Reply to Stanciu et al. and Weber et al.

On behalf of my co-authors, I would like to thank Stanciu et al. and Weber et al. for their letters to the Editor. The most efficient diagnostic algorithm for evaluation of acute upper gastrointestinal hemorrhage (UGIH) in the emergency department remains unclear [1]. Most patients who present with signs of acute UGIH are often put through uncomfortable diagnostic tests (e. g. nasogastric aspiration) that have questionable value. Moreover, most patients, even when they are considered to be at low risk for poor outcomes, are admitted to the hospital for reasons that are multifactorial. We believe that more efficient tools (e. g. video capsule endoscopy [VCE]) are needed in this clinical scenario, especially for those patients who are considered to be clinically at low risk and for whom hospital admission could be avoided.

We are in full agreement that additional, prospective, well designed studies are needed in order to better define the test characteristics and the positioning of VCE in the diagnostic evaluation of patients presenting to the emergency department with acute UGIH. Emerging data appear to demonstrate that VCE, with use of the real time viewer, may be used by emergency medicine physicians to more accurately stratify patients for risk and to identify what will be called “very low risk” patients: patients who are defined as low risk by validated risk stratification scoring tools (e. g. Blatchford, Clinical Rockall Score) and in addition have no evidence of blood or coffee grounds on VCE in the emergency department [2] [3] [4]. Moreover, we agree that in the near future an initial “wet read” in the emergency department by the emergency medicine physician could be confirmed in real time by an on-call gastroenterologist using currently available technology (e. g. cloud computing, high speed internet lines). We recently evaluated the ability of emergency medicine physicians to correctly interpret VCE findings in patients with acute UGIH. We found that emergency medicine physicians showed high agreement with gastroenterologists (the gold standard) in correctly interpreting VCE findings [4] [5].

We also fully agree that in order to make VCE a cost-effective diagnostic tool, such “very low risk” patients will need to be discharged directly from the emergency department with subsequent outpatient follow-up, and possible “tube-based” upper endoscopy, within 24 – 48 hours. The cost savings of avoiding even a single hospital day will more than pay for the higher up-front unit costs of VCE. We have recently submitted for peer-review publication, a cost-effectiveness analysis that compared competing emergency department strategies for evaluating patients presenting with suspected acute UGIH. Our economic analysis demonstrated that use of VCE in this setting appears to be cost effective, especially in identifying “very low risk” patients.

In summary, we have known for more than a decade that low risk patients with UGIH can be managed safely as outpatients. However, in practice this does not occur due to concerns about patient safety and medical legalities [6]. We believe that use of VCE in the emergency department in the clinical setting of acute UGIH deserves additional study and that this is only the beginning of an interesting journey or, better yet, a fantastic voyage.

• References

• 1 Gralnek IM, Barkun AN, Bardou M. Current concepts: management of acute bleeding from a peptic ulcer. N Engl J Med 2008; 359: 928-937
• 2 Rubin M, Hussain SA, Shalamov A et al. Live view video capsule endoscopy enables risk stratification of patients with acute upper GI bleeding in the emergency room: a pilot study. Dig Dis Sci 2011; 56: 786-791
• 3 Gralnek IM, Ching JYL, Maza I et al. Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. Endoscopy 2013; 45: 12-19
• 4 Meltzer AC, Ali MA, Kreisberg RB et al. Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med 2013; 61: 438-443
• 5 Meltzer AC, Pinchbeck C, Burnett S et al. Emergency medicine physicians accurately interpret video capsule endoscopy in suspected upper gastrointestinal hemorrhage: a video survey. Acad Emerg Med 2013; In press
• 6 Gralnek IM. Management of “low-risk” non-variceal upper gastrointestinal hemorrhage. Are we ready to put evidence into practice?. Gastrointest Endosc 2002; 55: 131-134