Negative Video Capsule Endoscopy Had Very High Negative Predictive Value For Small Bowel Lesions, But Beware Of Young Patients

Video capsule endoscopy (VCE) has good diagnostic yield in patients with potential small bowel bleeding. However, the rebleeding rate after negative VCE has been reported to be as high as 20%. Recognizing what types of lesion that are usually missed by VCE and predictors of rebleeding after negative VCE would guide physicians to pursue additional investigation in order to treat their patients appropriately. A retrospective study in a single tertiary care center was conducted. We included all patients who presented with potential small bowel bleeding and had normal small bowel VCE from January 2008 to December 2016. All patients were required to have a follow-up period of at least 2 years. Patients were interviewed by telephone for any rebleeding episodes if their medical record during follow-up period were not available. Missed lesions on VCE were defined as those that were found by other investigations during the same bleeding episode or any lesions subsequently found during rebleeding episodes. One-hundred and seventy-eight potential small bowel bleeding patients had normal VCE findings. Thirty-five patients were excluded due to follow-up period of less than 2 years, resulting in 143 patients being included in the analyses. The mean age was 60.7 years, and 52.4% were male. Eighty-two (58.2%) patients presented with overt bleeding. The median duration of follow up was 5.1 years (range 2.2 – 11.7 years). During follow-up period, 30 (21%) patients rebled. The causes of rebleeding were in small bowel in 5 (16.7%) patients including 3 small bowel tumors, 1 angiodysplasia, 1 Meckel’s diverticulum. Six-teen (53.3%) patients were found to have bleeding site in upper or lower GI tract. One patient was diagnosed with anemia from chronic kidney disease. Bleeding cause could not be identified in 8 (26.6%) patients. Univariate analysis showed male gender, smoking, use of nonsteroidal anti-inflammatory agent (NSAID), and presentation of overt bleeding were significant predictors for rebleeding. Use of NSAID and overt bleeding remained significant in multivariate analysis as shown in Table 1. Among patients who did not rebleed, 4 had culprit lesions in small bowel demonstrated by other investigations including 2 small bowel tumors, 1 ileal ulcer, and 1 Meckel’s diverticulum. Therefore, in total, there were 9 significant small bowel lesions (6.3%) missed by VCE. These 9 patients, when compared to others, were significantly younger (Table 2). Rebleeding was not uncommon in potential small bowel bleeding after negative VCE; however, majority of rebleeding was non-small bowel in origin. Use of NSAID and overt bleeding were independent predictors for rebleeding. Although the missed rate by VCE was low, further investigations may be considered in the patients with negative VCE who are young.Table 2Characteristics of patients whose lesions were or were not missed by video capsule endoscopyView Large Image Figure ViewerDownload Hi-res image Download (PPT)