Don’t waste the chance to see everything at once!

We read with great interest the article by Rosa et al. [11], which analyzed the role of pan-intestinal capsule endoscopy (PCE) in patients with suspected mid- or lower gastrointestinal bleeding (MLGIB). The evaluation of a new algorithm is highly valued in this setting. Patients recruited to the study, who had iron-deficiency anemia (IDA) or overt gastrointestinal (GI) bleeding and a negative gastroscopy, underwent both PCE and colonoscopy on the same day in order to compare an alternative approach for suspected bleeding.

In our opinion, the first misunderstanding may arise from the definition of MLGIB, in which the authors included IDA; unfortunately, this inclusion method led to a high proportion of non-GI IDA or non-“hemorrhagic” IDA (26% of patients).

The concept of PCE in patients with melena and negative gastroscopy was first introduced by our group in a feasibility study in 2021 [22], and the decision to select only patients with melena was taken to reduce the risk of enrolling patients with other GI and non-GI diseases (e.g. H. pylori infection or autoimmune gastritis).

The use of capsule endoscopy after standard endoscopy is recommended by current guidelines [33], which highlight the importance of timing for small-bowel exploration, with an examination within 48–72 hours after the bleeding episode to be the best scenario. In the paper by Rosa et al., 15.8% of patients underwent PCE within 72 hours, 57.9% in 72 hours–14 days, and 26.3% underwent the procedure later than 14 days, thus raising the question of significant organizational issues in the setting of overt bleeding.

Moreover, for a thorough comparison between the capsule and conventional endoscopy, the retrograde exploration of the ileum in only 43% of patients appears disappointing. Was the endoscopist’s decision based on prior diagnostic findings in the colon or on technical difficulties (e.g. poor cleansing)?

Furthermore, as already discussed by the authors, the intestinal preparation for both capsule and colonoscopy appears poor. The adequate cleansing in 72% of PCEs perhaps warrants a broader discussion on preparation regimens in this clinical setting. Were standard colonoscopies with inadequate preparation excluded from the analysis?

Finally, we believe that, as expressed in our study and another retrospective study by Carretero et al. [22] [44], PCE may be a promising tool for avoiding unnecessary colonoscopies and for better targeting of the therapeutic process in patients with high-risk features of MLGIB, possibly enhancing the bowel preparation and the completion rate, thus ensuring a real and effective pan-enteric exploration.

Publication History

Article published online:
25 March 2025

• References

• 1 Rosa B, Cúrdia Gonçalves T, Moreira MJ. et al. Pan-intestinal capsule endoscopy as first-line procedure in patients with suspected mid or lower gastrointestinal bleeding. Endoscopy 2024; 56: 572-580
• 2 Mussetto A, Arena A, Fuccio L. et al. A new panenteric capsule endoscopy-based strategy in patients with melena and a negative upper gastrointestinal endoscopy: a prospective feasibility study. Eur J Gastroenterol Hepatol 2021; 33: 686-690
• 3 Pennazio M, Rondonotti E, Despott EJ. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – update 2022. Endoscopy 2023; 55: 58-95
• 4 Carretero C, Prieto de Frias C, Angos R. et al. Pan-enteric capsule for bleeding high-risk patients. Can we limit endoscopies?. Rev Esp Enferm Dig 2021; 113: 580-584