Endoscopy 2004; 36(12): 1067-1073
DOI: 10.1055/s-2004-826034
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Clinical Usefulness of the Endoscopic Video Capsule as the Initial Intestinal Investigation in Patients with Obscure Digestive Bleeding: Validation of a Diagnostic Strategy Based on the Patient Outcome after 12 Months

M.  Delvaux1 , I.  Fassler1 , G.  Gay1
  • 1Dept. of Internal Medicine and Digestive Pathology, Centre Hospitalier Universitaire de Brabois, Nancy, France
Further Information

Publication History

Submitted 22 February 2004

Accepted after Revision 4 October 2004

Publication Date:
01 December 2004 (online)

Background and Study Aims: In patients with obscure digestive bleeding, the bleeding source is frequently located in the small bowel. Capsule endoscopy (CE) is an effective method of investigating the whole small bowel in such patients. In the present study, a diagnostic approach was tested in patients with obscure digestive bleeding in which CE was included as the initial examination of the small bowel when the esophagogastroduodenoscopy (EGD) and colonoscopy findings were normal.
Patients and Methods: Patients admitted between October 2000 and February 2002 for obscure digestive bleeding underwent CE as the initial intestinal investigation, and the further management was decided on the basis of the results. After 12 months, follow-up data were obtained from all patients and referring physicians. The positive predictive value was calculated as the percentage of patients in whom CE detected a relevant lesion, and the negative predictive value as the percentage of patients with normal CE in whom no intestinal lesion was detected during the follow-up period.
Results. Forty-four patients (21 men, 23 women, aged 63 ± 17 y) were included in the study. Twenty-two had overt bleeding and 22 had occult bleeding. CE detected an intestinal lesion in 18 patients (41.9 %) - nine with angiomas, five with ulcers, one with a tumor, two with portal hypertension, and one with ischemic ileitis. The findings were normal in 17 patients (39.5 %). CE detected upper gastrointestinal lesions missed at EGD in four patients and blood in the stomach in two patients or in the proximal colon in three, leading to new endoscopies. Intestinal lesions detected at CE were treated as follows: push enteroscopy with treatment in eight patients, surgery in four, and medical treatment in six. In eight patients who underwent push enteroscopy, the procedure did not reveal lesions missed by CE. After 1 year, 15 of the 18 patients treated for intestinal lesions had no further bleeding and no anemia; one died after surgery (for resection of an ischemic intestinal loop), one relapsed, and one was diagnosed with a different intestinal condition. In all patients with extraintestinal lesions or blood detected at CE, further endoscopies led to diagnosis and therapy, with a favorable outcome. In patients with normal CE, no intestinal lesion was detected, but an extraintestinal source of bleeding was diagnosed and treated in nine patients (in the upper gastrointestinal tract in five cases and in the colon in four). Three patients had anemia of hematological origin and four had inadequate iron intake. The positive predictive value of CE was 94.4 % in patients with intestinal lesions, and the negative predictive value was 100 % in patients with normal CE findings.
Conclusions: In patients with obscure digestive bleeding, CE positively predicted the intestinal diagnosis or normal status in 95.5 % of cases. A diagnostic approach to obscure digestive bleeding that includes CE after the initial endoscopic work-up thus appears to be a valid strategy for small-bowel examinations.


  • 1 Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy.  Nature. 2000;  405 417
  • 2 Meron G D. The development of the swallowable video capsule M2A.  Gastrointest Endosc. 2000;  52 817-819
  • 3 Lewis B S, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study.  Gastrointest Endosc. 2002;  56 349-353
  • 4 Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy-negative gastrointestinal bleeding.  Gut. 2003;  52 1122-1126
  • 5 Ell C, Remke S, May A. et al . The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding.  Endoscopy. 2002;  34 685-689
  • 6 Saurin J C, Delvaux M, Gaudin J L. et al . Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push enteroscopy.  Endoscopy. 2003;  35 576-584
  • 7 Eliakim R, Fischer D, Suissa A. et al . Wireless capsule video endoscopy is a superior diagnostic tool in comparison to barium follow-through and computed tomography in patients with suspected Crohn’s disease.  Eur J Gastroenterol Hepatol. 2003;  15 363-367
  • 8 Costamagna G, Shah S K, Riccioni M E. et al . A prospective trial comparing small-bowel radiographs and video capsule endoscopy for suspected small-bowel disease.  Gastroenterology. 2002;  123 999-1005
  • 9 Herrerias J M, Caunedo A, Rodriguez-Tellez M. et al . Capsule endoscopy in patients with suspected Crohn’s disease and negative endoscopy.  Endoscopy. 2003;  35 564-568
  • 10 Bardan E, Nadler M, Chowers Y. et al . Capsule endoscopy for the evaluation of patients with chronic abdominal pain.  Endoscopy. 2003;  35 688-689
  • 11 Vasquez-Iglesias J, Gonzalez-Conde B, Estevez-Prieto E. et al . A prospective study of COX-2 inhibitors versus nonspecific NSAID-induced small-bowel lesions using video capsule endoscopy [abstract].  Endoscopy. 2003;  35 A183
  • 12 Lewis B S. Small-intestinal bleeding.  Gastroenterol Clin N Am. 1994;  23 67-91
  • 13 Pennazio M, Rondonotti E, Abbiati C. et al . Clinical outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases [abstract].  Gut. 2003;  52 (Suppl VI) A6
  • 14 Saurin J C, Delvaux M, Gaudin J L. et al . Clinical impact of small-bowel examination by wireless video capsule compared to push enteroscopy in patients with obscure digestive bleeding: one-year follow-up study [abstract].  Gastrointest Endosc. 2003;  57 AB 84
  • 15 Johanson J F, Schmitt C M, Deas T M Jr. et al . Quality and outcome assessment in gastrointestinal endoscopy.  Gastrointest Endosc. 2000;  52 827-830
  • 16 Blackshaw G R, Barry J D, Edwards P. et al . Open-access gastroscopy is associated with improved outcomes in gastric cancer.  Eur J Gastroenterol Hepatol. 2003;  15 1333-1337
  • 17 American Gastroenterological  Association. Medical position statement: evaluation and management of occult and obscure gastrointestinal bleeding.  Gastroenterology. 2000;  118 197-200
  • 18 Liangpunsakul S, Mays L, Rex D K. Performance of Given suspected blood indicator.  Am J Gastroenterol. 2003;  98 2676-2678
  • 19 Hartmann D, Schilling D, Bolz G. et al . Capsule endoscopy versus push enteroscopy in patients with occult gastrointestinal bleeding.  Z Gastroenterol. 2003;  41 377-382
  • 20 Scapa E, Jacob H, Lewkowicz S. et al . Initial experience of wireless-capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small-bowel pathology.  Am J Gastroenterol. 2002;  97 2776-2779
  • 21 Neu B, Schmid E, Ell C. et al . GECCO - German Cooperative Capsule Outcome study 2: capsule endoscopy compared to other diagnostic tests in suspected small-bowel bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 164
  • 22 Landi B, Tkoub M, Gaudric M, Guimbaud R. Diagnostic yield of push enteroscopy in relation to indication.  Gut. 1998;  42 421-425
  • 23 Descamps C, Schmit A, van Gossum A. ”Missed” upper gastrointestinal tract lesions may explain ”occult” bleeding.  Endoscopy. 1999;  31 452-455
  • 24 Van Gossum A, Erik F, Schmit A, Devière J. A prospective comparative study between push enteroscopy and wireless video capsule in patients with obscure digestive bleeding [abstract].  Gastrointest Endosc. 2002;  55 AB 88
  • 25 Cave D, Wolff R, Mitty R. et al . Validation and initial management of video-capsule endoscopy findings performed for obscure gastrointestinal bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 165
  • 26 Rastogi A, Schoen R E, Slivka A. Diagnostic yield and outcomes of capsule endoscopy [abstract].  Gastrointest Endosc. 2003;  57 AB 163
  • 27 Chong A, Taylor A, Miller A, Desmond P. Clinical outcomes following capsule endoscopy examination of patients with obscure gastrointestinal bleeding [abstract].  Gastrointest Endosc. 2003;  57 AB 166

M. Delvaux, M. D.

Dept. of Internal Medicine and Digestive Pathology

CHU de Brabois, Tour Drouet · F-54511 Vandoeuvre-les-Nancy · France

Fax: + 33-383 15 40 12

Email: m.delvaux@chu-nancy.fr