**5.1 VCE**

*Digestive System - Recent Advances*

**3. Clinical presentation**

**4. Clinical evaluation**

• Drug history: NSAIDs.

Lynch syndrome).

suggest Peutz-Jeghers syndrome.

mid-GI bleeding:

Rarely, polyposis syndromes involving the small bowel may present with mid-GI bleeding. These include familial adenomatous polyposis, Peutz-Jeghers syndrome, and generalized juvenile polyposis. Over the age of 40, the most common causes of mid-GI bleeding include angioectasia, nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers, Dieulafoy's lesion, and small bowel tumors. On rare occasions, other small bowel lesions can cause gastrointestinal bleeding. These include small intestinal diverticuli, small intestinal varices, hereditary hemorrhagic telangiectasia, Kaposi sarcoma, intestinal tuberculosis, blue rubber bleb nevus syndrome, hematobilia, hemosuccus entericus, aortoenteric fistula, infectious enteritis, radiation enteritis, ulcerative jejunoileitis due to celiac disease, cryptogenic multifocal ulcerous stenosing enteritis [12], amyloidosis, Behcet's disease, pseudoxanthoma elasticum, and Ehlers-Danlos syndrome [13]. The incidence of small bowel neuroendocrine tumors (SBNET) has been increasing over the last few decades, and they are now considered as the most common primary malignancy of small bowel. Adenocarcinomas are generally seen in the proximal small bowel, whereas SBNET and lymphoma are commonly located in the distal small bowel. Sarcomas (GIST and non-GIST mesenchymal tumors: leiomyosarcoma, liposarcoma, fibrosarcoma, Kaposi's sarcoma, angiosarcoma) are evenly located throughout the small bowel.

Patients with mid-GI bleeding generally present with melena, occult gastrointestinal bleeding (anemia with heme-positive stool), or iron deficiency anemia. Sometimes, they may present with hematochezia as well when there is brisk mid-gut bleeding. Hematemesis is rare but can happen if bleeding occurs proximal to the ligament of Treitz. Patients can have abdominal pain, constipation, diarrhea, or constitutional symptoms like fever, anorexia, or weight loss depending on the underlying etiology. Symptoms (fatigue, shortness of breath, dysphagia due to esophageal web) and signs (pallor of conjunctiva, atrophic glossitis, and koilonychia) can be present depending on the severity and chronicity of iron deficiency anemia [14]. Patients may give history of receiving multiple blood transfusions acutely, subacutely, or chronically despite having multiple endoscopies, colonoscopies, and imaging studies.

A thorough history and physical examination are essential in the evaluation of mid-GI bleeding. Besides the symptoms and signs mentioned above, there are certain clinical clues which may direct us to suspect the underlying etiology of

• Personal history: aortic stenosis (suspecting Heyde syndrome), cancer, melanoma, lymphoma, immunosuppressive state including human immunodeficiency virus (HIV) infection, celiac disease, radiation, polyposis syndrome.

• Family history: early colorectal cancer or endometrial cancer (suspecting

• Hyperpigmentation around the mouth and on the lips, fingers, or toes may

**24**

VCE has revolutionized the visualization of the entire mucosa of the small bowel. It was approved by the US Food and Drug Administration (FDA) in 2001. The video capsule (size: 13 × 27.9 mm) takes 2 pictures per second with a total of approximately 57,600 color pictures wirelessly over a period of 8 hours [19]. It can detect subtle mucosal changes which cannot be detected by imaging studies. VCE is very useful not only in patients with chronic or intermittent mid-GI bleeding but also in acute overt mid-GI bleeding. VCE should be done as soon as possible after the bleeding episode ideally within 14 days in the case of chronic or recurrent overt mid-GI bleeding and within 24–72 hours of acute overt mid-GI bleeding for maximal diagnostic yield [20]. The European Society of Gastrointestinal Endoscopy (ESGE) recommends that patients should take 2 L of polyethylene glycol (PEG) and simethicone (80–200 mg) prior to VCE. Prokinetic drugs (metoclopramide or domperidone) should be given if the video capsule stays in the stomach for more than 30–60 minutes as shown by real-time VCE viewer [21, 22]. Ideally video capsule should be placed endoscopically into the small bowel by using a capsule endoscope delivery device in patients with dysphagia or abnormal gastrointestinal anatomy or delayed gastric emptying where there will be increased risk of incomplete VCE study [23]. It is safe to perform VCE in patients with cardiac pacemaker, automatic implantable cardioverter-defibrillator (AICD), and left ventricular assist device [24].
