
      Gastrointest Endosc. 1998; 47: 372-376
      Invasive methods, such as laparotomy or intraoperative enteroscopy, may improve the yield up to 70%.
      • Ress A.M.
      • Benacci J.C.
      • Sarr M.G.
      Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding.
      Am J Surg. 1992; 163: 94-99
      However, complications such as mucosal laceration, avulsion of mesenteric vessels, prolonged ileus, and wound infection are not uncommon, and death has been reported in the literature.
      • Desa L.A.
      • Ohri S.K.
      • Hutton K.A.
      • et al.
      Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin.
      Br J Surg. 1991; 78: 192-195
      Thanks to the latest advancement in miniaturization and wireless technology, we are now capable of containing a color camera, light-emitting diode, battery, and signal transducer in a miniature plastic capsule. A meta-analysis has shown that capsule endoscopy (CE) is superior to barium radiography and push enteroscopy in OGIB.
      • Triester S.L.
      • Leighton J.A.
      • Leontiadis G.I.
      • et al.
      A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding.
      Am J Gastroenterol. 2005; 100: 2407-2418
      Furthermore, CE is well known for its safety and acceptance, and the risk of capsule retention is less than 2%.
      • Li K.
      • Gurudu S.R.
      • De Petris G.
      • et al.
      Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures.
      Gastrointest Endosc. 2008; 68: 174-180
      Given its noninvasiveness and satisfactory diagnostic yield, CE is now recommended as the first-line investigation for OGIB.
      • Raju G.S.
      • Gerson L.
      • Das A.
      • et al.
      American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding.
      Gastroenterology. 2007; 133: 1697-1717
      Although most existing trials only focused on the diagnostic value of CE, few studied its clinical impact on the long-term outcome of OGIB. In a 1-year study based on telephone interview, the negative predictive value of CE for clinical rebleeding was 87%.
      • Saurin J.C.
      • Delvaux M.
      • Vahedi K.
      • et al.
      Clinical impact of capsule endoscopy compared to push enteroscopy: 1-year follow-up study.
      Endoscopy. 2005; 37: 318-323
      In current issue of Gastrointestinal Endoscopy, Macdonald et al
      • Macdonald J.
      • Porter V.
      • McNamara D.
      Negative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates.
      Gastrointest Endosc. 2008; 68: 1122-1127
      present their long-term follow-up data of patients with OGIB. Altogether, 49 patients underwent CE; 42 (86%) of them had complete capsule examination and at least 1 year of follow-up. The study was regarded as “positive” when at least one highly relevant lesion was found (P2), and “negative” when the abnormality found could not explain for blood loss (P1) or when no abnormality (P0) was seen. The overall diagnostic yield was 57% for P2 lesions, and the most commonly found lesion was angiodysplasia (79%). As expected, there exists a significant difference in the clinical rebleeding rate between the positive and negative groups (42% vs 11%, P < .01). Of the 18 negative studies, 5 had P1 lesions, and none of them had rebleeding reported. The negative predictive value was 89%.
      Limited by its inability for biopsy and therapy, the development of CE has been focused on its capacity as a first-line diagnostic tool for OGIB. As demonstrated by Macdonald et al, patients with OGIB had a low risk of rebleeding if CE study was negative. Previously, our group also reported a similar finding, with a rebleeding rate as low as 6% among patients with no lesion (P0) detected after a mean follow-up of 19 months.
      • Lai L.H.
      • Wong G.L.
      • Chow D.K.
      • et al.
      Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy.
      Am J Gastroenterol. 2006; 101: 1224-1228
      Moreover, CE can guide the management of these small-bowel lesions. In a Japanese study, patients with OGIB and a positive CE examination had lower rebleeding rate if a follow-up therapeutic intervention was adopted compared with those without intervention.
      • Endo H.
      • Matsuhashi N.
      • Inamori M.
      • et al.
      Rebleeding rate after interventional therapy directed by capsule endoscopy in patients with obscure gastrointestinal bleeding.
      BMC Gastroenterol. 2008; 8: 12
      Thus, a major advantage of CE is that it can serve as a noninvasive triage tool.
      However, the reliability of CE is challenged by Postgate et al
      • Postgate A.
      • Despott E.
      • Burling D.
      • et al.
      Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy.
      Gastrointest Endosc. 2008; 68: 1209-1214
      in the same issue of Gastrointestinal Endoscopy. They report a case series of 6 patients with a negative CE who had missed conditions. Three of them had large tumors at the distal duodenum or proximal jejunum diagnosed by repeating double-balloon enteroscopy (DBE) and CT enteroclysis (CTE); 1 had a distal duodenal varix diagnosed by DBE, and 1 had a large ileal Peutz-Jeghers polyp detected by magnetic resonance imaging.
      Is CE really reliable as a first-line investigation for OGIB? Before addressing this question, a few factors that are known to affect its diagnostic yield must be considered. In a series of 100 consecutive patients with OGIB, it was found that the diagnostic yield was up to 92% among patients with continuing bleeding, which was significantly higher than those with prior overt bleeding.
      • Pennazio M.
      • Sanucci R.
      • Rondonotti E.
      • et al.
      Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases.
      Gastroenterology. 2004; 126: 643-653
      Similar finding was also reported by Carey et al,
      • Carey E.J.
      • Leighton J.A.
      • Heigh R.I.
      • et al.
      A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding.
      Am J Gastroenterol. 2007; 102: 89-95
      with a pathological condition identified in 87% of patients with continuing bleeding. Therefore, one approach to maximize the diagnostic yield of CE is to perform the study as close to the bleeding episode as possible. The location of bleeding condition has an impact on the outcome of CE as well. In an experimental study using implantable color beads in a canine model, push enteroscopy performed better than CE within the reach of enteroscopy, although the ability to detect implanted beads throughout the whole small bowel was still better with CE.
      • Appleyard M.
      • Fireman Z.
      • Glukhovsky A.
      • et al.
      A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions.
      Gastroenterology. 2000; 119: 1431-1438
      In 2 retrospective clinical studies, CE missed the major duodenal papilla in more than half of the cases.
      • Kong H.
      • Kim Y.S.
      • Hyun J.J.
      • et al.
      Limited ability of capsule endoscopy to detect normally positioned duodenal papilla.
      Gastrointest Endosc. 2006; 64: 538-541
      , 
      • Clarke J.O.
      • Giday S.A.
      • Magno P.
      • et al.
      How good is capsule endoscopy for detection of periampullary lesions? Results of a tertiary-referral center.
      Gastrointest Endosc. 2008; 68: 267-272
      The suboptimal performance of CE in the proximal small bowel, in particular the duodenum, is not surprising. Because peristalsis is more vigorous in proximal small intestine,
      • Husebye E.
      The patterns of small bowel motility: physiology and implications in organic disease and functional disorders.
      Neurogastroenterol Motil. 1999; 11: 141-161
      without the aid of insufflation and locomotion control, CE is more likely to miss a subtle condition, especially if it is behind a mucosal fold and not actively bleeding. To complicate the issue more, complete small-bowel examination is never guaranteed in a CE study. In the literature, up to 25% of patients failed to have CE to reach the cecum within the limited battery life.
      • Selby W.
      Complete small-bowel transit in patients undergoing capsule endoscopy: determining factors and improvement with metoclopramide.
      Gastrointest Endosc. 2005; 61: 80-85
      To date, it is controversial to suggest any usage of bowel preparation or prokinetic agent to improve the complete small-bowel examination rate, although the utility of a real-time viewer has been suggested as a guide for the bowel preparation regimen.
      • Niv Y.
      Efficiency of bowel preparation for capsule endoscopy examinations: a meta-analysis.
      World J Gastroenterol. 2008; 14: 1313-1317
      , 
      • Lai L.H.
      • Wong G.L.
      • Lau J.Y.
      • et al.
      Initial experience of real-time capsule endoscopy in monitoring progress of the videocapsule through the upper GI tract.
      Gastrointest Endosc. 2007; 66: 1211-1214
      Last but not least, interobserver variation is a well-known problem in the interpretation of CE findings.
      • De Leusse A.
      • Landi B.
      • Edery J.
      • et al.
      Video capsule endoscopy for investigation of obscure gastrointestinal bleeding: feasibility, results, and interobserver agreement.
      Endoscopy. 2005; 37: 617-621
      , 
      • Lai L.H.
      • Wong G.L.
      • Chow D.K.
      • et al.
      Inter-observer variations on interpretation of capsule endoscopies.
      Eur J Gastroenterol Hepatol. 2006; 18: 283-286
      , 
      • Rondonotti E.
      • Spada C.
      • Cave D.
      • et al.
      Video capsule enteroscopy in the diagnosis of celiac disease: a multicenter study.
      Am J Gastroenterol. 2007; 102: 1624-1631
      The reproducibility of CE results can always be challenged, especially because we cannot obtain histological proof.
      Is there any way to optimize the diagnostic yield of OGIB? CE study should be conducted close to the bleeding episode, and CE videoclip should be reread by a second endoscopist. We cannot emphasize more the role of second-look EGD. In a prospective trial studying the role of push enteroscopy in OGIB, it was found that 26.3% of bleeding sources were missed by the initial EGD.
      • Zaman A.
      • Katon P.M.
      Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a stand endoscope.
      Gastrointest Endosc. 1998; 47: 372-376
      Some lesions are easily overlooked, such as Cameron ulcers, Dieulafoy lesions, vascular ectasias, gastric antral vascular ectasia, and peptic ulcers at certain sites (eg, higher lesser curve, posterior wall of duodenal bulb). We do recommend a second-look EGD with special attention to the “blind spots” of CE, such as the duodenum, before a patient is labeled as having OGIB. Second-look CE has also been suggested for patients with a prior nondiagnostic CE. Bar-Meir et al
      • Bar-Meir S.
      • Eliakim R.
      • Nadler M.
      • et al.
      Second capsule endoscopy for patients with severe iron deficiency anemia.
      Gastrointest Endosc. 2004; 60: 711-713
      reported that 7 of a series of 20 patients (35%) who underwent second-look CE had positive or suspicious findings. Another study published in abstract form found that repeating CE within a short interval improved the diagnostic yield.
      • Kimble J.S.
      • Wong R.C.
      • Chak A.
      • et al.
      Variation in diagnostic yield of back-to-back capsule endoscopy in obscure GI bleeding: preliminary results.
      Gastrointest Endosc. 2006; 63 ([abstract]) (AB90)
      However, these preliminary data need to be confirmed by prospective trials with robust economic modeling. Other technical advancements, such as the introduction of a wireless power receiver, can make unlimited power supply possible.
      • Ryu M.
      • Kim J.D.
      • Chin H.U.
      • et al.
      Three-dimensional power receiver for in vivo robotic capsules.
      Med Biol Eng Comput. 2007; 45: 997-1002
      This may allow improvement of luminal visualization of CE by coupling with a second backward camera and viewing with a higher frame rate, such as the esophageal capsule.
      • Gralnek I.M.
      • Adler S.N.
      • Yassin K.
      • et al.
      Detecting esophageal disease with second-generation capsule endoscopy: initial evaluation of the PillCam ESO 2.
      Endoscopy. 2008; 40: 275-279
      The etiology of OGIB is another important factor when deciding its first-line investigation. Unfortunately, comprehensive epidemiological studies for OGIB are lacking. Data from a cohort of 260 CE studies showed that angiodysplasia constituted more than 60% of the OGIB cases.
      • Carey E.J.
      • Leighton J.A.
      • Heigh R.I.
      • et al.
      A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding.
      Am J Gastroenterol. 2007; 102: 89-95
      Such vascular lesions are notoriously difficult to treat. Small-bowel tumors, on the other hand, are rare. In a multicenter study involving 5129 patients with CE performed, only 2.4% of patients were found to have small-bowel tumors.
      • Rondonotti E.
      • Pennazio M.
      • Toth E.
      • et al.
      Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study.
      Endoscopy. 2008; 40: 488-495
      Large population-based cancer registries also confirm that small-bowel malignancies are extremely rare, with an overall annual incidence of less than 10 per million population.
      • Weiss N.S.
      • Yang C.P.
      Incidence of histologic types of cancer of the small intestine.
      J Natl Cancer Inst. 1987; 78: 653-656
      The most common form, adenocarcinoma, is found in duodenum and jejunum in three fourths of the cases and should be reachable by EGD.
      • Dabaja B.S.
      • Suki D.
      • Pro B.
      • et al.
      Adenocarcinoma of the small bowel: presentation, prognostic factors, and outcome of 217 patients.
      Cancer. 2004; 101: 518-526
      Newer advancements in imaging, such as CTE, certainly improve the diagnostic yield on small-bowel neoplasms.
      • Pilleul F.
      • Penigaud M.
      • Milot L.
      • et al.
      Possible small-bowel neoplasms: contrast-enhanced and water-enhanced multidetector CT enteroclysis.
      Radiology. 2006; 241: 796-801
      Although CTE has theoretic advantages over CE in detecting extraluminal extension of any small-bowel tumor, several comparison studies did not reveal any significant difference between the 2 modalities in tumor detection.
      • Voderholzer W.A.
      • Ortner M.
      • Rogalla P.
      • et al.
      Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis.
      Endoscopy. 2003; 35: 1009-1014
      , 
      • Johanssen S.
      • Boivin M.
      • Lochs H.
      • et al.
      The yield of wireless capsule endoscopy in the detection of neuroendocrine tumors in comparison with CT enteroclysis.
      Gastrointest Endosc. 2006; 63: 660-665
      , 
      • Rajesh A.
      • Sandrasegaran K.
      • Jennings S.G.
      • et al.
      Comparison of capsule endoscopy with enteroclysis in the investigation of small bowel disease.
      Abdom Imaging. 2008 Jun 11; ([Epub ahead of print])
      Therefore, a conservative approach with regular follow-up may be adequate after a negative CE for OGIB.
      Discussion of the management of OGIB is never complete without mentioning DBE. Its advantages over CE include its ability to obtain histological specimens and perform therapeutic procedures. In a meta-analysis of 11 head-to-head comparison studies with a total of 350 patients with OGIB, the overall diagnostic yields of both procedures were comparable (57% vs 60%, weighted incremental yield 3%, 95% CI –4% to 10%, P = .42, finite element method algorithm [FEM]).
      • Pasha S.F.
      • Leighton J.A.
      • Das A.
      • et al.
      Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis.
      Clin Gastroenterol Hepatol. 2008; 6: 671-676
      DBE has been suggested to be more cost-effective than CE in OGIB, but such analysis is debatable.
      • Gerson L.
      • Kamal A.
      Cost-effectivenes analysis of management strategies for obscure GI bleeding.
      Gastrointest Endosc. 2008 Apr 11; ([Epub ahead of print])
      As a first-line investigation, we recommend CE over DBE in view of its noninvasiveness, its higher chance to visualize the entire small intestine, and the similar diagnostic yield of both investigations.
      Although there is inadequacy in the current CE technology, it is by far the most appropriate first-line investigation for OGIB in terms of diagnostic yield and comfort to the patient. A second-look EGD should always be considered before diagnosing a patient to have OGIB, and attention must be paid to optimize the diagnostic yield of CE. Future technology can be beyond our imagination. One day we may be able to use a wireless robot to manipulate the entire GI tract at our fingertips. As quoted by Bertrand Russell, the Nobel Prize winner, “Science may set limits to knowledge, but should not set limits to imagination.”

      Disclosure

      The author reports that there are no disclosures relevant to this publication.

      References

        • Rex D.K.
        • Lappas J.C.
        • Maglinte D.D.
        • et al.
        Enteroclysis in the evaluation of suspected small intestinal bleeding.
        Gastroenterology. 1989; 97: 58-60
        View in Article
        • Olds G.D.
        • Cooper G.S.
        • Chak A.
        • et al.
        The yield of bleeding scans in acute lower gastrointestinal hemorrhage.
        J Clin Gastroenterol. 2005; 39: 273-277
        View in Article
        • Zaman A.
        • Katon P.M.
        Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a stand endoscope.
        Gastrointest Endosc. 1998; 47: 372-376
        View in Article
        • Ress A.M.
        • Benacci J.C.
        • Sarr M.G.
        Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding.
        Am J Surg. 1992; 163: 94-99
        View in Article
        • Desa L.A.
        • Ohri S.K.
        • Hutton K.A.
        • et al.
        Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin.
        Br J Surg. 1991; 78: 192-195
        View in Article
        • Triester S.L.
        • Leighton J.A.
        • Leontiadis G.I.
        • et al.
        A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding.
        Am J Gastroenterol. 2005; 100: 2407-2418
        View in Article
        • Li K.
        • Gurudu S.R.
        • De Petris G.
        • et al.
        Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures.
        Gastrointest Endosc. 2008; 68: 174-180
        View in Article
        • Raju G.S.
        • Gerson L.
        • Das A.
        • et al.
        American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding.
        Gastroenterology. 2007; 133: 1697-1717
        View in Article
        • Saurin J.C.
        • Delvaux M.
        • Vahedi K.
        • et al.
        Clinical impact of capsule endoscopy compared to push enteroscopy: 1-year follow-up study.
        Endoscopy. 2005; 37: 318-323
        View in Article
        • Macdonald J.
        • Porter V.
        • McNamara D.
        Negative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates.
        Gastrointest Endosc. 2008; 68: 1122-1127
        View in Article
        • Lai L.H.
        • Wong G.L.
        • Chow D.K.
        • et al.
        Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy.
        Am J Gastroenterol. 2006; 101: 1224-1228
        View in Article
        • Endo H.
        • Matsuhashi N.
        • Inamori M.
        • et al.
        Rebleeding rate after interventional therapy directed by capsule endoscopy in patients with obscure gastrointestinal bleeding.
        BMC Gastroenterol. 2008; 8: 12
        View in Article
        • Postgate A.
        • Despott E.
        • Burling D.
        • et al.
        Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy.
        Gastrointest Endosc. 2008; 68: 1209-1214
        View in Article
        • Pennazio M.
        • Sanucci R.
        • Rondonotti E.
        • et al.
        Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases.
        Gastroenterology. 2004; 126: 643-653
        View in Article
        • Carey E.J.
        • Leighton J.A.
        • Heigh R.I.
        • et al.
        A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding.
        Am J Gastroenterol. 2007; 102: 89-95
        View in Article
        • Appleyard M.
        • Fireman Z.
        • Glukhovsky A.
        • et al.
        A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions.
        Gastroenterology. 2000; 119: 1431-1438
        View in Article
        • Kong H.
        • Kim Y.S.
        • Hyun J.J.
        • et al.
        Limited ability of capsule endoscopy to detect normally positioned duodenal papilla.
        Gastrointest Endosc. 2006; 64: 538-541
        View in Article
        • Clarke J.O.
        • Giday S.A.
        • Magno P.
        • et al.
        How good is capsule endoscopy for detection of periampullary lesions? Results of a tertiary-referral center.
        Gastrointest Endosc. 2008; 68: 267-272
        View in Article
        • Husebye E.
        The patterns of small bowel motility: physiology and implications in organic disease and functional disorders.
        Neurogastroenterol Motil. 1999; 11: 141-161
        View in Article
        • Selby W.
        Complete small-bowel transit in patients undergoing capsule endoscopy: determining factors and improvement with metoclopramide.
        Gastrointest Endosc. 2005; 61: 80-85
        View in Article
        • Niv Y.
        Efficiency of bowel preparation for capsule endoscopy examinations: a meta-analysis.
        World J Gastroenterol. 2008; 14: 1313-1317
        View in Article
        • Lai L.H.
        • Wong G.L.
        • Lau J.Y.
        • et al.
        Initial experience of real-time capsule endoscopy in monitoring progress of the videocapsule through the upper GI tract.
        Gastrointest Endosc. 2007; 66: 1211-1214
        View in Article
        • De Leusse A.
        • Landi B.
        • Edery J.
        • et al.
        Video capsule endoscopy for investigation of obscure gastrointestinal bleeding: feasibility, results, and interobserver agreement.
        Endoscopy. 2005; 37: 617-621
        View in Article
        • Lai L.H.
        • Wong G.L.
        • Chow D.K.
        • et al.
        Inter-observer variations on interpretation of capsule endoscopies.
        Eur J Gastroenterol Hepatol. 2006; 18: 283-286
        View in Article
        • Rondonotti E.
        • Spada C.
        • Cave D.
        • et al.
        Video capsule enteroscopy in the diagnosis of celiac disease: a multicenter study.
        Am J Gastroenterol. 2007; 102: 1624-1631
        View in Article
        • Bar-Meir S.
        • Eliakim R.
        • Nadler M.
        • et al.
        Second capsule endoscopy for patients with severe iron deficiency anemia.
        Gastrointest Endosc. 2004; 60: 711-713
        View in Article
        • Kimble J.S.
        • Wong R.C.
        • Chak A.
        • et al.
        Variation in diagnostic yield of back-to-back capsule endoscopy in obscure GI bleeding: preliminary results.
        Gastrointest Endosc. 2006; 63 ([abstract]) (AB90)
        View in Article
        • Ryu M.
        • Kim J.D.
        • Chin H.U.
        • et al.
        Three-dimensional power receiver for in vivo robotic capsules.
        Med Biol Eng Comput. 2007; 45: 997-1002
        View in Article
        • Gralnek I.M.
        • Adler S.N.
        • Yassin K.
        • et al.
        Detecting esophageal disease with second-generation capsule endoscopy: initial evaluation of the PillCam ESO 2.
        Endoscopy. 2008; 40: 275-279
        View in Article
        • Rondonotti E.
        • Pennazio M.
        • Toth E.
        • et al.
        Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study.
        Endoscopy. 2008; 40: 488-495
        View in Article
        • Weiss N.S.
        • Yang C.P.
        Incidence of histologic types of cancer of the small intestine.
        J Natl Cancer Inst. 1987; 78: 653-656
        View in Article
        • Dabaja B.S.
        • Suki D.
        • Pro B.
        • et al.
        Adenocarcinoma of the small bowel: presentation, prognostic factors, and outcome of 217 patients.
        Cancer. 2004; 101: 518-526
        View in Article
        • Pilleul F.
        • Penigaud M.
        • Milot L.
        • et al.
        Possible small-bowel neoplasms: contrast-enhanced and water-enhanced multidetector CT enteroclysis.
        Radiology. 2006; 241: 796-801
        View in Article
        • Voderholzer W.A.
        • Ortner M.
        • Rogalla P.
        • et al.
        Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis.
        Endoscopy. 2003; 35: 1009-1014
        View in Article
        • Johanssen S.
        • Boivin M.
        • Lochs H.
        • et al.
        The yield of wireless capsule endoscopy in the detection of neuroendocrine tumors in comparison with CT enteroclysis.
        Gastrointest Endosc. 2006; 63: 660-665
        View in Article
        • Rajesh A.
        • Sandrasegaran K.
        • Jennings S.G.
        • et al.
        Comparison of capsule endoscopy with enteroclysis in the investigation of small bowel disease.
        Abdom Imaging. 2008 Jun 11; ([Epub ahead of print])
        View in Article
        • Pasha S.F.
        • Leighton J.A.
        • Das A.
        • et al.
        Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis.
        Clin Gastroenterol Hepatol. 2008; 6: 671-676
        View in Article
        • Gerson L.
        • Kamal A.
        Cost-effectivenes analysis of management strategies for obscure GI bleeding.
        Gastrointest Endosc. 2008 Apr 11; ([Epub ahead of print])
        View in Article

      Article info

      Identification

      DOI: https://doi.org/10.1016/j.gie.2008.08.008

      Copyright

      © 2008 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

      ScienceDirect

      Access this article on ScienceDirect
      We use cookies to help provide and enhance our service and tailor content. To update your cookie settings, please visit the for this site.
      Copyright © 2023 Elsevier Inc. except certain content provided by third parties. The content on this site is intended for healthcare professionals.


      RELX