title: Are repeat upper gastrointestinal endoscopy and colonoscopy necessary within six months of capsule endoscopy in patients with obscure gastrointestinal bleeding?
abstract: OBJECTIVE
  Medicare reimbursement for capsule endoscopy for the investigation of obscure gastrointestinal bleeding in Australia requires endoscopy and colonoscopy to have been performed within 6 months. This study aims to determine the diagnostic yield of repeating these procedures when they had been non-diagnostic more than 6 months earlier.
  
  
  METHODS
  Of 198 consecutive patients who were referred for the investigation of obscure gastrointestinal bleeding, 50 underwent repeat endoscopy and colonoscopy solely to enable reimbursement (35 females and 15 males; mean age 59.4 [range: 21-82] years). The average duration of obscure bleeding was 50.16 (range: 9-214) months. The mean number of prior endoscopies was 3 (median: 2) and 2.8 colonoscopies (median: 2). The most recent endoscopy had been performed 18.9 (median: 14; range: 7-56) months, and for colonoscopy, 19.1 (median 14; range 8-51) months earlier.
  
  
  RESULTS
  A probable cause of bleeding was found at endoscopy in two patients: gastric antral vascular ectasia (1) and benign gastric ulcer (1). Colonoscopy did not reveal a source of bleeding in any patient. Capsule endoscopy was performed in 47 patients. Twenty four (51%) had a probable bleeding source identified, and another five (11%) a possible source. These included angioectasia (17 patients), mass lesion (2), non-steroidal anti-inflammatory drug enteropathy (2), Cameron's erosions (2), and Crohn's disease (1). Four patients undergoing repeat capsule endoscopy had a probable bleeding source detected.
  
  
  CONCLUSIONS
  The yield of repeat endoscopy and colonoscopy immediately prior to capsule endoscopy is low when these procedures have previously been non-diagnostic. Such an approach is also not cost-effective.
authors.affiliation: AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Gilbert
authors.forename: Sue
authors.initials: S
authors.lastname: O'Malley
authors.forename: Warwick
authors.initials: W
authors.lastname: Selby
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D053704:Capsule Endoscopy / Q000191:economics*; D003113:Colonoscopy / Q000191:economics*; D003362:Cost-Benefit Analysis; D016099:Endoscopy, Gastrointestinal / Q000191:economics*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D007349:Insurance, Health, Reimbursement; D008297:Male; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics*; D009517:New South Wales; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D012307:Risk Factors; D013997:Time Factors; D055815:Young Adult