Video capsule endoscopy in the emergency department: A prospective study of acute upper gastrointestinal hemorrhage

Study objective: Video capsule endoscopy has been used to diagnose gastrointestinal hemorrhage and other small bowel diseases but has not been tested in an emergency department (ED) setting. The objectives in this pilot study are to demonstrate the ability of emergency physicians to detect blood in the upper gastrointestinal tract with capsule endoscopy after a short training period, measure ED patient acceptance of capsule endoscopy, and estimate the test characteristics of capsule endoscopy to detect acute upper gastrointestinal hemorrhage. Methods: During a 6-month period at a single academic hospital, eligible patients underwent video capsule endoscopy (Pillcam Eso2; Given Imaging) in the ED. Video images were reviewed by 4 blinded physicians (2 emergency physicians with brief training in capsule endoscopy interpretation and 2 gastroenterologists with capsule endoscopy experience). Results: A total of 25 subjects with acute upper gastrointestinal hemorrhage were enrolled. There was excellent agreement between gastroenterologists and emergency physicians for the presence of fresh or coffee-ground blood (0.96 overall agreement; k=0.90). Capsule endoscopy was well tolerated by 96% of patients and showed an 88% sensitivity (95% confidence interval 65% to 100%) and 64% specificity (95% confidence interval 35% to 92%) for the detection of fresh blood. Capsule endoscopy missed 1 bleeding lesion located in the postpyloric region, which was not imaged because of expired battery life. Conclusion: Video capsule endoscopy is a sensitive way to identify upper gastrointestinal hemorrhage in the ED. It is well tolerated and there is excellent agreement in interpretation between gastroenterologists and emergency physicians.