Reply to Mussetto et al.

We appreciate the insightful comments from Mussetto et al. regarding our study [11] on pan-intestinal capsule endoscopy (PCE) as a promising approach to reducing unnecessary colonoscopies and enabling earlier evaluation of the small bowel in patients with suspected mid- or lower gastrointestinal bleeding (MLGIB). Our study included patients with both melena and iron-deficiency anemia (IDA) without visible bleeding, which reflects real-life clinical practice, as gastrointestinal conditions are a leading cause of IDA, warranting endoscopic evaluation. Indeed, 46% of patients with IDA in our study had potentially hemorrhagic lesions, which could be detected by PCE with a sensitivity of 95%, while the sensitivity of conventional colonoscopy was only 43%. Moreover, the PCE-first strategy allows for earlier small-bowel examinations compared with standard practices, which delay capsule endoscopy until after a nondiagnostic colonoscopy.

Despite challenges posed by the COVID-19 pandemic, which limited our capacity to provide timely access to these procedures during the first year of patient recruitment, our results remained consistent, as the pandemic affected PCE and colonoscopy equally.

Although it seems reasonable to consider that retrograde ileoscopy could potentially increase the diagnostic yield of conventional colonoscopy, there were no lesions located in the terminal ileum in any of the patients included.

Our findings indicate that PCE outperforms conventional colonoscopy despite lower bowel preparation rates. Nonetheless, we acknowledge the need for improved preparation protocols before PCE can be settled as a first-line examination for suspected MLGIB. Indeed, in a recent systematic review and meta-analysis, our group demonstrated that the current rates of adequate cleansing and complete examinations remain suboptimal for PCE [22].

In conclusion, our study supports a PCE-first strategy for suspected MLGIB. Such a disruptive approach may represent a paradigm change that poses new challenges for the coming years, and further evaluation of its strengths and limitations is essential for future recommendations.

Publication History

Article published online:
25 March 2025

• References

• 1 Rosa B, Curdia Goncalves 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 Rosa B, Donato H, Curdia Goncalves T. et al. What is the optimal bowel preparation for capsule colonoscopy and pan-intestinal capsule endoscopy? A systematic review and meta-analysis. Dig Dis Sci 2023; 68: 4418-4431