Key clinical point: A three-variable scoring system identified patients with suspected small-bowel bleeding who could potential defer video capsule endoscopy.
Major finding: At a cutoff threshold of ≤0, specificity 30.6%, sensitivity was at least 90%, positive predictive value was 48.6%, and negative predictive value was 83.6%.
Study details: A two-center retrospective and prospective study of 314 adults with suspected small-bowel bleeding.
Disclosures: 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.
Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Jun 19. doi: 10.1016/j.tige.2020.06.001
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.
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.