Published Online:

The addition of multiphase CT enterography to the routine diagnostic work-up of patients with obscure gastrointestinal bleeding should be considered, particularly in patients with negative findings at previous capsule endoscopy.


To compare the performance of multiphase computed tomographic (CT) enterography with that of capsule endoscopy in a group of patients with obscure gastrointestinal bleeding (OGIB).

Materials and Methods

This prospective HIPAA-compliant study was approved by the institutional review board and the institutional conflict of interest committee. All patients provided written informed consent. Two radiologists, blinded to clinical data and results of capsule endoscopy, interpreted images from CT enterography independently, with discordant interpretations resolved by consensus. Results were compared with those from a reference standard (surgery or endoscopy) and clinical follow-up. Sensitivity and 95% confidence intervals were calculated for each modality.


Fifty-eight adult patients, referred for the evaluation of OGIB (occult, 25 patients [43%]; overt, 33 patients [57%]), underwent both tests. A small bowel bleeding source was identified in 16 of the 58 patients (28%). The sensitivity of CT enterography was significantly greater than that of capsule endoscopy (88% [14 of 16 patients] vs 38% [six of 16 patients], respectively; P = .008), largely because it depicted more small bowel masses (100% [nine of nine patients] vs 33% [three of nine patients], respectively; P = .03). No additional small bowel tumors were discovered during the follow-up period (range, 5.6–45.9 months; mean, 16.6 months).


In this referral population, the sensitivity of CT enterography for detecting small bowel bleeding sources and small bowel masses was significantly greater than that of capsule endoscopy. On the basis of these findings, the addition of multiphase CT enterography to the routine diagnostic work-up of patients with OGIB should be considered, particularly in patients with negative findings at capsule endoscopy.

© RSNA, 2011

Supplemental material:


  • 1 Raju GS, Gerson L, Das A, Lewis B; American Gastroenterological Association. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007;133(5):1697–1717. Crossref, MedlineGoogle Scholar
  • 2 Adler DG, Knipschield M, Gostout C. A prospective comparison of capsule endoscopy and push enteroscopy in patients with GI bleeding of obscure origin. Gastrointest Endosc 2004;59(4):492–498. Crossref, MedlineGoogle Scholar
  • 3 Ell C, Remke S, May A, Helou L, Henrich R, Mayer G. The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding. Endoscopy 2002;34(9):685–689. Crossref, MedlineGoogle Scholar
  • 4 Magnano A, Privitera A, Calogero Get al.. The role of capsule endoscopy in the work-up of obscure gastrointestinal bleeding. Eur J Gastroenterol Hepatol 2004;16(4):403–406. Crossref, MedlineGoogle Scholar
  • 5 Mata A, Bordas JM, Feu Fet al.. Wireless capsule endoscopy in patients with obscure gastrointestinal bleeding: a comparative study with push enteroscopy. Aliment Pharmacol Ther 2004;20(2):189–194. Crossref, MedlineGoogle Scholar
  • 6 Pennazio M, Santucci R, Rondonotti Eet al.. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126(3):643–653. Crossref, MedlineGoogle Scholar
  • 7 Scapa E, Jacob H, Lewkowicz Set al.. Initial experience of wireless-capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small bowel pathology. Am J Gastroenterol 2002;97(11):2776–2779. Crossref, MedlineGoogle Scholar
  • 8 Triester SL, Leighton JA, Leontiadis GIet al.. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100(11):2407–2418. Crossref, MedlineGoogle Scholar
  • 9 Arnott ID, Lo SK. The clinical utility of wireless capsule endoscopy. Dig Dis Sci 2004;49(6):893–901. Crossref, MedlineGoogle Scholar
  • 10 Fireman Z, Kopelman Y. The role of video capsule endoscopy in the evaluation of iron deficiency anaemia. Dig Liver Dis 2004;36(2):97–102. Crossref, MedlineGoogle Scholar
  • 11 Bodily K, Fletcher J, Solem Cet al.. Quantification of mucosal hyperenhancement at CT enterography: correlation with histologic and endoscopic inflammation. Presented at the 104th Annual Meeting of the American Roentgen Ray Society, Miami Beach, Fla, May 2–7, 2004. Google Scholar
  • 12 Wold PB, Fletcher JG, Johnson CD, Sandborn WJ. Assessment of small bowel Crohn disease: noninvasive peroral CT enterography compared with other imaging methods and endoscopy—feasibility study. Radiology 2003;229(1):275–281. LinkGoogle Scholar
  • 13 Huprich JE, Fletcher JG, Alexander JA, Fidler JL, Burton SS, McCullough CH. Obscure gastrointestinal bleeding: evaluation with 64-section multiphase CT enterography—initial experience. Radiology 2008;246(2):562–571. LinkGoogle Scholar
  • 14 Huprich JE. Multi-phase CT enterography in obscure GI bleeding. Abdom Imaging 2009;34(3):303–309. Crossref, MedlineGoogle Scholar
  • 15 Schwartz GD, Barkin JS. Small-bowel tumors detected by wireless capsule endoscopy. Dig Dis Sci 2007;52(4):1026–1030. Crossref, MedlineGoogle Scholar
  • 16 Voderholzer WA, Ortner M, Rogalla P, Beinhölzl J, Lochs H. Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis. Endoscopy 2003;35(12):1009–1014. Crossref, MedlineGoogle Scholar
  • 17 Hara AK, Leighton JA, Sharma VK, Fleischer DE. Small bowel: preliminary comparison of capsule endoscopy with barium study and CT. Radiology 2004;230(1):260–265. LinkGoogle Scholar
  • 18 Saperas E, Dot J, Videla Set al.. Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding. Am J Gastroenterol 2007;102(4):731–737. Crossref, MedlineGoogle Scholar
  • 19 Baichi MM, Arifuddin RM, Mantry PS. Small-bowel masses found and missed on capsule endoscopy for obscure bleeding. Scand J Gastroenterol 2007;42(9):1127–1132. Crossref, MedlineGoogle Scholar
  • 20 Postgate A, Despott E, Burling Det al.. Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy. Gastrointest Endosc 2008;68(6):1209–1214. Crossref, MedlineGoogle Scholar
  • 21 Chong AK, Chin BW, Meredith CG. Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy. Gastrointest Endosc 2006;64(3):445–449. Crossref, MedlineGoogle Scholar
  • 22 Ross A, Mehdizadeh S, Tokar Jet al.. Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy. Dig Dis Sci 2008;53(8):2140–2143. Crossref, MedlineGoogle Scholar
  • 23 Bailey AA, Debinski HS, Appleyard MNet al.. Diagnosis and outcome of small bowel tumors found by capsule endoscopy: a three-center Australian experience. Am J Gastroenterol 2006;101(10):2237–2243. Crossref, MedlineGoogle Scholar
  • 24 Cheung DY, Lee IS, Chang DKet al.. Capsule endoscopy in small bowel tumors: a multicenter Korean study. J Gastroenterol Hepatol 2010;25(6):1079–1086. Crossref, MedlineGoogle Scholar
  • 25 Rondonotti E, Pennazio M, Toth Eet al.. Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study. Endoscopy 2008;40(6):488–495. Crossref, MedlineGoogle Scholar
  • 26 Duchesne J, Jacome T, Serou Met al.. CT-angiography for the detection of a lower gastrointestinal bleeding source. Am Surg 2005;71(5):392–397. Crossref, MedlineGoogle Scholar
  • 27 Grassi R, di Mizio R, Romano S, Cappabianca S, del Vecchio W, Severini S. Multiple jejunal angiodysplasia detected by enema-helical CT. Clin Imaging 2000;24(2):61–63. Crossref, MedlineGoogle Scholar
  • 28 Junquera F, Quiroga S, Saperas Eet al.. Accuracy of helical computed tomographic angiography for the diagnosis of colonic angiodysplasia. Gastroenterology 2000;119(2):293–299. Crossref, MedlineGoogle Scholar
  • 29 Tew K, Davies RP, Jadun CK, Kew J. MDCT of acute lower gastrointestinal bleeding. AJR Am J Roentgenol 2004;182(2):427–430. Crossref, MedlineGoogle Scholar
  • 30 Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol 2003;13(1):114–117. Crossref, MedlineGoogle Scholar
  • 31 Mindelzun RE, Beaulieu CF. Using biphasic CT to reveal gastrointestinal arteriovenous malformations. AJR Am J Roentgenol 1997;168(2):437–438. Crossref, MedlineGoogle Scholar
  • 32 Miller FH, Hwang CM. An initial experience: using helical CT imaging to detect obscure gastrointestinal bleeding. Clin Imaging 2004;28(4):245–251. Crossref, MedlineGoogle Scholar
  • 33 Yoshikawa K, Yamaguti T, Nakamura Met al.. The role of dual-phase enhanced helical computed tomography in difficult intestinal bleeding. J Clin Gastroenterol 2000;31(1):83–84. Crossref, MedlineGoogle Scholar
  • 34 Yamaguchi T, Yoshikawa K. Enhanced CT for initial localization of active lower gastrointestinal bleeding. Abdom Imaging 2003;28(5):634–636. Crossref, MedlineGoogle Scholar
  • 35 Ettorre GC, Francioso G, Garribba AP, Fracella MR, Greco A, Farchi G. Helical CT angiography in gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol 1997;168(3):727–731. Crossref, MedlineGoogle Scholar
  • 36 Thacker P, Huprich J, Barlow Jet al.. The performance of triple-phase CT enterography compared to single-phase and double-phase enterography in the evaluation of obscure GI bleeding (abstr). In: Radiological Society of North America scientific assembly and annual meeting program. Oak Brook, Ill: Radiological Society of North America, 2009; 631. Google Scholar
  • 37 Park JJ, Cheon JH, Kim HMet al.. Negative capsule endoscopy without subsequent enteroscopy does not predict lower long-term rebleeding rates in patients with obscure GI bleeding. Gastrointest Endosc 2010;71(6):990–997. Crossref, MedlineGoogle Scholar
  • 38 Macdonald J, Porter V, McNamara D. Negative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates. Gastrointest Endosc 2008;68(6):1122–1127. Crossref, MedlineGoogle Scholar
  • 39 Rokkas T, Papaxoinis K, Triantafyllou K, Pistiolas D, Ladas SD. Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy?: A meta-analysis. Am J Gastroenterol 2009;104(1):219–227. Crossref, MedlineGoogle Scholar
  • 40 Bresci G, Parisi G, Bertoni M, Tumino E, Capria A. The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use. J Gastroenterol 2005;40(3):256–259. Crossref, MedlineGoogle Scholar
  • 41 Carey EJ, Leighton JA, Heigh RIet al.. A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 2007;102(1):89–95. Crossref, MedlineGoogle Scholar
  • 42 May A, Wardak A, Nachbar L, Remke S, Ell C. Influence of patient selection on the outcome of capsule endoscopy in patients with chronic gastrointestinal bleeding. J Clin Gastroenterol 2005;39(8):684–688. Crossref, MedlineGoogle Scholar

Article History

Received February 10, 2011; revision requested March 28; revision received April 25; final version accepted May 2.
Published online: Sept 2011
Published in print: Sept 2011