Camera pill in the ED shows promise, may cut costs

Emergency department (ED) physicians may use video capsule endoscopy to detect upper gastrointestinal bleeding, with excellent agreement between gastroenterologists and ED physicians, according to a study published in the February issue of Annals of Emergency Medicine.

Gastrointestinal hemorrhage is a fairly common diagnosis for hospital admission and frequently requires a hospital stay with mean charges in the $25,000 range for a 4.5 day stay in 2008. Risk stratification of these patients can be challenging. Although esophagoduodenoscopy provides a means to risk-stratify patients, gastroenterologists are often unavailable to perform the exam. Thus, benign patients may be admitted to the hospital.

Andrew C. Meltzer, MD, from the department of emergency medicine at George Washington University in Washington, D.C., and colleagues devised a pilot study to determine the ability of ED physicians to detect upper gastrointestinal hemorrhage via camera pill after a short training period, assess patient acceptance of video capsule endoscopy and compare the test characteristics of video capsule endoscopy with traditional endoscopy to detect hemorrhage.

The researchers enrolled 25 patients who presented to the ED between April 1, 2011, and Oct. 1, 2011, with symptoms of upper gastrointestinal hemorrhage. The 11 x 26 mm, 4 g camera pill was set to record for 30 minutes. Emergency physicians were provided training focused on the detection of fresh or coffee-ground blood.

Two emergency physicians and two gastroenterologists reviewed the images and recorded results on a structured data abstraction form.  A research assistant administered a questionnaire focused on perceptions and tolerance to patients. Conventional endoscopy results were abstracted and compared for patients who underwent both procedures.

The overall agreement for the two emergency physicians was 91 percent and 96 percent, respectively, compared with the gastroenterologists’ arbitrated video capsule endoscopy interpretation for detection of fresh or coffee-ground blood.

A total of 19 patients underwent esophagoduodenoscopy within 24 hours of ED triage, and eight had blood detected. Physicians detected blood on video capsule endoscopy in seven of these patients, resulting in a sensitivity of 88 percent and specificity of 64 percent.

No complications were reported among the 24 patients followed by chart abstraction or telephone calls, and the study indicated patients could tolerate the video camera procedure.

The researchers listed several limitations to the study, including the time lapse between video camera and conventional endoscopy. They noted this lapse could explain the limited specificity of video capsule endoscopy.

Camera pill cost will be a key factor in its use in the ED, according to Meltzer and colleagues. Although the average Medicare fee is $705 and professional fee is $50, the procedure may be cost-effective if it reduces hospital admissions or emergency esophagoduodenoscopies.

The researchers concluded that the current study should not be used as a basis to change clinical practice, but instead may provide a basis for additional research. “Future studies are needed to determine the utility of video capsule endoscopy to safely guide clinical decisionmaking, test the cost-effectiveness in the ED and determine how the use of video capsule endoscopy compares with the current standard of care.”