Evaluation of Capsule Endoscopy and Anemia: Do the Outcomes Justify the Study?

1. Evaluation of Capsule Endoscopy and Anemia: Do the Outcomes Justify the Study? Heather Figurelli, D.O., Igor Naryzhny, D.O., Mahreen Majid, M.D., Hymie Kavin, M.D. Department of Medicine, Advocate Lutheran General Hospital Department of Gastroenterology, Advocate Lutheran General Hospital Introduction: . • Evaluation of iron-deficiency anemia typically involves complete investigation of the gastrointestinal tract to locate a source of chronic blood loss • Upper endoscopy and colonoscopy is the preferred initial test, however, when these endoscopic studies are negative, a small bowel source for the gastrointestinal bleeding is considered • Patients with iron deficiency anemia from presumed occult gastrointestinal bleeding are typically referred for wireless capsule endoscopy (WCE) after negative conventional endoscopy • Capsule endoscopy has become a valuable tool in patients with prior negative endoscopic studies • In our open access system, patients are referred for WCE for evaluation of iron deficiency anemia; however, we have noted that a number of patients are referred inappropriately, lacking evidence of iron deficiency • To our knowledge, there no studies which look specifically at the findings of WCE in non-iron deficiency anemia patients in the setting of inappropriate referrals in an open access system. Furthermore, data is lacking regarding the financial impact of such inappropriate referrals Study Design: • Our retrospective analysis includes patients evaluated by WCE endoscopy from January 2004 through December 2007. This will allow at least thirty-six months in assessing outcomes • WCE findings as well as laboratory values and individual follow-up are included • Patients will be mailed a letter of study intent with an attached questionnaire and consent form along with a self-addressed, stamped envelope. Once consent is obtained, if patients are agreeable, they will be contacted for telephone follow-up investigation of their anemia • Only patients with negative EGD and colonoscopy will be included • Exclusion Criteria: • Active gastrointestinal bleeding at the time of WCE • History of hematemesis, melena, or bright red rectal bleeding in the 5 years preceding WCE • Inclusion Criteria: • Group 1: Definite Iron Deficiency • Group 2: Other Etiologies of Anemia • Group 3: Anemia of Chronic Disease (with change in hemoglobin) • Group 4: Anemia with hemoccult positive stools • Group 5: Anemia of unknown cause without evidence of iron deficiency • Data Analysis • Categories: No Findings (NF), Definite Findings (DF), Equivocal or Incidental Findings (EF) • Data will be analyzed to assess: • Clinical value of WCE in patients with iron deficiency anemia (an outcome analysis) • Incidence of definite findings in patients with anemia not due to iron deficiency • Frequency of inappropriate referral for WCE • Cost assessment of inappropriate referrals • Descriptive statistics for continuous (mean ± SD)  and categorical [N (%)] data will be calculated on all patient characteristics and results Fig 1: Capsule Endoscopy Study Goals: Fig 2: Patient Survey/Consent Form Conclusion: • Allow an assessment of appropriate use of WCE • Review clinical diagnosis of iron deficiency anemia along with identification of inappropriate referrals • Recommendations for WCE use • Evaluation of cost analysis to aide future recommendations of WCE referrals • No conclusions can be made at this time as the study is still ongoing • Current objective is to re-send surveys to patients to increase number of responses. An incentive for patients will be considered • Once a maximum number of responses will be obtained, data will be calculated to attempt achieving study goal Data: References: • 142 patients are included in the study • After sending patients surveys, 14 responses were obtained in which only 4 patients had iron deficiency anemia • All 14 patients had WCE with 8 patients having findings that could have been the etiologies of iron deficiency anemia • Of the 4 patients that did have iron deficiency anemia, only 3 had findings on WCE • Thus far 8 patients were found to be deceased Apostolopoulos P., Liatsos C, Gralnek IM, Giannakoulopoulou E, Alexandrakis G, Kalantzis C, Gabriel P, Kalantzis N. The role of capsule endoscopy in investigating unexplained iron deficiency anemia after negative endoscopic evaluation of the upper and lower gastrointestinal tract. Endoscopy. 2006 Nov; 38(11):1127-32. Muhammad A, Pitchumoni C.S. Evaluation of iron deficiency anemia in older adults. The role of wireless capsule endoscopy. J Clin Gastroenterol. 2009 Aug; 43: 627-631. Tatar E, Shen E, Palance A, Sun J, Pitchumoni C.S. Clinical utility of wireless capsule endoscopy experience with 200 cases. J Clin Gastroenterol. 2006; 40:140-144. Sheibani S, Levesque BG, Friedland S, Roost J, Gerson LB. Long-term impact of capsule endoscopy in patients referred for iron-deficiency anemia. Dig Dis Sci. 2009 Nov. Abstract. Kim S, Kedia P, Jaffe D. Impact of capsule endoscopy findings on patient outcomes. Dig Dis Sci. 2009 April; 2441-2448. Sheibani S, Levesque B, Friedland S, Roost J, Gerson L. Long-term impact of capsule endoscopy in patients with iron-deficiency anemia. Dig Dis Sci. 2010 Mar; 55(3):703-708. Knight Ridder/Tribune. Capsule Endoscopy. San Jose Gastroenterology. 2009.