Clinical outcomes of negative small-bowel capsule endoscopy for small-bowel bleeding: a systematic review and meta-analysis.
OBJECTIVE
Small-bowel bleeding is the primary indication for capsule endoscopy (CE). Many experts advocate a "watch-and-wait" policy in negative CE. This meta-analysis examines the odds of rebleeding after negative index CE and the impact on long-term follow-up.


METHODS
A comprehensive literature search identified articles examining the rebleeding rate after negative CE. Demographic and clinical information with emphasis on outcomes was retrieved, pooled, and analyzed. Heterogeneity among studies was assessed using the I2statistic. A random effects model was used as the pooling method because of high heterogeneity. Risk of bias was assessed using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. The primary outcome evaluated was the pooled odds ratios (ORs) for rebleeding after a negative CE for obscure GI bleeding (OGIB).


RESULTS
Twenty-six studies with 3657 patients were included. The pooled rate of rebleeding after negative CE was .19 (95% CI, .14-.25; P < .0001). The pooled OR of rebleeding was .59 (95% CI, .37-.95; P < .001). The effect was more pronounced in studies with a short follow-up (OR, .47; 95% CI, .24-.94; P < .001). There was no statistically significant difference in rebleeding after CE for occult and overt OGIB. Prospective studies showed a lower OR of rebleeding of .24 (95% CI, .08-.73; P = .01). Most studies were high quality.


CONCLUSIONS
Our analysis shows that negative CE provides adequate evidence of a subsequently low risk of rebleeding. Such patients can therefore be safely managed with watchful waiting. However, patients who rebleed after 2 years may need to be investigated for a new source of blood loss.
Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
Diana E
DE
Yung
Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
Anastasios
A
Koulaouzidis
Department of Medicine E, Rabin Medical Center, Petach Tikva and Sackler Medical School, Tel Aviv, Israel.
Tomer
T
Avni
Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Uri
U
Kopylov
Faculty of Economics and Management, The Open University of Cyprus, Nicosia, Cyprus.
Andry
A
Giannakou
Gastroenterology Unit, Valduce Hospital, Como, Italy.
Emanuele
E
Rondonotti
Division of Gastroenterology U, San Giovanni AS University-Teaching Hospital, Torino, Italy.
Marco
M
Pennazio
Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Rami
R
Eliakim
Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden.
Ervin
E
Toth
Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
John N
JN
Plevris
D053704:Capsule Endoscopy; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000628:therapy; D006801:Humans; D007410:Intestinal Diseases / Q000175:diagnosis* / Q000628:therapy; D007421:Intestine, Small; D016017:Odds Ratio; D012008:Recurrence; D057832:Watchful Waiting