Elsevier

Gastrointestinal Endoscopy

Volume 85, Issue 2, February 2017, Pages 305-317.e2
Gastrointestinal Endoscopy

Systematic review and meta-analysis
Clinical outcomes of negative small-bowel capsule endoscopy for small-bowel bleeding: a systematic review and meta-analysis

https://doi.org/10.1016/j.gie.2016.08.027Get rights and content

Background and Aims

Small-bowel bleeding is the primary indication for capsule endoscopy (CE). Many experts advocate a “watch-and-wait” policy in negative CE. This meta-analysis examines the odds of rebleeding after negative index CE and the impact on long-term follow-up.

Methods

A comprehensive literature search identified articles examining the rebleeding rate after negative CE. Demographic and clinical information with emphasis on outcomes was retrieved, pooled, and analyzed. Heterogeneity among studies was assessed using the I2 statistic. A random effects model was used as the pooling method because of high heterogeneity. Risk of bias was assessed using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. The primary outcome evaluated was the pooled odds ratios (ORs) for rebleeding after a negative CE for obscure GI bleeding (OGIB).

Results

Twenty-six studies with 3657 patients were included. The pooled rate of rebleeding after negative CE was .19 (95% CI, .14-.25; P < .0001). The pooled OR of rebleeding was .59 (95% CI, .37-.95; P < .001). The effect was more pronounced in studies with a short follow-up (OR, .47; 95% CI, .24-.94; P < .001). There was no statistically significant difference in rebleeding after CE for occult and overt OGIB. Prospective studies showed a lower OR of rebleeding of .24 (95% CI, .08-.73; P = .01). Most studies were high quality.

Conclusions

Our analysis shows that negative CE provides adequate evidence of a subsequently low risk of rebleeding. Such patients can therefore be safely managed with watchful waiting. However, patients who rebleed after 2 years may need to be investigated for a new source of blood loss.

Section snippets

Study selection

This study was constructed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.8 A comprehensive literature search was conducted using the PubMed and Embase databases (January 2000 to November 2015). The search was performed on November 12, 2015. To capture as many articles and abstracts as possible, a broad search strategy was used by combining the terms “capsule endoscopy,” “negative OR normal,” “obscure gastrointestinal bleeding,” “iron

Results

The process of selection of studies for inclusion in this meta-analysis is detailed in the flow diagram in Figure 1. In total, 61 titles were initially identified with the aforementioned search strategy; no further articles were identified from reference list review. Of those, 28 studies were excluded after preliminary review of the titles and/or abstracts, leaving 33 articles for further detailed evaluation. Seven more articles were excluded after full-text review.

Discussion

The use of SBCE has changed the clinical management of patients with OGIB.1, 3 However, there are limitations in the use of SBCE related to the uncontrollable movement of the capsule and the amount of mucosal coverage any type of single-headed capsule model can provide.37, 38 Therefore, over the last few years, there has been an accumulating body of evidence that significant SB lesions can be missed during SBCE, only to be found by cross-sectional imaging or other complementary modalities such

Acknowledgments

We express our gratitude to the following authors who kindly provided further information on their studies included in the analysis: Periklis Apostolopoulos, Elizabeth Carey, Tiago Cúrdia Gonçalves, Pieter Hindryckx, Pedro Magalhães Costa, Ryoto Niikura, Bruno Rosa, Eduardo Redondo-Cerezo, Cedric Van de Bruaene, Nikos Viazis, and Atsuo Yamada. We also thank the IASGO Head Office for their assistance in retrieving 1 of the manuscripts required for our meta-analysis.

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    DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: A. Koulaouzidis: Grant recipient from Given Imaging; material support for research from Symmed UK; M. Pennazio: Speaker for Given Imaging; R. Eliakim: Consultant for Given Imaging; Rami Eliakim, E. Toth: Speaker for Given Imaging. All other authors disclosed no financial relationships relevant to this publication.

    If you would like to chat with an author of this article, you may contact Dr Yung at [email protected].

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