Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Original Article

Volume 10, Number 5, October 2017, pages 280-287

Efficacy of Video Capsule Endoscopy in the Management of Suspected Small Bowel Bleeding in Patients With Continuous Flow Left Ventricular Assist Devices

Figure 1. Flow chart for inclusion in the study and subsequent management of CF-LVAD patients with suspected small bowel bleed.

Figure 2. Kaplan-Meier plot showing time to re-bleed or related death. Panel a shows the cumulative failure function for our primary endpoint with all patient encounters included. Panel b shows the same data but after removal of patients in the control group who did not get VCE due to death or critical illness. Data were censored at the time of transplant, death unrelated to GI bleeding, or last contact in the chart, and is indicated by a vertical dash in the figure. P values displayed are calculated by the log-rank test.

**Table 1.** Baseline Characteristics of VCE and non-VCE Encounters
	Capsule (n = 15)	No capsule (n = 25)	P value
VAD: ventricular assist device; COPD: chronic obstructive pulmonary disease; GI: gastrointestinal; ASA: American Society of Anesthesiology; RBC: red blood cell; INR: international normalized ratio; EGD: esophagogastroduodenoscopy.
Demographics
Age (mean)	63.1 (57.0 - 69.3)	63.7 (59.1 - 68.3)	0.884
Sex (% male)	93.3 (68.1 - 99.8)	68.0 (46.5 - 85.1)	0.117
Ethnicity (% White/Black/Hispanic/Asian)	46.6/33.3/6.7/13.3	44.0/36.0/20.0/0	0.224
Co-morbidities
VAD as destination therapy (%)	66.7 (38.4 - 88.2)	48.0 (27.8 - 68.7)	0.332
Ischemic cardiomyopathy (%)	53.3 (26.6 - 78.7)	72.0 (50.6 - 87.9)	0.310
Diabetes (%)	53.3 (26.9 - 78.7)	36.0 (18.0 - 57.5)	0.336
COPD or asthma (%)	40.0 (16.3 - 67.7)	24.0 (9.4 - 45.1)	0.311
Prior GI bleed (%)	40.0 (16.3 - 67.7)	48.0 (28.0 - 68.7)	0.747
ASA status (mean)	3.33 (2.88 - 3.79)	3.20 (2.96 - 3.44)	0.549
Clinical presentation
Melena (%)	60.0 (32.3 - 83.7)	84.0 (63.9 - 95.5)	0.135
Hematochezia (%)	33.3 (11.8 - 61.6)	16.0 (4.5 - 36.1)	0.225
Hematemesis (%)	0 (0 - 21.8)	12.0 (2.5 - 31.2)	0.279
Occult bleed (%)	20.0 (4.3 - 48.1)	8.0 (0.1 - 26.0)	0.345
Anticoagulation
Aspirin (%)	73.3 (44.9 - 92.2)	96.1 (79.6 - 99.9)	0.056
Warfarin (%)	80.0 (51.9 - 95.7)	80.0 (59.3 - 93.2)	1.000
Heparin (%)	13.3 (1.7 - 40.5)	16.0 (4.5 - 36.1)	1.000
Argatroban (%)	0 (0 - 21.8)	4.0 (0.1 - 20.4)	1.000
Plavix (%)	0 (0 - 21.8)	4.0 (0.1 - 20.4)	1.000
Eptifatide (%)	0 (0 . 21.8)	0 (0 - 13.7)	1.000
Laboratory values
RBC transfusion (median units 72 h prior to scope)	3 (0 - 4)	2 (1 - 3)	0.591
Platelet transfusion (median units 72 h prior to scope)	0 (0 - 0)	0 (0 - 0)	0.267
FFP transfusion (median units 72 h prior to scope)	0 (0 - 0)	0 (0 - 1)	0.276
Hemoglobin (mean)	7.97 (7.38 - 8.56)	8.55 (8.05 - 9.04)	0.135
Platelets (mean)	245 (198 - 290)	188 (154 - 222)	0.041
Creatinine (mean)	1.25 (1.19 - 1.62)	1.40 (1.19 - 1.62)	0.421
Dialysis (%)	0 (0 - 21.8)	12.0 (2.5 - 31.2)	0.279
INR (mean)	1.83 (1.52 - 2.14)	2.06 (1.79 - 2.32)	0.269
Vital signs before endoscopy
Intubated prior (%), not including for procedure	0 (0 - 21.8)	24.0 (9.4 - 45.1)	0.067
Inspired O₂ (median %)	21.0 (21.0 - 21.0)	21.0 (21.0 - 40.0)	0.378
Vasopressors (median)	0 (0 - 0)	0 (0 - 0)	0.140
Initial workup
EGD and Colonoscopy (%)	86.6 (59.5 - 98.3)	36.0 (18.0 - 57.5)	0.003
EGD only (%)	13.3 (1.7 - 40.5)	64.0 (42.5 - 82.0)	0.003

Table 1. Baseline Characteristics of VCE and non-VCE Encounters

Capsule (n = 15)

No capsule (n = 25)

P value

VAD: ventricular assist device; COPD: chronic obstructive pulmonary disease; GI: gastrointestinal; ASA: American Society of Anesthesiology; RBC: red blood cell; INR: international normalized ratio; EGD: esophagogastroduodenoscopy.

Demographics

Age (mean)

63.1 (57.0 - 69.3)

63.7 (59.1 - 68.3)

0.884

Sex (% male)

93.3 (68.1 - 99.8)

68.0 (46.5 - 85.1)

0.117

Ethnicity (% White/Black/Hispanic/Asian)

46.6/33.3/6.7/13.3

44.0/36.0/20.0/0

0.224

Co-morbidities

VAD as destination therapy (%)

66.7 (38.4 - 88.2)

48.0 (27.8 - 68.7)

0.332

Ischemic cardiomyopathy (%)

53.3 (26.6 - 78.7)

72.0 (50.6 - 87.9)

0.310

Diabetes (%)

53.3 (26.9 - 78.7)

36.0 (18.0 - 57.5)

0.336

COPD or asthma (%)

40.0 (16.3 - 67.7)

24.0 (9.4 - 45.1)

0.311

Prior GI bleed (%)

40.0 (16.3 - 67.7)

48.0 (28.0 - 68.7)

0.747

ASA status (mean)

3.33 (2.88 - 3.79)

3.20 (2.96 - 3.44)

0.549

Clinical presentation

Melena (%)

60.0 (32.3 - 83.7)

84.0 (63.9 - 95.5)

0.135

Hematochezia (%)

33.3 (11.8 - 61.6)

16.0 (4.5 - 36.1)

0.225

Hematemesis (%)

0 (0 - 21.8)

12.0 (2.5 - 31.2)

0.279

Occult bleed (%)

20.0 (4.3 - 48.1)

8.0 (0.1 - 26.0)

0.345

Anticoagulation

Aspirin (%)

73.3 (44.9 - 92.2)

96.1 (79.6 - 99.9)

0.056

Warfarin (%)

80.0 (51.9 - 95.7)

80.0 (59.3 - 93.2)

1.000

Heparin (%)

13.3 (1.7 - 40.5)

16.0 (4.5 - 36.1)

1.000

Argatroban (%)

0 (0 - 21.8)

4.0 (0.1 - 20.4)

1.000

Plavix (%)

0 (0 - 21.8)

4.0 (0.1 - 20.4)

1.000

Eptifatide (%)

0 (0 . 21.8)

0 (0 - 13.7)

1.000

Laboratory values

RBC transfusion (median units 72 h prior to scope)

3 (0 - 4)

2 (1 - 3)

0.591

Platelet transfusion (median units 72 h prior to scope)

0 (0 - 0)

0.267

FFP transfusion (median units 72 h prior to scope)

0 (0 - 0)

0 (0 - 1)

0.276

Hemoglobin (mean)

7.97 (7.38 - 8.56)

8.55 (8.05 - 9.04)

0.135

Platelets (mean)

245 (198 - 290)

188 (154 - 222)

0.041

Creatinine (mean)

1.25 (1.19 - 1.62)

1.40 (1.19 - 1.62)

0.421

Dialysis (%)

0 (0 - 21.8)

12.0 (2.5 - 31.2)

0.279

INR (mean)

1.83 (1.52 - 2.14)

2.06 (1.79 - 2.32)

0.269

Vital signs before endoscopy

Intubated prior (%), not including for procedure

0 (0 - 21.8)

24.0 (9.4 - 45.1)

0.067

Inspired O₂ (median %)

21.0 (21.0 - 21.0)

21.0 (21.0 - 40.0)

0.378

Vasopressors (median)

0 (0 - 0)

0.140

Initial workup

EGD and Colonoscopy (%)

86.6 (59.5 - 98.3)

36.0 (18.0 - 57.5)

0.003

EGD only (%)

13.3 (1.7 - 40.5)

64.0 (42.5 - 82.0)

0.003

**Table 2.** Endoscopic Findings and Management of VCE and Non-VCE Encounters
	Capsule (n = 15)	No capsule (n = 25)	P value
AVM: arteriovenous malformation; GAVE: gastric antral vascular ectasia; APC: argon plasma coagulation; IR: interventional radiology; RBC: red blood cell.
Findings
AVM (%)	46.7 (21.3 - 73.4)	32.0 (14.9 - 53.5)	0.502
Ulcer or erosion (%)	33.3 (11.8 - 61.6)	20.0 (6.8 - 40.7)	0.457
Gastritis (%)	13.3 (1.7 - 40.5)	12.0 (2.5 - 31.2)	1.000
Polyp (%)	40.0 (16.3 - 67.7)	8.0 (0.9 - 26.0)	0.036
GAVE (%)	13.3 (1.7 - 40.5)	4.0 (0.1 - 20.4)	0.545
Endoscopic intervention
APC (%)	40.0 (16.3 - 67.7)	24.0 (9.4 - 45.1)	0.311
Clip (%)	13.3 (1.7 - 40.5)	12.0 (2.5 - 31.2)	1.000
Injection (%)	0 (0 - 21.8)	0 (0 - 13.7)	1.000
Snare (%)	6.7 (0.1 - 31.9)	0 (0 - 13.7)	0.375
Management
IR intervention (%)	6.7 (0.2 - 31.9)	0 (0 - 13.7)	0.375
Tagged RBC scan (%)	0 (0 - 21.8)	8.0 (0.9 - 26.0)	0.519
Start octreotide or thalidomide (%)	46.7 (21.3 - 73.4)	52.0 (31.3- 72.2)	1.000
Double balloon enteroscopy (%)	20.0 (4.3 - 48.1)	12.0 (2.5 - 31.2)	0.654
Push enteroscopy (%)	6.7 (0.2 - 31.9)	12.0 (2.5 - 31.2)	1.000
Any enteroscopy (%)	26.7 (7.8 - 55.1)	20.0 (6.8 - 40.7)	0.705

Table 2. Endoscopic Findings and Management of VCE and Non-VCE Encounters

Capsule (n = 15)

No capsule (n = 25)

P value

AVM: arteriovenous malformation; GAVE: gastric antral vascular ectasia; APC: argon plasma coagulation; IR: interventional radiology; RBC: red blood cell.

Findings

AVM (%)

46.7 (21.3 - 73.4)

32.0 (14.9 - 53.5)

0.502

Ulcer or erosion (%)

33.3 (11.8 - 61.6)

20.0 (6.8 - 40.7)

0.457

Gastritis (%)

13.3 (1.7 - 40.5)

12.0 (2.5 - 31.2)

1.000

Polyp (%)

40.0 (16.3 - 67.7)

8.0 (0.9 - 26.0)

0.036

GAVE (%)

13.3 (1.7 - 40.5)

4.0 (0.1 - 20.4)

0.545

Endoscopic intervention

APC (%)

40.0 (16.3 - 67.7)

24.0 (9.4 - 45.1)

0.311

Clip (%)

13.3 (1.7 - 40.5)

12.0 (2.5 - 31.2)

1.000

Injection (%)

0 (0 - 21.8)

0 (0 - 13.7)

1.000

Snare (%)

6.7 (0.1 - 31.9)

0 (0 - 13.7)

0.375

Management

IR intervention (%)

6.7 (0.2 - 31.9)

0 (0 - 13.7)

0.375

Tagged RBC scan (%)

0 (0 - 21.8)

8.0 (0.9 - 26.0)

0.519

Start octreotide or thalidomide (%)

46.7 (21.3 - 73.4)

52.0 (31.3- 72.2)

1.000

Double balloon enteroscopy (%)

20.0 (4.3 - 48.1)

12.0 (2.5 - 31.2)

0.654

Push enteroscopy (%)

6.7 (0.2 - 31.9)

12.0 (2.5 - 31.2)

1.000

Any enteroscopy (%)

26.7 (7.8 - 55.1)

20.0 (6.8 - 40.7)

0.705

**Table 3.** Thirty Day Outcomes for VCE and Non-VCE Encounters
Events within 30 days	Capsule (n = 15)	No capsule (n = 25)	P value
PRBC: packed red blood cell: GI: gastrointestinal.
Readmission (%)	46.7 (21.3 - 73.4)	16.0 (4.5 - 36.1)	0.065
Related readmission (%)	20.0 (4.3 - 48.1)	8.0 (1.0 - 26.0)	0.345
Length of stay (median days)	12 (5 - 30)	6 (3 - 15)	0.117
Any adverse event (%)	6.7 (0.2 - 31.9)	36.0 (18.0 - 57.5)	0.060
Any adverse event or re-bleeding (%)	33.3 (11.8 - 61.6)	56.0 (34.9 - 75.6)	0.204
PRBC transfusion (median units)	3 (0 - 7)	1 (0 - 10)	0.864
Death (%)	0 (0 - 21.8)	20.0 (6.8 - 40.7)	0.137
Death related to GI bleed (%)	0 (0 - 21.8)	12.0 (2.5 - 31.2)	0.279

Table 3. Thirty Day Outcomes for VCE and Non-VCE Encounters

Events within 30 days

Capsule (n = 15)

No capsule (n = 25)

P value

PRBC: packed red blood cell: GI: gastrointestinal.

Readmission (%)

46.7 (21.3 - 73.4)

16.0 (4.5 - 36.1)

0.065