Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Apr 16, 2015; 7(4): 403-410
Published online Apr 16, 2015. doi: 10.4253/wjge.v7.i4.403
Re-bleeding events in patients with obscure gastrointestinal bleeding after negative capsule endoscopy
Pedro Magalhães-Costa, Miguel Bispo, Sofia Santos, Gilberto Couto, Leopoldo Matos, Cristina Chagas
Pedro Magalhães-Costa, Miguel Bispo, Sofia Santos, Gilberto Couto, Leopoldo Matos, Cristina Chagas, Gastroenterology Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, 1349-019 Lisboa, Portugal
Author contributions: Magalhães-Costa P, Bispo M and Chagas C designed the research; Magalhães-Costa P performed the research; Magalhães-Costa P analyzed the data; Magalhães-Costa P wrote the paper; Bispo M, Santos S, Couto G, Matos L and Chagas C critically revised the manuscript.
Ethics approval: This study was reviewed and approved by the Centro Hospitalar de Lisboa Ocidental Institutional Review Board.
Informed consent: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest: None reported (all authors). All authors declare not having received any fee for serving as a speaker nor had received any research funding nor is an employee nor owns stocks and/or shares nor own any patent related to the article content.
Data sharing: Technical appendix, statistical code, and dataset avaliable from the corresponding author at pmagalhaescosta@gmail.com. Participants gave informed consent for data sharing.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Pedro Magalhães-Costa, Gastroenterology Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Rua da Junqueira 126, 1349-019 Lisboa, Portugal. pmagalhaescosta@gmail.com
Telephone: +351-96-3532531 Fax: +351-21-0432430
Received: October 1, 2014
Peer-review started: October 1, 2014
First decision: October 28, 2014
Revised: November 27, 2014
Accepted: January 18, 2015
Article in press: January 20, 2015
Published online: April 16, 2015
Processing time: 200 Days and 14.8 Hours
Abstract

AIM: To investigate long-term re-bleeding events after a negative capsule endoscopy in patients with obscure gastrointestinal bleeding (OGIB) and the risk factors associated with the procedure.

METHODS: Patients referred to Hospital Egas Moniz (Lisboa, Portugal) between January 2006 and October 2012 with OGIB and a negative capsule endoscopy were retrospectively analyzed. The following study variables were included: demographic data, comorbidities, bleeding-related drug use, hemoglobin level, indication for capsule endoscopy, post procedure details, work-up and follow-up. Re-bleeding rates and associated factors were assessed using a Cox proportional hazard analysis. The Kaplan-Meier method was used to estimate the cumulative incidence of re-bleeding at 1, 3 and 5 years, and the differences between factors were evaluated.

RESULTS: The study population consisted of 640 patients referred for OGIB investigation. Wireless capsule endoscopy was deemed negative in 113 patients (17.7%). A total of 64.6% of the population was female, and the median age was 69 years. The median follow-up was forty-eight months (interquartile range 24-60). Re-bleeding occurred in 27.4% of the cases. The median time to re-bleeding was fifteen months (interquartile range 2-33). In 22.6% (n = 7) of the population, small-bowel angiodysplasia was identified as the culprit lesion. A univariate analysis showed that age > 65 years old, chronic kidney disease, aortic stenosis, anticoagulant use and overt OGIB were risk factors for re-bleeding; however, on a multivariate analysis, there were no risk factors for re-bleeding. The cumulative risk of re-bleeding at 1, 3 and 5 years of follow-up was 12.9%, 25.6% and 31.5%, respectively. Patients who presented with overt OGIB tended to re-bleed sooner (median time for re-bleeding: 8.5 mo vs 22 mo).

CONCLUSION: Patients with OGIB despite a negative capsule endoscopy have a significant re-bleeding risk; therefore, these patients require an extended follow-up strategy.

Keywords: Capsule endoscopy; Gastrointestinal hemorrhage; Anemia; Angiodysplasia; Risk factors

Core tip: This study describes a large cohort of patients with obscure gastrointestinal bleeding in whom the first capsule endoscopy was negative. Re-bleeding events, risk factors and causes were analyzed. A significant risk of re-bleeding was observed; however, independent predictors for re-bleeding were not identified. Re-bleeding due to small-bowel angiodysplasia was a frequent occurrence; therefore, these patients require an extended follow-up strategy, perhaps involving repeated endoscopic procedures if re-bleeding occurs.