Toward an expanded role for video capsule endoscopy in patients with gastrointestinal bleeding: A review of the literature

The role of small bowel capsule endoscopy (CE) in suspected small bowel bleeding is well established and current European and other international guidelines position it as the first line test after negative bidirectional endoscopies. In suspected mid-lower gastrointestinal bleeding (MLGIB) the diagnostic yield of colonoscopy is poor and may cause a delay in detecting small bowel disease. A crucial aspect of small bowel capsule endoscope performance is the timing of the procedure, the interval between the bleeding episode and capsule ingestion is inversely related to the diagnostic yield as confirmed by a recent meta-analysis. Currently the ongoing advances achieved by video CE in particular to evaluate both small bowel and colon in a single test using double headed capsules, raises questions regarding the position of pan intestinal capsule in the current algorithm to investigate patients presenting with suspected MLGIB ahead of colonoscopy. Early evidence suggests pan intestinal capsule could fit well as a diagnostic "filter" test in this cohort of patients, thereby reserving invasive conventional colonoscopy or device assisted enteroscopy as therapeutics options only. The recent development of magnetically controlled CE and a blood sensing capsule push the boundaries of CE even further in patients presenting with suspected gastrointestinal bleeding. This review will discuss the current available evidence and future directions of CE in suspected MLGIB.