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Scoring system identified patients with suspected small-bowel bleeding

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Scoring system to predict diagnosis on video capsule endoscopy of suspected small bowel bleeding

Over the last 20 years the use of video capsule endoscopy (VCE) for the evaluation of suspected small-bowel bleeding has increased logarithmically and has profoundly affected our ability to identify hemorrhagic lesions and manage GI bleeding. The current standard of care after negative bidirectional endoscopy is deployment of VCE, but recommendations about more discriminate use of this device are limited. This paper helps provide some guidance and direction. While the specific clinical predictors of small-bowel bleeding cited in this paper, such as overt hemorrhage, significant anemia, older age, and inpatient status, are not new revelations, what is unique is the creation of a simple, user-friendly scoring system for predicting a positive diagnosis. This is the first such scoring system for VCE management.

Dr. Laurel Fisher, professor of clinical medicine, division of gastroenterology, University of Pennsylvania, Philadelphia.

Dr. Laurel Fisher

The benefits of utilizing a scoring system include refining clinical decision-making, minimizing low-yield testing, and possibly lowering health care costs for hospitalized patients, although this has not been specifically studied. Because this system is sensitive but not specific, it is most useful for identifying low-risk patients. Physicians need to be cautious, however in excluding patients from testing solely on the basis of a score. Pathology found in younger patients is often more sinister, and clinical judgment is critical in all decisions.

This is an important step forward in more rational and precise utilization of VCE as a diagnostic tool. Refining a scoring system to reflect a high positive predictive value may be the next goal.

Laurel Fisher, MD, is professor of clinical medicine and director of the small-bowel imaging program, division of gastroenterology, University of Pennsylvania, Philadelphia.


 

FROM TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY

For patients with suspected small-bowel bleeding, a three-variable scoring system predicted the diagnostic outcomes of video capsule endoscopy, according to the findings of a multicenter study.

“Admission to the hospital with overt bleeding and having a hemoglobin [level] of less than 6.4 g/dL were two positive predictors of a diagnosis. Being younger than 54 years old at the time of the video capsule endoscopy exam was a significant negative predictor of a diagnosis,” Neil B. Marya, MD, of the University of California, Los Angeles, and associates wrote in Techniques and Innovations in Gastrointestinal Endoscopy.

To develop the scoring system, they analyzed retrospective data from 162 adults with suspected small-bowel bleeding who received video capsule endoscopies at the University of Massachusetts or the University of California, Los Angeles, in 2016 or 2017. Most of these individuals were outpatients with occult gastrointestinal bleeding, but nearly one-third were inpatients with overt bleeding.

In all, 70 (43%) patients had a relevant finding on video capsule endoscopy, most frequently arteriovenous malformation (26%), blood (10.5%), or ulceration (10.5%). On multivariable analysis, the odds of positive video capsule endoscopy were significantly higher when patients had been admitted to the hospital with overt bleeding (adjusted odds ratio, 2.38; 95% confidence interval, 1.05-5.39) or had a baseline hemoglobin level less than or equal to 6.4 g/dL (aOR, 2.68; 95% CI, 1.11-6.48). In contrast, patients who were younger than 54 years were significantly less likely to have diagnostic lesions (aOR, 0.25; 95% CI, 0.11-0.58). After designating these variables as A, B, and C, respectively, the researchers derived the following equation to produce the score: (0.87 x A) + (0.99 x B) – (1.38 x C). Each variable was scored as 1 (present) or 0 (absent). Based on this equation, the highest score possible score was 1.86, and the lowest possible score was –1.38.

The researchers validated this scoring system by analyzing data from 152 adults with suspected small-bowel bleeding who were examined prospectively at the two centers. The development and validation cohorts resembled each other except that the validation cohort had lower mean hemoglobin levels (8.2 g/dL versus 9.0 g/dL in the development cohort; P < .01) and higher mean blood urea nitrogen levels (25.3 mg/dL vs. 19.9 mg per dL; P =.03). Receiver operating curves were similar between the two groups (respective C-statistics, 0.70 and 0.69; P = .91).

However, the scoring system’s maximum specificity was only 30.6%, yielding a positive predictive value of only 48.6%. The associated cutoff score was greater than or equal to 0. At this cutoff, sensitivity was “at least 90%,” and negative predictive value was 83.6%. Thus, the scoring system is best suited for identifying patients who are unlikely to have a diagnostic lesion found on video capsule endoscopy, the researchers said.

“Patients with scores of less than 0 could conceivably have capsule examinations deferred,” they concluded. “For example, consider a clinician taking care of a hospitalized patient who meets criteria for undergoing video capsule endoscopy for the indication of suspected small intestinal bleeding, but finds that the patient has a suspected small-bowel bleeding capsule diagnosis score of less than 0. The clinician could decide to have their patient undergo the video capsule endoscopy as an outpatient, since the likelihood of detecting an actionable lesion is low. This decision could have a [beneficial] financial impact.”

No external funding sources were reported. Dr. Marya disclosed a recent consulting relationship with AnX Robotica. Two coinvestigators disclosed a consulting relationship with Medtronic and research support from Olympus and Medtronic.

SOURCE: Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Jun 19. doi: 10.1016/j.tige.2020.06.001.

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