Over the 19-year period, a total of 2160 SBCE were performed (Table 1). Among these, 130 patients underwent more than one SBCE. The overall yield of all patients undergoing SBCE was 14.7% for detecting lesions with stigmata of recent bleeding or active bleeding. In patients being treated with one or more antiplatelet agents, the yield was 21.6%. In patients that were on anticoagulation, the overall yield of SBCE for detecting stigmata of recent bleeding and/or actively bleeding lesions was 22.5% (Table 2).
Of the total number of patients, 39.6% (n=536) were prescribed an antiplatelet agent. Specifically, of these patients, 34.3% (n=456) were taking aspirin 81mg (higher doses of aspirin were not included in this study), 10.2% (n=136) were taking clopidogrel, and 0.8% (n=10) were taking ticagrelor. 90 patients (6.8%) were taking dual-antiplatelet therapy (DAPT, i.e., aspirin plus either clopidogrel or ticagrelor). Of the total number of patients, 22.6% (n=302) were prescribed anticoagulation. Of these 2.2% (n=29) were taking enoxaparin, 14.9% (n=199) were taking warfarin, 3.1% (n=42) were taking apixaban, and 3.7% (n=49) were taking rivaroxaban. 136 (10.1%) were being treated with both an antiplatelet agent and anticoagulation (Table 3).
14.7% of patients (n=318) had a lesion identified on SBCE that had stigmata of recent bleeding and/or active bleeding. These patients were more likely to be older than 60 (odds ratio (OR)=1.025, 95% CI [1.017-1.034]; p<0.001), have at least one comorbidity (OR=2.141, 95% CI [1.597-2.870; p<0.0001), and have a diagnosis of either atrial fibrillation (OR=1.686, 95% CI [1.183-2.401; p=0.003) and AS (OR=2.288, 95% CI [1.326-3.948; p=0.002). These patients were more likely to be treated with an antiplatelet agent (OR=2.007, 95% CI [1.568-2.569]; p<0.0001). They were more likely to be on anticoagulation (OR=1.703, 95% CI [1.236-2.347]; p=0.001). These patients were more likely to be treated with both an antiplatelet agent and be anticoagulated (OR=2.426, 95% CI [1.529-3.848]; p=0.002). Lastly, identification of stigmata of recent bleeding and/or actively bleeding lesion on SBCE was more likely if the procedure was performed while the patient was inpatient (OR=2.051, 95% CI [1.597-2.634; p<0.0001) (Table 4).
When applying multivariable GEE logistic regression in order to control for the effects of confounding factors, we found that patients being treated with antiplatelet agents and/or anticoagulation were still more likely to have stigmata of recent bleeding or actively bleeding lesion identified on SBCE (OR=1.507, 95% CI [1.071-2.119]; p=0.01) (Table 5).
From the 318 patients that had stigmata of recent bleeding or actively bleeding lesions identified on SBCE, 118 (37.1%) had a P1 lesion with intermediate bleeding potential identified on SBCE, 136 (42.8%) had a P2 lesion with high bleeding potential identified (Table 6).19
Of the patients that had stigmata of recent bleeding and/or actively bleeding source identified on SBCE, 25.2% (n=80) underwent subsequent endoscopy. Of these patients 58.8% (n=47) underwent deep (push or device-assisted) enteroscopy, 10% (n=8) underwent enteroscopy and colonoscopy, one patient (1.3%) underwent enteroscopy and EGD, 15% (n=12) underwent an EGD, 6.3% (n=5) underwent a colonoscopy, and 4.8% (n=4) underwent EGD and colonoscopy. From the patients that underwent endoscopy following SBCE, 42 (52.5%) received endoscopic hemostasis therapy, and one patient was started on octreotide for treatment of recurrent angioectasias. Of the patients that received endoscopic hemostasis therapy, the majority were treated with argon plasma coagulation (APC; n=21 [50%]), the rest were treated with other modalities (3 patients [7.1%] were treated with cautery and clips, 9 [21.4%] with clips alone, 6 [14.3%] with cautery alone, and 3 [7.2%] with APC and clips) (Table 7).
From the patients that had stigmata of recent bleeding and/or actively bleeding source identified on SBCE, 9.8% (n=31) underwent radiologic evaluation. Thirteen (42%) underwent CTA, which was negative. Eleven (35.5%) underwent CTA with embolization. Two patients (6.5%) underwent CTA (which was negative), followed by tagged red blood cells scan. Three patients (9.7%) underwent a tagged red blood cells scan alone, and one patient (6.3%) underwent a Meckel’s scan (Table 7).
Of the patients that had stigmata of recent bleeding and/or actively bleeding source identified on SBCE, 27.4% (n=87) had recurrent bleeding episodes, and 12.3% (n=38) required hospitalization for this reason. Of the 87 patients who had recurrent episodes of GIB, 11 (29%) had previously undergone endoscopic hemostasis of lesions detected by SBCE prior to the recurrent bleeding episode, and 1 (2.6%) underwent CTA with embolization prior to the recurrent GIB. Twenty-nine patients (9.1%) underwent repeat SBCE as part of the evaluation for recurrent GIB. From the 87 patients that rebled post-SBCE, 28 (32.2%) had a P1 lesion with intermediate bleeding potential identified on their SBCE, 59 (67.8%) had a P2 lesion with high bleeding potential identified on their SBCE.19
In 2.6% (n=3) of patients taking antiplatelet agents and 23.8% (n=5) of patients taking anticoagulation, these medications were held at least for 1-month post-SBCE. Only one cardiovascular event was documented within 18 months after SBCE, a myocardial infarction at 1-month post-SBCE in a patient whose antiplatelet agent had been discontinued at the time of SBCE.