It was designed as a retrospective observational, single-center study. A total of 72 patients presenting to the emergency department of Renji hospital Shanghai with acute GI bleeding were screened for eligibility during the study period from December 2017 to December 2019.
Inclusion criteria were acute GI bleeding defined as hematemesis, melena and hematochezia. They had been treated on enteric-coated aspirin (100 mg/day) daily at least one month for ischemic heart disease, valvular disease, cerebrovascular disease, venous thrombus, primary thrombocytosis. All subjects underwent blood biochemistry test and EGD within 48 hours. Capsule endoscopy was performed within 7 days of admission after abdominal computed tomography enterography (CTE) canning.
The subjects who had contraindications for EGD, CTE and CE or had not finish all these three examinations, who had a known stricture or fistula of the small intestine, who were pregnant, younger than 18 years, in instable clinical status, use of other oral anticoagulants drugs (Clopidogrel, dabigatran, rivaroxaban) and nonsteroidal anti-inflammatory drugs (NSAIDs) were excluded. The ethical committee of Renji hospital approved this study.
Serological test of H. pylori
H. pylori infection was detected by anti-H. pylori antibody (MP Biomedicals Asia Pacific Pte. Ltd. Singapore).
Computed Tomography Enterography (CTE)
Computed Tomography Enterography (CTE) (GE-hispeed NX/i2, United States) examination was performed from the diaphragmatic apex to the superior margin of the pubic symphysis. The enhancer was Niopam (Iopamidol, 370mgl/mL, Shanghai Bracco Sine Pharmaceutical Corp. Ltd), with a total dose of 60–100 ml, and a high pressure injector was used to inject the drug through the cubital vein with a pellet injection rate of 3.5 ml/s. Double-phase arterial and venous scans were performed at 20–30 s and 65 s after the injection of the booster. The current is set as 150-400mAs, the voltage is 120 kV, the matrix is 512 × 512, colalignment: 0.625 mm × 8 mm, FOV: 35 cm × 35 cm, reconstruction thickness: 1.25 mm, reconstruction interval: 0 mm.
CTE images were interpreted by experienced consultants of GI tract radiology who were blinded to patients’ clinical and endoscopic evaluations.
Esophagogastroduodenoscopy (EGD) examinations were performed with a gastroscope (GIF-H290, Olympus Medical Systems, Tokyo, Japan) by two endoscopists with more experience, who were not informed of the treatment assignments. The esophagus, stomach and first and second parts of the duodenum were comprehensively observed, with size of each lesion estimated by comparison with the opening diameter of biopsy forceps (5.5 mm). Peptic ulcer was defined as a > 5 mm in diameter mucosal break with depth in the stomach and/or duodenum.
Capsule Endoscopy (CE)
For CE of the small intestine, a PillcamSB3 video capsule endoscopic device (Given Imaging Ltd, GA USA) was employed. The system includes PillCam™ SB3 capsule, Sensor Array, a data recorder, and a computer workstation.
After the examination, the images were transmitted from the recorder to the computer workstation. The CE findings were blind evaluated by one independent gastroenterologist who had interpreted more than 100 CE studies. All patients were asked to ingest of polyethylene glycol electrolyte solution (Wanhe Pharmaceutical Co. Ltd; china) 12 h before the procedure and took 8 ml of simethicone emulsion (Berlin-Chemie, Germany), 30 min before swallowing the capsule. The patients were observed for adverse events until the capsule had been excreted.
Small intestinal mucosal injury was assessed based on the number of findings with respect to five types of injury: normal, erythema, small erosion, big erosion and ulcer. Erythema was defined as a red region with a border extending from the peripheral normal mucosa, erosion was defined as a defect of the normal lustrous mucosa and ulcer was defined as mucosal defects covered with white moss based on the classification reported by Graham.
Categorical variables are represented by mean values ± standard deviation (SD) and frequency or percentage. The statistical analysis was carried out using SPSS for Windows (version 16.0).