title: Capsule Studies Performed in a Tertiary Care Center Versus Community Referrals Prior to Single-Balloon Enteroscopy: Does It Matter?
abstract: OBJECTIVE
  Within the community, patients with positive capsule endoscopy (CE) are often referred to centers performing balloon-assisted enteroscopy. There is limited data evaluating the concordance and diagnostic/therapeutic yield of CE performed in the community versus CE conducted at institutions experienced with enteroscopy. The primary aim of this retrospective study was to evaluate the concordance between CE and SBE after CE was performed either in the community or at our tertiary care center.
  
  
  METHODS
  A total of 141 patients were analyzed after selecting patients undergoing evaluation of obscure GI bleeding from January 2010 to May 2014. Forty-seven CE were performed inside and the remaining 94 CE were performed at outside institutions prior to single-balloon enteroscopy at our institution. Agreement beyond chance was evaluated using kappa coefficient. A p value <5% was considered significant.
  
  
  RESULTS
  The most frequent findings on CE were vascular lesions in 39 patients (41.5%) within the referral group and 23 within inside patients (48.9%), followed by active bleeding/clots in 23 patients (24.5%) and in 14 patients (29.8%) respectively. There was a fair degree of concordance in the referral group for vascular lesions 0.23 (0.03-0.42) compared to a good degree in the inside group 0.65 (0.44-0.87). Fair agreement was found looking at ulcers within the referral group 0.29 (0.06-0.65) compared to a moderate agreement in the inside group 0.55 (0.17-0.94).
  
  
  CONCLUSIONS
  Degree of concordance for vascular lesions and ulcers was significantly higher for patients undergoing CE at our institution compared to those referred from the community. Patients referred to tertiary care centers for balloon-assisted enteroscopy may benefit from advanced endoscopists re-reading the capsule findings or even potentially repeating CE in hemodynamically stable patients if the study is not available.
authors.affiliation: Department of Internal Medicine, University of South Florida Morsani College of Medicine, 17 Davis Blvd, Suite 308, Tampa, FL, 33606, USA. andrea.rodriguez930@gmail.com.
authors.forename: Andrea C
authors.initials: AC
authors.lastname: Rodriguez
authors.affiliation: Department of Internal Medicine, University of South Florida Morsani College of Medicine, 17 Davis Blvd, Suite 308, Tampa, FL, 33606, USA.
authors.forename: Ashok
authors.initials: A
authors.lastname: Shiani
authors.affiliation: Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
authors.forename: Seth
authors.initials: S
authors.lastname: Lipka
authors.affiliation: Department of Internal Medicine, University of South Florida Morsani College of Medicine, 17 Davis Blvd, Suite 308, Tampa, FL, 33606, USA.
authors.forename: Kirbylee K
authors.initials: KK
authors.lastname: Nelson
authors.affiliation: Department of Internal Medicine, University of South Florida Morsani College of Medicine, 17 Davis Blvd, Suite 308, Tampa, FL, 33606, USA.
authors.forename: Ashley H
authors.initials: AH
authors.lastname: Davis-Yadley
authors.affiliation: Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
authors.forename: Roshanak
authors.initials: R
authors.lastname: Rabbanifard
authors.affiliation: Evidence Based Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
authors.forename: Ambuj
authors.initials: A
authors.lastname: Kumar
authors.affiliation: Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
authors.forename: Patrick G
authors.initials: PG
authors.lastname: Brady
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016099:Endoscopy, Gastrointestinal / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers
keywords: Balloon-assisted enteroscopy; Capsule endoscopy; Concordance; Obscure; Obscure gastrointestinal bleeding; Occult; Single-balloon enteroscopy