Clinical Trials Logo

Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT02442830
Other study ID # H00006661
Secondary ID
Status Completed
Phase N/A
First received
Last updated
Start date April 19, 2015
Est. completion date July 2, 2017

Study information

Verified date July 2018
Source University of Massachusetts, Worcester
Contact n/a
Is FDA regulated No
Health authority
Study type Interventional

Clinical Trial Summary

The objectives of this study are to test whether there are statistically significant differences between the standard of care workup workup of non-hematemesis gastrointestinal bleeding by endoscopy [upper, lower and other tests], compared with deployment of a video capsule as the first test followed by the most appropriate endoscopic procedure based on video capsule findings, if needed. The investigators propose to examine differences in time to diagnosis, reduction in numbers of procedures, and length of stay between a standard of care workup protocol and our proposed protocol of early capsule endoscopy deployment.


Description:

After 40 years of considering gastrointestinal bleeding as upper or lower and largely ignoring the small intestine, there is accumulating evidence that the standard of care approach to the assessment of non-hematemesis gastrointestinal bleeding could be improved by early deployment of a video capsule (VCE) as the first diagnostic test. Currently, VCE is considered the gold standard as the diagnostic test for small intestinal bleeding. In a recent study at the University of Massachusetts (UMass) 336 patients who presented to the emergency department (ED) with complaints of gastrointestinal bleeding 36 patients (10.7%) were given a VCE during their stay.

In patients with hematemesis, upper endoscopy remains the diagnostic and therapeutic modality of choice. However patients with melena and hematochezia may benefit from early VCE since both signs and symptoms provide poor localization as to the origin of bleeding. Data from this previous Umass study suggests that the ingestion of a VCE in the ED could quickly and non-invasively provide clinicians accurate data as to the origin of the bleeding. This information could provide a guide to further management of the patient. VCE is able to visualize bleeding in the esophagus, stomach, duodenum, small intestine and right colon, thereby eliminating the guess work of deciding which endoscopic approach to use.

At UMass, that same study showed that of the 36 patients who received a video capsule, 26 (72.2%) had diagnostic studies (i.e. bleeding was identified). In comparison, 152 patients required upper endoscopy (of which 52.9% were diagnostic) and 64 patients required colonoscopy (of which 47% were diagnostic). Of those 26 patients with diagnostic capsule studies, 13 also required upper endoscopy, 1 required a colonoscopy, and 4 required both a colonoscopy and endoscopy. It is important to recognize, however, that often capsule studies are performed after upper endoscopy and colonoscopy and performed and are found to be negative. This sequence is the standard of care work up of bleeding. Despite being performed later in the hospital course of our patients, capsule studies have a high diagnostic yield. In reality VCE is used uncommonly in acute bleeding because it is rarely considered in the context of acute GI bleeding In this study, the investigators propose the approach of using the video capsule as the first diagnostic test prior to colonoscopy and endoscopy; this may lead to a shortened time to diagnosis, a reduction in length of stay, and a reduction in numbers of procedures due to early, accurate localization of the source of bleeding. All of these components could result in better quality of care and cost containment. Further, it is known that 80% of patients stop bleeding spontaneously. Thus the earlier they are examined the more likely the origin of the bleeding is likely to be found The use of VCE has been approved by the FDA since 2001 for small intestinal bleeding obscure GI Bleeding. It is very safe and no deaths associated with its use have been reported. More than two million capsules have been used and complications of obstruction and perforation are extremely rare.

Interest in the broader use of VCE is accumulating. More recently studies of VCE deployed in the ED, in patients with upper GI bleeding showed improved management. Our group recently demonstrated that the closer a VCE is performed to the time of bleeding the higher the likelihood of locating the sources and the higher the therapeutic intervention rate. The investigators also have demonstrated that the use of capsule endoscopy in patients with non-hematemesis gastrointestinal bleeding (NHGIB) has a higher diagnostic yield than does colonoscopy. With improved diagnostic yields, capsule endoscopy may help clinicians by providing guidance in the management of patients with NHGIB.

This protocol is be the first attempt to prospectively examine this concept in a large randomized prospective trial. The questions the investigators are studying are: can early capsule intervention decrease time to diagnosis, numbers of procedures and hospital length of stay in patients with non-hematemesis gastrointestinal bleeding?


Recruitment information / eligibility

Status Completed
Enrollment 87
Est. completion date July 2, 2017
Est. primary completion date July 2, 2017
Accepts healthy volunteers No
Gender All
Age group 18 Years and older
Eligibility Inclusion Criteria:

- Age greater than 18 years old

- New onset of melena or hematochezia

- Able to sign consent

- Hemodynamically stable (i.e. blood pressure >100/60 or pulse <110 at the time of consent)

- ED must plan to admit patient to the hospital or Clinical Decision Unit.

Exclusion Criteria:

- Adults unable to consent

- Individuals who are not yet adults (infants, children, teenagers)

- Pregnant women

- Prisoners

- Prior history of gastroparesis

- Prior history of gastric, or small bowel surgery

- Prior history of Crohn's disease

- Concern for infectious colitis

- Non-English speaking

- Evidence of dysphagia at the time of presentation

- Presence of bright red blood per rectum concerning for hemorrhoids

- Allergy to metoclopramide or erythromycin

- Code status of Do Not Resuscitate/Do Not Intubate (DNR/DNI) or Comfort Measures Only (CMO)

- Prior history of abdominal radiation

- Presence of Implantable Cardioverter Defibrillator (ICD) or pacemaker or other implanted electronic devices

- Abdominal pain suggesting an acute abdomen or obstruction. In clinical practice, only patients with crampy abdominal pain due to Crohn's disease, previous intestinal surgery and a previous history of radiation therapy require a patency capsule or CT enterography before capsule endoscopy.

- Patients who cannot undergo surgery

Study Design


Related Conditions & MeSH terms


Intervention

Device:
Early Video Capsule Endoscopy
The intervention is the use of video capsule endoscopy as the first test in a patient presenting to the ED with active bleeding. The capsule allows for visualization of the entire GI tract. Once a capsule has been given to a study patient, a staff member will use the capsule's real-time viewer to see if there is any active bleeding in the stomach. If bleeding is seen the investigators will pursue an upper endoscopy. If no bleeding is seen a staff member will review the entire findings of the capsule and make a decision regarding which therapeutic measure to pursue.

Locations

Country Name City State
United States University of Massachusetts Memorial Medical Center -- University Campus Worcester Massachusetts

Sponsors (2)

Lead Sponsor Collaborator
University of Massachusetts, Worcester Olympus Corporation

Country where clinical trial is conducted

United States, 

References & Publications (3)

Jawaid S, Gondal B, Singh, A, Marshall C, and Cave D. The epidemiology of gastrointestinal bleeding in an academic emergency department as a basis for reconfiguring the conventional approach to its diagnosis and management. Gastrointestinal Endsocopy 2013;77:Supplement, Page AB483.

Jawaid S, Marya N, Gondal B, Maranda L, Marshall C, Charpentier J, Singh A, Foley A, and Cave D. . A reconsideration of the diagnosis and management of gastrointestinal bleeding based on its epidemiology and outcomes analysis. Gastrointestinal Endsocopy 2014;79:Supplement, Page AB231.

Singh A, Marshall C, Chaudhuri B, Okoli C, Foley A, Person SD, Bhattacharya K, Cave DR. Timing of video capsule endoscopy relative to overt obscure GI bleeding: implications from a retrospective study. Gastrointest Endosc. 2013 May;77(5):761-6. doi: 10.1016/j.gie.2012.11.041. Epub 2013 Feb 1. — View Citation

Outcome

Type Measure Description Time frame Safety issue
Primary Time to Localization of Bleeding Time to localization of bleeding refers to the time after a patient is admitted to the emergency room and a bleeding source is localized. We defined localization of bleeding as endoscopic visualization of stigmata of recent hemorrhage. Enrollment to localization of bleeding as measured in hours, up to 720 hours, whichever is sooner.
Secondary Number of Participants With Localization of Bleeding by the End of Admission This measurement counts the number of participants with a bleeding source localized by the end of admission. Patient's will be assessed for the duration of their hospital stay and for thirty days afterwards.
See also
  Status Clinical Trial Phase
Completed NCT02903017 - Local Administration of Tranexamic Acid in Upper Gastrointestinal Hemorrhage Phase 4
Recruiting NCT02514304 - Study of the Risk Factors and Outcomes After Gastrointestinal Bleeding
Completed NCT02384122 - Efficacy of Octreotide on Blood and Iron Requirements in Patients With Anemia Due to Angiodysplasias Phase 3
Completed NCT01477320 - Enteral Nutrition as Stress Ulcer Prophylaxis in Critically Ill Patients. N/A
Not yet recruiting NCT01549418 - The Risk of Bleeding After Removal of Large Colorectal Polyps in Patients Taking Aspirin Phase 4
Completed NCT02105532 - Transfusion in Gastrointestinal Bleeding Phase 2/Phase 3
Recruiting NCT05226221 - Gastrointestinal Emergency Surgery: Evaluation of Morbidity and Mortality
Active, not recruiting NCT02874326 - Octreotide in Patients With GI Bleeding Due to Rendu-Osler-Weber Phase 2
Completed NCT02928939 - Therapeutic Conflicts and Multimorbidity
Withdrawn NCT01215058 - Gastroprotective Agent Compliance in Patients at Risk Suffering From a Gastrointestinal(GI) Ulcer N/A
Completed NCT01029626 - Glasgow-Blatschford Score Validation in Digestive Hemorrhage N/A
Completed NCT00251979 - A Study to Prevent Rebleeding After Initial Successful Primary Endoscopic Haemostasis of a Bleeding Peptic Ulcer Phase 3
Completed NCT02991612 - Rifaximin in Patients With Gastroesophageal Variceal Bleeding N/A
Recruiting NCT02964195 - Efficacy of Rifaximin in Treatment of Cirrhotic Gastroesophageal Variceal Bleeding N/A
Completed NCT02965209 - European Novel Motorized Spiral Endoscopy Trial N/A
Terminated NCT02609100 - Video Capsule Endoscopy Versus Colonoscopy in Patients With Melena and Negative Upper Endoscopy N/A
Completed NCT01872286 - Comparison of the Frequency-altering AKE-1 Capsule and Pillcam SB2 N/A
Completed NCT02349490 - Seraseal for Endoscopic Hemostasis Phase 4
Withdrawn NCT01005147 - Effect of Tranexamic Acid in Upper Gastrointestinal Bleeding N/A
Completed NCT00570973 - Band Ligation Versus Transjugular Intrahepatic Portosystemic Stent Shunt (TIPS) in Cirrhotics With Recurrent Variceal Bleeding Non Responding to Medical Therapy Phase 4