Background and Aim. Angioectasias are the most common vascular anomalies found in the gastrointestinal tract. In small bowel (SB), they can cause obscure gastrointestinal bleeding (OGIB) and in this setting, small bowel capsule endoscopy (SBCE) is an important diagnostic tool. This study aimed to identify predictive factors for the presence of SB angioectasias, detected by SBCE. Methods. We retrospectively analyzed the results of 284 consecutive SBCE procedures between April 2006 and December 2012, whose indication was OGIB, of which 47 cases with SB angioectasias and 53 controls without vascular lesions were selected to enter the study. Demographic and clinical data were collected. Results. The mean age of subjects with angioectasias was significantly higher than in controls ; . The presence of SB angioectasias was significantly higher when the indication for the exam was overt OGIB versus occult OGIB (13/19 versus 34/81, . Hypertension and hypercholesterolemia were significantly associated with the presence of SB angioectasias (38/62 versus 9/38, and 28/47 versus 19/53, , resp.). Other studied factors were not associated with small bowel angioectasias. Conclusions. In patients with OGIB, overt bleeding, older age, hypercholesterolemia, and hypertension are predictive of the presence of SB angioectasias detected by SBCE, which may be used to increase the diagnostic yield of the SBCE procedure and to reduce the proportion of nondiagnostic examinations. 1. Introduction Obscure gastrointestinal bleeding (OGIB) remains one of the most challenging issues for gastroenterologists. It is defined as bleeding from gastrointestinal (GI) tract that persists or recurs without obvious etiology after esophagogastroduodenoscopy (EGD), colonoscopy, and radiologic evaluation of the small bowel (SB). OGIB accounts for about 5% of the cases of gastrointestinal bleeding [1]. The source of bleeding is located in the SB in about 75% of cases, where lesions can be scarcely accessed by standard endoscopy [1, 2]. These patients frequently require several blood transfusions and repeated hospital admissions, being at risk for complications not only related to anemia, but also caused by numerous exploratory procedures [3]. As a consequence, OGIB negatively affects patients’ quality of life and represents a significant burden of healthcare resources [3]. Small bowel capsule endoscopy (SBCE) has become a particularly useful tool in the management of OGIB, which remains the most common indication for the procedure [4]. Several studies have confirmed the higher diagnostic yield of
References
[1]
G. S. Raju, L. Gerson, A. Das, and B. Lewis, “American Gastroenterological Association (AGA) Institute Technical Review on Obscure Gastrointestinal Bleeding,” Gastroenterology, vol. 133, no. 5, pp. 1697–1717, 2007.
[2]
A. de Leusse, K. Vahedi, J. Edery et al., “Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?” Gastroenterology, vol. 132, no. 3, pp. 855–862, 2007.
[3]
F. Li, J. A. Leighton, and V. K. Sharma, “Capsule endoscopy in the evaluation of obscure gastrointestinal bleeding: a comprehensive review,” Gastroenterology and Hepatology, vol. 3, no. 10, pp. 777–785, 2007.
[4]
Z. Liao, R. Gao, C. Xu, and Z.-S. Li, “Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review,” Gastrointestinal Endoscopy, vol. 71, no. 2, pp. 280–286, 2010.
[5]
S. L. Triester, J. A. Leighton, G. I. Leontiadis et al., “A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding,” The American Journal of Gastroenterology, vol. 100, no. 11, pp. 2407–2418, 2005.
[6]
W. A. Voderholzer, M. Ortner, P. Rogalla, J. Beinh？lzl, and H. Lochs, “Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis,” Endoscopy, vol. 35, no. 12, pp. 1009–1014, 2003.
[7]
E. Saperas, J. Dot, S. Videla et al., “Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding,” The American Journal of Gastroenterology, vol. 102, no. 4, pp. 731–737, 2007.
[8]
D. Hartmann, H. Schmidt, G. Bolz et al., “A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding,” Gastrointestinal Endoscopy, vol. 61, no. 7, pp. 826–832, 2005.
[9]
S. K. G？lder, A. G. Schreyer, E. Endlicher et al., “Comparison of capsule endoscopy and magnetic resonance (MR) enteroclysis in suspected small bowel disease,” International Journal of Colorectal Disease, vol. 21, no. 2, pp. 97–104, 2006.
[10]
M. Nakamura, Y. Niwa, R. Miyahara et al., “Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding,” Endoscopy, vol. 38, no. 1, pp. 59–66, 2006.
[11]
K. Liu and A. J. Kaffes, “Review article: the diagnosis and investigation of obscure gastrointestinal bleeding,” Alimentary Pharmacology and Therapeutics, vol. 34, no. 4, pp. 416–423, 2011.
[12]
G. Bresci, “Occult and obscure gastrointestinal bleeding: Causes and diagnostic approach in 2009,” World Journal of Gastrointestinal Endoscopy, vol. 1, pp. 3–6, 2009.
[13]
J. Regula, E. Wronska, and J. Pachlewski, “Vascular lesions of the gastrointestinal tract,” Best Practice and Research, vol. 22, no. 2, pp. 313–328, 2008.
[14]
M. Kovacs, P. Pak, G. Pak, J. Feher, and K. Huttl, “Multiple angiodysplasias diagnosed by capsule endoscopy,” Orvosi Hetilap, vol. 148, pp. 2435–2440, 2007.
[15]
A. T. DeBenedet, S. D. Saini, M. Takami, and L. R. Fisher, “Do clinical characteristics predict the presence of small bowel angioectasias on capsule endoscopy?” Digestive Diseases and Sciences, vol. 56, no. 6, pp. 1776–1781, 2011.
[16]
S. D. Ladas, K. Triantafyllou, C. Spada et al., “European Society of Gastrointestinal Endoscopy (ESGE): Recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic diseases,” Endoscopy, vol. 42, no. 3, pp. 220–227, 2010.
[17]
D. S. Mishkin, R. Chuttani, J. Croffie et al., “ASGE Technology Status Evaluation Report: Wireless capsule endoscopy,” Gastrointestinal Endoscopy, vol. 63, no. 4, pp. 539–545, 2006.
[18]
A. K. Hara, J. A. Leighton, V. K. Sharma, R. I. Heigh, and D. E. Fleischer, “Imaging of small bowel disease: comparison of capsule endoscopy, standard endoscopy, barium examination, and CT,” Radiographics, vol. 25, no. 3, pp. 697–711, 2005.
[19]
T. Yamada and D. H. Alpers, Textbook of Gastroenterology, Lippincott Williams and Wilkins, Philadelphia, Pa, USA, 4th edition, 2003.
[20]
F. Junquera, E. Saperas, I. De Torres, M. T. Vidai, and J.-R. Malagelada, “Increased expression of angiogenic factors in human colonic angiodysplasia,” The American Journal of Gastroenterology, vol. 94, no. 4, pp. 1070–1076, 1999.
[21]
D. E. Roskell, S. C. Biddolph, and B. F. Warren, “Apparent deficiency of mucosal vascular collagen type IV associated with angiodysplasia of the colon,” Journal of Clinical Pathology, vol. 51, no. 1, pp. 18–20, 1998.
[22]
P. Tsibouris, C. Kalantzis, P. Apostolopoulos, G. Alexandrakis, P. Mavrogianni, and N. Kalantzis, “Capsule endoscopy findings in patients with occult or overt bleeding older than 80 years,” Digestive Endoscopy, vol. 24, no. 3, pp. 154–158, 2012.
[23]
M. Pennazio, R. Santucci, E. Rondonotti et al., “Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases,” Gastroenterology, vol. 126, no. 3, pp. 643–653, 2004.
[24]
W. Selby, “Can clinical features predict the likelihood of finding abnormalities when using capsule endoscopy in patients with GI bleeding of obscure origin?” Gastrointestinal Endoscopy, vol. 59, no. 7, pp. 782–787, 2004.
[25]
M. Pennazio, G. Eisen, and N. Goldfarb, “ICCE consensus for obscure gastrointestinal bleeding,” Endoscopy, vol. 37, no. 10, pp. 1046–1050, 2005.
[26]
M. Esaki, T. Matsumoto, S. Yada et al., “Factors associated with the clinical impact of capsule endoscopy in patients with overt obscure gastrointestinal bleeding,” Digestive Diseases and Sciences, vol. 55, no. 8, pp. 2294–2301, 2010.
[27]
S. Ueno, H. Nakase, K. Kasahara et al., “Clinical features of Japanese patients with colonic angiodysplasia,” Journal of Gastroenterology and Hepatology, vol. 23, no. 8, pp. e363–e366, 2008.
[28]
J. MacDonald, V. Porter, N. W. Scott, and D. McNamara, “Small bowel lymphangiectasia and angiodysplasia: a positive association; Novel clinical marker or shared pathophysiology?” Journal of Clinical Gastroenterology, vol. 44, no. 9, pp. 610–614, 2010.
[29]
M. A. Creager, T. F. Lüscher, F. Cosentino, and J. A. Beckman, “Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy. Part I,” Circulation, vol. 108, no. 12, pp. 1527–1532, 2003.
[30]
H. K. Saini, A. S. Arneja, and N. S. Dhalla, “Role of cholesterol in cardiovascular dysfunction,” Canadian Journal of Cardiology, vol. 20, no. 3, pp. 333–346, 2004.
[31]
M. Battistel, M. Plebani, F. Di Mario, M. Jocic, I. T. Lippe, and P. Holzer, “Chronic nicotine intake causes vascular dysregulation in the rat gastric mucosa,” Gut, vol. 34, no. 12, pp. 1688–1692, 1993.
[32]
M. Moshkowitz, S. Brill, F. M. Konikoff, M. Averbuch, N. Arber, and Z. Halpern, “Additive deleterious effect of smoking on gastroduodenal pathology and clinical course in Helicobacter pylori-positive dyspeptic patients,” Israel Medical Association Journal, vol. 2, no. 12, pp. 892–895, 2000.
[33]
M. S. Cappell and A. Gupta, “Changing epidemiology of gastrointestinal angiodysplasia with increasing recognition of clinically milder cases: angiodysplasia tend to produce mild chronic gastrointestinal bleeding in a study of 47 consecutive patients admitted from 1980–1989,” The American Journal of Gastroenterology, vol. 87, no. 2, pp. 201–206, 1992.
[34]
Y. Sekino, H. Endo, E. Yamada, et al., “Clinical associations and risk factors for bleeding from colonic angiectasia: a case-controlled study,” Colorectal Disease, vol. 14, pp. 740–746, 2012.
[35]
N. Chalasani, G. Cotsonis, and C. M. Wilcox, “Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia,” The American Journal of Gastroenterology, vol. 91, no. 11, pp. 2329–2332, 1996.
[36]
G. Galanopoulos, “Angiodysplastic lesions as a cause of colonic bleeding in patients with chronic renal disease: is there an association?” Saudi Journal of Kidney Diseases and Transplantation, vol. 23, pp. 925–928, 2012.
[37]
A. Vaz, A. Correia, B. Martins et al., “Heyde syndrome: the link between aortic stenosis and gastrointestinal bleeding,” Revista Portuguesa de Cardiologia, vol. 29, no. 2, pp. 309–314, 2010.
[38]
S. Naveau, P. Bedossa, T. Poynard, B. Mory, and J.-C. Chaput, “Portal hypertensive colopathy: a new entity,” Digestive Diseases and Sciences, vol. 36, no. 12, pp. 1774–1781, 1991.
[39]
C. Balzer, E. Lotterer, G. Kleber, and W. E. Fleig, “Transjugular intrahepatic portosystemic shunt for bleeding angiodysplasia-like lesions in portal-hypertensive colopathy,” Gastroenterology, vol. 115, no. 1, pp. 167–172, 1998.
[40]
N. Yuki, M. Kubo, Y. Noro et al., “Jejunal varices as a cause of massive gastrointestinal bleeding,” The American Journal of Gastroenterology, vol. 87, no. 4, pp. 514–517, 1992.
[41]
Y.-E. Joo, H.-S. Kim, S.-K. Choi, J.-S. Rew, H.-R. Kim, and S.-J. Kim, “Massive gastrointestinal bleeding from jejunal varices,” Journal of Gastroenterology, vol. 35, no. 10, pp. 775–778, 2000.
[42]
S. J. B. Van Weyenberg, S. T. Van Turenhout, M. A. Jacobs, G. Bouma, and C. J. J. Mulder, “Video capsule endoscopy for previous overt obscure gastrointestinal bleeding in patients using anti-thrombotic drugs,” Digestive Endoscopy, vol. 24, pp. 247–254, 2012.
[43]
T. Matsumura, M. Arai, S. Sazuka et al., “Negative capsule endoscopy for obscure gastrointestinal bleeding is closely associated with the use of low-dose aspirin,” Scandinavian Journal of Gastroenterology, vol. 46, no. 5, pp. 621–626, 2011.
[44]
H. Imagawa, S. Oka, S. Tanaka et al., “Improved detectability of small-bowel lesions via capsule endoscopy with computed virtual chromoendoscopy: a pilot study,” Scandinavian Journal of Gastroenterology, vol. 46, no. 9, pp. 1133–1137, 2011.
[45]
Y. Kobayashi, H. Watabe, A. Yamada, et al., “Efficacy of flexible spectral imaging color enhancement on the detection of small intestinal diseases,” Journal of Diagnostic Diseases, vol. 13, pp. 614–620, 2012.
[46]
G. Duque, N. Almeida, P. Figueiredo, et al., “Virtual chromoendoscopy can be a useful software tool in capsule endoscopy,” Revista Espanola de enfermedades Digestivas, vol. 104, no. 5, pp. 231–236, 2012.
