Capsule endoscopy in acute upper gastrointestinal bleeding: goodbye to nasogastric tube aspiration?
29 August 2013 (online)
We read with interest the article by Gralnek et al.  evaluating the role of video capsule endoscopy (VCE) in patients who present at the emergency department with acute upper gastrointestinal bleeding (UGIB), and we would like to make a few comments.
Firstly, Gralnek et al.  found that fresh or coffee-ground blood in the upper gastrointestinal tract was identified significantly more often by VCE than by nasogastric tube (NGT) aspiration (83 % vs. 33 %) and that patient satisfaction was significantly higher with VCE. The initial evaluation of a patient with acute UGIB in the emergency department is now well summarized in international consensus statements and guidelines . There are several scoring systems  that allow the identification of patients who are at low risk and therefore suitable for elective esophagogastroduodenoscopy (EGD), early hospital discharge, or outpatient treatment. However, none of the published risk scores are routinely used by emergency physicians, who usually rely on clinical and laboratory data and, in many cases, on the assessment of NGT aspirate.
The use of NGT aspiration remains controversial . It should be emphasized that although a bloody gastric aspirate may be useful in identifying patients at high risk, the absence of blood does not exclude the presence of an active lesion. Subsequently, a serious lesion may be overlooked and thus, its effective treatment undermined. In addition, NGT aspiration is one of the most distressful procedures for bleeding patients in the emergency department. Despite these limitations, NGT aspiration is still recommended by consensus guidelines .
Obviously, both patients and emergency physicians would prefer a non-invasive method such as VCE rather than the conventional but unpleasant NGT aspiration. However, before saying goodbye to NGT aspiration, important questions remain unanswered: Does the use of VCE instead of NGT aspiration improve the outcomes in patients with acute UGIB or does it just add to medical costs? Are we ready to use an expensive method such as VCE (€ 500) just for detecting blood in the upper gastrointestinal tract rather than NGT, which costs only a few cents? Acute UGIB is a costly condition, mainly due to the hospital admission. The use of VCE may generate additional costs if its use in the emergency department does not result in a significant reduction in the number of patients admitted or the requirement for further EGD.
Secondly, Gralnek et al. found that VCE had an ability to identify inflammatory lesions, excluding gastric and duodenal ulcers, similar to EGD (68 % vs. 84 %, respectively). However, if we take a closer look at the details of the diagnosis obtained by VCE and EGD, we see that findings were concordant in only 15 patients (32.6 %). Moreover, 4 patients (8.7 %) with normal EGD had positive VCE results, and 13 patients (28.2 %) with positive EGD findings had normal VCE results. Therefore, we fully agree with the authors’ conclusion that VCE should not be considered as a substitute for standard EGD.
Thirdly, although the study has a solid basis (prospective, multicenter, well designed), it also suffers from limitations such as the small number of patients included and manufacturer support. There is a need for further high quality prospective, non-manufacturer-supported, randomized controlled studies to evaluate the role of VCE in patients with UGIB who present at the emergency department. Until then, complete risk stratification can only be accomplished after EGD examination which, according to current guideline recommendations, should be performed within 24 hours from patient arrival at the department . Our emergency department physicians are reluctant to discharge a patient with acute UGIB without first carrying out an EGD, mainly because of patient safety and medico-legal concerns.
Finally, Gralnek’s study might be followed by enthusiastic support for VCE among emergency physicians who are eager to use it in triage of patients with acute UGIB. Nevertheless, until it is clearly demonstrated that the use of VCE in the emergency department improves the outcomes and cost-effectiveness of healthcare, its applicability will be only sporadic and certainly not adopted as a routine method for evaluation of a patient with suspected acute UGIB. Perhaps in the future, advanced VCE technologies will lead to the “promised land” of safety and low cost!
- 1 Gralnek IM, Ching JYL, Maza I et al. Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. Endoscopy 2013; 45: 12-19
- 2 Barkun AN, Bardou M, Kuipers EJ et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Int Med 2010; 152: 101-103
- 3 Pang SH, Ching JYL, Lau JYW et al. Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc 2010; 71: 1134-1140
- 4 Huang ES, Karsan S, Kanwal F et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc 2011; 74: 971-980