The COVID-19 pandemic could prompt a revised standard of care for endoscopic evaluation of acute gastrointestinal bleeding. 

Findings from a recent study show that video capsule endoscopy (VCE), which limits the amount of aerosolized virus particles to which physicians are exposed, also improves localization of GI bleeding compared with traditional endoscopy (JAMA Netw Open 2021;4[7]:e2118769). 

Lead researcher Shahrad Hakimian, MD, a gastroenterology fellow at the University of Massachusetts Medical School, in Worcester, at the time of the study, and his colleagues shifted to first-line use of VCE instead of traditional endoscopy for diagnosis of GI bleeding during the peak of the pandemic. 

“We did so in light of a randomized controlled trial showing the safety and efficacy of VCE in localizing lesions in acute nonhematemesis GI bleeding, and because capsules do not generate aerosols and therefore could reduce personal protective equipment use and staff exposure to the virus,” said Dr. Hakimian, who has since moved to UCLA Health, in Los Angeles. 

The retrospective analysis included 74 inpatients admitted during the pandemic for GI bleeding who underwent VCE (PillCam SB 3, Medtronic) and 72 inpatients with GI bleeding who underwent traditional diagnostic endoscopy prior to the COVID-19 pandemic. Dr. Hakimian’s team found that clinicians were able to localize active bleeding sites or stigmata of recent bleeding in 59.5% of cases using VCE and 25% with traditional endoscopy (odds ratio [OR], 5.23; 95% CI, 2.23-12.27; P<0.001). 

Although 48.7% of patients who underwent VCE required additional invasive endoscopic or surgical procedures for evaluation and management of bleeding during hospitalization, that number was 97.2% of those in the traditional endoscopy group (OR, 0.01; 95% CI, 0.001-0.08; P<0.001). 

“In effect, this minimally invasive tool can be used to triage patients who absolutely need endoscopy versus those who do not,” Dr. Hakimian said about VCE. 

According to the researchers, there were notable differences in the sites of bleeding between the VCE and traditional endoscopy patients, with more of those in the former group experiencing bleeding in the small intestine (15% vs. 3%). Angioectasias were the most common cause of bleeding in VCE patients (24%), while peptic ulcer disease was the most common cause in the usual-care group (31%). 

“Video capsule is a much better test in picking up small bowel lesions and angioectasias than traditional endoscopy,” Dr. Hakimian said. 

The investigator said the results support replacing traditional endoscopy with VCE as the standard of care for first-line diagnostic evaluation of GI bleeding, but larger randomized trials in non?COVID-19 patients are needed to validate the findings. In addition, VCE has limitations, he said. 

“The advantages of video capsule [are] that it is far less invasive; does not require sedation, bowel prep; and only entails very limited patient contact,” Dr. Hakimian said. “But the disadvantage is that it is purely a diagnostic modality and does not allow therapeutic interventions if a source of bleeding is identified.”

—David Wild

Dr. Hakimian reported no relevant financial disclosures.