Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study

Route selection for double-balloon endoscopy, based on capsule transit time, in obscure gastrointestinal bleeding

BACKGROUND

Double-balloon endoscopy (DBE) utilizes both oral and anal routes. The proper selection of the initial route is important for more rapid management of obscure gastrointestinal bleeding (OGIB). The aim of this retrospective study was to clarify the accuracy of the transit time of video capsule endoscopy (VCE) to the lesion as a predictive indicator for the decision on the initial DBE route.

METHODS

Of 172 patients who underwent both DBE and VCE, 65 who were diagnosed with small-intestinal hemorrhagic lesions by both means were enrolled. The relation between VCE transit time to the lesion and the DBE route by which the lesion was discovered was analyzed, distinguishing between 46 complete and 19 incomplete VCEs.

RESULTS

Among the 46 patients with a complete VCE, the transit time and position of the lesion were strongly correlated. The best cutoff values for route selection by the VCE transit time from capsule intake and from the duodenal bulb to the lesion, determined using a receiver operating characteristic (ROC) curve, were 60% and 50%, respectively, of the transit time to the cecum. At that point, the accuracy of route selection was 90% and 94%, respectively. Positions shown by VCE for ileal lesions tended to be more proximal than those shown by surgery. In the 19 patients with incomplete VCEs, the best cutoff for transit time was 180 min from the duodenal bulb.

CONCLUSIONS

The VCE transit time was useful for determining the route for DBE in OGIB. This parameter was most accurate when the cutoff value for the selection was half of the small-bowel transit time in the complete VCE examination.

Double balloon enteroscopy and acute pancreatitis

Double balloon enteroscopy (DBE) is a new technique, first published and introduced into clinical practice in 2001 by Yamamoto, the inventor of this outstanding method. DBE allows complete visualization, biopsy and treatment of the small bowel. Nowadays, we have some experience of this method for evaluation of the complication rate. Severe complications are described in 1%-1.7% of patients. Acute pancreatitis is a rare complication of the investigation. The incidence of acute pancreatitis after diagnostic DBE is 0.3% in most studies. More than 50 cases of acute pancreatitis have been described in the literature so far. On the contrary, hyperamylasemia after DBE seems to be a rather common condition. Association with acute pancreatitis is supposed to be possible, but not obligatory. The causal mechanism of post-DBE acute pancreatitis is uncertain, and there are several theories in the literature. The most probable cause seems to be a mechanical straining of the endoscope with over-tube on the pancreas or in the papillary area.

Antegrade double balloon enteroscopy for continued obscure gastrointestinal bleeding following push enteroscopy: is there a role?

BACKGROUND

The benefit of double balloon endoscopy (DBE) over push enteroscopy (PE) for the proximal small bowel in patients with obscure gastrointestinal bleeding remains unclear.

AIM

To quantify the benefit of DBE if PE fails to benefit patients with obscure gastrointestinal bleeding.

METHODS

This retrospective DBE database review between July 2004 and April 2008 was conducted at a tertiary university hospital in Australia. Thirty-three patients with obscure gastrointestinal bleeding who had undergone PE for proximal small bowel lesions were identified from a DBE database of 280 patients. Mean age was 68.6 (range 30-91) years, and 17 were men. In group A (n = 15) the target lesion was not reached by PE, and in group B (n = 18) an abnormality was found by PE (angioectasia in 17 and red spots in 1) but the patient had ongoing bleeding. Mean follow-up for the cohort was 19.2 (range 5-39) months. DBE interventions were performed as appropriate.

RESULTS

An abnormality was found at DBE in 28/33 (85%) patients. DBE found an abnormality in 12/15 (80%) in group A and 16/18 (89%) in group B. Endoscopic intervention was performed in 23/33 patients (70%). In 27/33 (82%) patients a clinical benefit was seen following DBE. Six patients (18%) had no clinical benefit from DBE.

CONCLUSIONS

In patients with obscure gastrointestinal bleeding and proximal small bowel lesions who fail to benefit from PE, DBE offers a very high benefit in finding and treating lesions with good long-term outcomes.

Predictors of depth of maximal insertion at double-balloon enteroscopy

The aim of this study was to determine the factors predictive of the depth of maximal insertion (DMI) at double-balloon enteroscopy (DBE). Eligible patients from the DBE database at our institution were stratified based on their anterograde or retrograde approach. The factors predictive of the DMI were calculated using ANOVA, Spearman, univariate, and multivariate regression analysis. A total of 79 patients had 98 procedures, 67 anterograde and 31 retrograde. Fifty-eight (73%) had previous abdominal surgeries. The average anterograde DMI was 187.5 cm, retrograde 116.5 cm. In univariate regression analysis, a history of abdominal surgery and surgery excluding appendectomy were negative predictors of the DMI for both the anterograde and retrograde approaches (P < 0.05). A history of bowel surgery and number of surgeries were negative predictive factors only for the anterograde approach (P < 0.005). In multivariate analysis, the number of abdominal surgeries (anterograde) and any abdominal surgery (retrograde) were predictors of the DMI (P = 0.02 and P = 0.003, respectively). Patients with three or more surgeries had a significantly lower DMI than those with <or=1 (137 vs. 214 cm, P < 0.001 for anterograde and 114 vs. 148 cm, P < 0.001 for retrograde). There was no correlation between the DMI and age, BMI, date of the study, or procedure duration for either approach. Previous abdominal surgeries can significantly impact the DMI at DBE.

[Endoscopy of the small bowel: light into the dark]

Since the introduction of capsule endoscopy and later balloon enteroscopy in clinical practice, endoscopic examination of the small bowel has dramatically improved. For the first time, it is possible to diagnose the whole small bowel without the necessity of laparotomy and intraoperative enteroscopy. The methods revolutionized the field of small bowel diagnostic and therapy and become part of daily clinical practice. This article provides a review of small bowel enteroscopic methods.

Obscure gastrointestinal bleeding as first symptom of eosinophilic jejunitis in a liver transplant recipient: diagnosis and treatment with single balloon enteroscopy

The small bowel is only partially accessible to traditional endoscopic techniques. The recently introduced push-and-pull enteroscopy technique allows endoscopists to examine the small bowel in its entirety and enables them to take biopsy specimens and administer treatment. We report the case of a liver transplant recipient presenting with obscure gastrointestinal bleeding, whose diagnosis of eosinophilic enteritis was achieved following a single balloon enteroscopy examination. The patient was discharged 3 days after endoscopic treatment. Eosinophilic enteritis is still not a well known disease. The modality of treatment was suggested by our endoscopic experience and not from codified guidelines. The patient's haemoglobin value was normal 12 months after treatment.

Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders

OBJECTIVES

Double-balloon enteroscopy (DBE) is now an established method for diagnostic and therapeutic small-bowel endoscopy. Single-balloon enteroscopy (SBE) has been introduced to simplify the technique. A prospective randomized study was carried out to compare the two methods.

METHODS

The study included 100 patients (50 in each group; 63 men, 37 women; mean age 55 years), with no previous small-bowel or colon surgery. The indications for enteroscopy were (suspected) mid-gastrointestinal bleeding, Crohn's disease, small-bowel masses, chronic diarrhea or abdominal pain or both, and other conditions. Fujinon instruments were used, with either two balloons or one. The end point of the study was complete enteroscopy as the most objective parameter.

RESULTS

No severe complications such as perforation, bleeding, or pancreatitis occurred. Instrument preparation time was significantly faster with SBE than with DBE (P<0.0001). Complete enteroscopy was achieved with the DBE technique in 66% of cases (33 patients), either with the oral route alone or with combined oral and anal approaches. With the SBE technique, the complete enteroscopy rate was significantly lower at 22% (P<0.0001; 11 patients, only with oral and anal routes combined). The rate of therapeutic consequences for the patients based on diagnostic yield and negative complete enteroscopy was significantly higher (P=0.025) in the DBE group at 72%, compared with 48% in the SBE group.

CONCLUSIONS

The complete enteroscopy rate was three times higher with DBE than with SBE, accompanied by a higher diagnostic yield. DBE must therefore continue to be regarded as the nonsurgical gold standard procedure for deep small-bowel endoscopy.

Safety and efficacy of double-balloon enteroscopy in pediatric patients

BACKGROUND

Although double-balloon enteroscopy (DBE) is performed increasingly often in adults, few findings are available on the use of DBE in pediatric patients in the published literature.

OBJECTIVES

The aim of our study was to evaluate the safety and efficacy of DBE in pediatric patients.

DESIGN

A retrospective database review.

SETTING AND PATIENTS

A database analysis was performed on all pediatric patients (18 years old or younger) who underwent DBE at the Jichi Medical University Hospital between September 2000 and October 2008 selected from a total of 825 patients.

MAIN OUTCOME MEASUREMENTS

Clinical utility and safety of DBE in pediatric patients.

RESULTS

A total of 92 procedures were performed in 48 patients (27 male, 21 female) with a median age (range) of 12.2 (4-18) years. DBE was performed with the patients under general anesthesia in 43 procedures and under moderate sedation in 49 procedures. The most common indication for DBE was treatment of a stricture of a biliary anastomosis after living-donor liver transplantation with establishment of Roux-en-Y hepaticojejunostomy (23 patients). Endoscopic retrograde cholangiography using DBE was performed, and endoscopic therapy could be performed successfully in 13 (56%) patients. The second most common indication was obscure GI bleeding (10 patients); the lesions responsible for the bleeding were found in 7 (70%) patients. Other indications included surveillance and treatment of hereditary polyposis syndromes (5 patients), abdominal pain (4 patients), and inflammatory bowel disease (2 patients). The overall diagnostic yield was 65% (31 of the 48 patients). Postpolypectomy bleeding occurred in 1 case, but no other complications such as perforation and pancreatitis were observed.

LIMITATIONS

Small number of patients, participation bias, and single center's experience.

CONCLUSIONS

DBE is a safe and clinically useful endoscopic procedure in pediatric patients.

Comparison of intraoperative enteroscopy and double-balloon enteroscopy for the diagnosis and treatment of Peutz-Jeghers syndrome

BACKGROUND

Double-balloon enteroscopy (DBE) is an enteroscopy method that allows examination and treatment of the small bowel. Intraoperative enteroscopy (IOE) was the only possibility of endoscopic treatment for patients with Peutz-Jeghers syndrome (PJS) before the DBE era. PJS is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. PJS predisposes sufferers to various malignancies. Bleeding, obstruction, and intussusception are common complications in patients with PJS. The goal of this study was compare our experience in diagnosis and treatment of small-bowel hamartomas by means of DBE and IOE.

METHODS

From 1999 to 2006, we performed seven IOEs in seven patients (four women, three men), and since 2006, 14 DBEs in another ten patients (seven women, three men).

RESULTS

A total of 182 polyps were removed during IOEs: 179 by the endoscopist and three were cut out by the surgeon. From 6 to 75 polyps were removed per session (mean, 26). The largest hamartoma measured 4 cm in diameter. The age of the patients ranged from 20 to 50 (mean, 31) years. In our DBE group, a total of 205 polyps were removed. From 1 to 37 polyps were removed per session (mean, 13). The age of the patients ranged from 12 to 48 (mean, 25) years. The largest hamartoma was 6 cm in diameter. We had no serious complications both in the IOE and the DBE group.

CONCLUSIONS

Polypectomy using DBE may obviate the need for repeated urgent operations and small-bowel resections leading to short-bowel syndrome. Patients are indicated for prophylactic procedure and polypectomy of the entire small bowel. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful.

Peutz-Jeghers syndrome: Diagnostic and therapeutic approach

Peutz-Jeghers syndrome (PJS) is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. Prevalence of PJS is estimated from 1 in 8300 to 1 in 280 000 individuals. PJS predisposes sufferers to various malignancies (gastrointestinal, pancreatic, lung, breast, uterine, ovarian and testicular tumors). Bleeding, obstruction and intussusception are common complications in patients with PJS. Double balloon enteroscopy (DBE) allows examination and treatment of the small bowel. Polypectomy using DBE may obviate the need for repeated urgent operations and small bowel resection that leads to short bowel syndrome. Prophylaxis and polypectomy of the entire small bowel is the gold standard in PJS patients. Intraoperative enteroscopy (IOE) was the only possibility for endoscopic treatment of patients with PJS before the DBE era. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful. An overall recommendation for PJS patients includes not only gastrointestinal multiple polyp resolution, but also regular lifelong cancer screening (colonoscopy, upper endoscopy, computed tomography, magnetic resonance imaging or ultrasound of the pancreas, chest X-ray, mammography and pelvic examination with ultrasound in women, and testicular examination in men). Although the incidence of PJS is low, it is important for clinicians to recognize these disorders to prevent morbidity and mortality in these patients, and to perform presymptomatic testing in the first-degree relatives of PJS patients.

A pilot study about tolerability to double balloon endoscopy: comparison to esophagogastroduodenoscopy and colonoscopy

BACKGROUND

Although the diagnostic and therapeutic values of double balloon endoscopy (DBE) have been investigated, the subjective tolerability to DBE has not been assessed. We aimed to evaluate patients' tolerability to DBE.

METHODS

We prospectively enrolled patients who underwent DBE. For the comparison of tolerability to DBE with that to esophagogastroduodenoscopy (EGD) and colonoscopy, those who had not undergone EGD nor colonoscopy were excluded. A total of 52 patients were included. All procedures were performed under conscious sedation with midazolam with or without pethidine. Patients' tolerability to DBE, EGD, and colonoscopy was assessed through an interview with a questionnaire using a 10-point Likert scale.

RESULTS

A total of 36 patients underwent both antegrade DBE and EGD under conscious sedation. The level of abdominal pain during procedures, the level of post-procedural abdominal discomfort, and the proportion of patients with persistent abdominal discomfort until the next morning were higher in antegrade DBE. However, when analyzed in 16 patients who had good quality of sedation, the differences in the level of abdominal pain during procedures and the persistent abdominal discomfort until the next morning disappeared. A total of 23 patients underwent both retrograde DBE and colonoscopy under conscious sedation. Tolerability parameters were not different between retrograde DBE and colonoscopy. Serious complications, including hemodynamic instability, did not occur during all procedures.

CONCLUSION

Patients tolerated DBE well. DBE may be performed as comfortably as EGD and colonoscopy if the quality of sedation is good enough.

Jejunal diverticulae: reports of two cases with review of literature

INTRODUCTION

Jejunal diverticulosis (JD) is a rare disease of elderly people. Majority of diagnosed individuals are asymptomatic and found incidentally. The disease is clinically significant because of associated potential risk of serious complications. Due to the rarity and variable presentation of this clinical entity, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. Clinical presentations, signs, diagnosis, complications and treatment of JD are discussed through a review of the literature and report of two cases.

METHODS

A literature review was done for analysis of diagnosis, treatment and complications of JD. Two cases of JD diagnosed and treated in our institution are also presented.

CONCLUSION

JD is a rare disease which has variable presentations and thus poses a challenge to our diagnostic skills. Awareness about complications and presentation of the condition is needed for early detection and avoiding unnecessary mortality.

Usefulness of double balloon endoscopy in patients with surgically distorted intestinal anatomy

BACKGROUND

Double balloon endoscopy (DBE) is a new endoscopic method with the capability for complete observation of whole small bowel. This study evaluated the feasibility and usefulness of DBE for the diagnosis and therapy of small bowel diseases in patients with distorted intestinal anatomy by previous surgeries.

PATIENTS AND METHODS

From January 2005 to August 2007, 15 patients with Roux-en-Y anastomosis underwent DBE in Asan Medical Center. Eight were men and the median age was 57 years (range, 40 to 68 y). Indications of DBE were suspected small bowel bleeding, chronic diarrhea, and recurrent acute pancreatitis. The main outcome measurements included completeness of the observation of afferent loop and DBE findings.

RESULTS

Because 1 patient underwent DBE twice separately owing to recurrent bleeding, a total of 16 cases were analyzed. The observation of afferent loop was complete in 13 (81%) of 16 cases. The overall diagnostic yield of DBE was 69% (11/16). Out of 11 cases in which DBE detected abnormalities, 6 (55%) showed definite lesions and 5 (45%) probable lesions. Of the 11 cases in which abnormalities were found, 7 (64%) showed lesions in afferent loop. Of the 6 cases in which definite lesions were found, 4 (67%) showed lesions in afferent loop. Therapeutic endoscopic procedures were performed in 4 cases, which include argon plasma coagulation, foreign body removal, and endoscopic nasobiliary drainage.

CONCLUSIONS

DBE in patients with distorted intestinal anatomy such as Roux-en-Y anastomosis is a useful tool for the management of small bowel lesions, especially those in the afferent loop.

Outcomes associated with deep enteroscopy

The purpose of this article is to describe the available data regarding the short- and long-term outcomes associated with deep enteroscopy. Deep enteroscopy can be defined as the use of an enteroscope to examine small bowel distal to the ligament of Treitz or proximal to the distal ileum. The term deep enteroscopy includes double-balloon, single-balloon, and spiral enteroscopy. Comparisons are made with push enteroscopy and intraoperative enteroscopy, the major therapeutic endoscopic options available to the gastroenterologist before the introduction of deep enteroscopy. The article concludes with a discussion regarding complications associated with deep enteroscopy and cost-effectiveness of management strategies for obscure bleeding. Proposed changes to the current algorithm for management of obscure bleeding are suggested.

Balloon enteroscopy: single- and double-balloon enteroscopy

Balloon enteroscopy is a method that allows endoscopic inspection of the entire small bowel, or large parts of it, while simultaneously making it possible to obtain histologic samples and carry out treatment measures. Studies of double-balloon enteroscopy (DBE) have confirmed the high diagnostic yield of the procedure, with an acceptably low complication rate (approximately 1% for diagnostic DBE and 3% to 4% for therapeutic DBE). The principal indication for the procedure is midgastrointestinal bleeding, that is, when the bleeding source is located in the small bowel. With good patient selection, the diagnostic yield here is 70% to 80%, and this has a substantial influence on subsequent treatment measures. Single-balloon enteroscopy appears to be a simplification of the technique that is easier to handle, but few original studies have been published on the topic to date, and the results of prospective and controlled studies with larger numbers of patients must therefore be awaited. At present, DBE must still be regarded as the standard method for diagnostic and therapeutic endoscopy in the small bowel, avoiding the need for intraoperative enteroscopy or therapeutic laparotomy.

Novel applications of balloon endoscopy

Double-balloon endoscopy has been available for investigation of the small bowel since 2001, concomitantly with capsule endoscopy. Beyond established indications, endoscopic examination of the small bowel is currently performed in many clinical conditions involving the small bowel, which were under investigated in the past. Biopsies of lesions observed by capsule endoscopy or balloon enteroscopy can be taken and the lesions can sometimes be treated during a balloon Endoscopic procedure. Double-balloon endoscopy can be used in patients when conventional endoscopy was incomplete. The main applications of double-balloon endoscopy are the examination of patients with a surgically modified gastrointestinal tract and colonoscopy after a previously failed attempt to reach the cecum. In the latter indication, using a dedicated double-balloon colonoscope, the success rate of cecal intubation may be nearly 100%.

Use of double-balloon enteroscopy in the management of patients with Crohn's disease: feasibility and diagnostic yield in a high-volume centre for inflammatory bowel disease

BACKGROUND

Double-balloon enteroscopy (DBE) is theoretically useful in Crohn's disease (CD) since it is potentially able to investigate the whole small intestine, but sparse data are available.

AIM

To assess the feasibility, safety, and diagnostic yield of DBE in CD.

METHODS

The study was conducted in a tertiary care centre for inflammatory bowel disease. Thirty-seven patients with CD (18/19 male/female, mean age 42 years, range 13-77 years) were considered. Thirty-two DBEs from the oral approach and 18 from the anal (in 6 patients from both ways with a complete exploration in 4, 10.8%) were performed. Indications were: first diagnosis/staging in 16 cases, diagnosis of stenosis in 7, obscure bleeding in 10, suspected neoplasia in 2, and postsurgical evaluation in 2. One hundred and thirty-three other procedures (3.7 per patient) were performed with the same indication.

RESULTS

Insertion depth from the oral route was 266.5 ± 100 cm and from the anal route 72.5 ± 60 cm. Ileocecal valve was passed in 8/13 patients, but in 4 DBE explored less than 50 cm of ileum. Diagnostic yield was 59.4% but changed according to indication (40% in obscure bleeding, 100% in case of strictures) and was higher when DBE was conducted on the basis of previous investigations (77.8% versus 40%, p = 0.037).

CONCLUSION

DBE is a feasible, useful, but technically demanding method in CD. Definition of the proper introduction route by means of previous investigations is associated with a higher efficacy of DBE.

Comparison of detectability of small-bowel lesions between capsule endoscopy and double-balloon endoscopy for patients with suspected small-bowel disease

BACKGROUND

There are many reports of the usefulness of capsule endoscopy (CE) or double-balloon endoscopy (DBE) for the detection of small-bowel disease. However, there are few reports that compared CE and DBE.

OBJECTIVE

To determine whether CE or DBE better detects small-bowel lesions in patients with suspected small-bowel disease.

DESIGN

A prospective single-center study.

SETTING

Department of Endoscopy, Hiroshima University Hospital.

MAIN OUTCOME MEASUREMENTS

Rates of CE and DBE detection of small-bowel lesions.

PATIENTS

Seventy-six consecutive patients (47 men, 29 women; mean age 56.0 years) who underwent both CE and DBE.

METHODS

CE was performed before DBE. DBEs were performed within 1 week, by both retrograde and antegrade approaches so that the entire small bowel could be examined, if possible.

RESULTS

Small-bowel lesions were detected by CE in 42 patients (55.3%) and by DBE in 46 patients (60.5%). The difference was not significant (P = .45). Total enteroscopy was achieved by both examinations in 35 patients, and small-bowel lesions were detected by both examinations in 21 of the 35 patients (60.0%). Agreement between results of the 2 examinations was good (kappa = 0.76).

LIMITATION

The main indication for examinations was not the same.

CONCLUSIONS

CE and DBE are nearly equal in their ability to detect small-bowel lesions if the entire small bowel is examined.

Cost-effectiveness analysis of management strategies for obscure GI bleeding

BACKGROUND AND AIMS

Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage.

METHODS

We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period.

RESULTS

An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses.

LIMITATIONS

The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions.

CONCLUSIONS

An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.

Enteroscopy

Until the end of the 20th century, push enteroscopy (PE) was the most commonly used method for the endoscopic investigation of the small bowel. However, PE has been almost completely replaced by double balloon enteroscopy (DBE). Undoubtedly the major endoscopic breakthrough of the last decade, DBE has contributed to the better diagnosis and understanding of diseases of the small bowel, opening-up this obscure part of the gastrointestinal tract to visualisation. Modern diagnostic and therapeutic DBE allows for a deeper and more thorough evaluation of the small bowel than PE, enabling the detection of more pathological lesions. In addition, DBE has for the first time enabled endoscopists to observe the entire small intestine, and has provided endoscopic interventions such as cauterisation of bleeding lesions, polypectomy, placement of small bowel stents, and foreign-body extraction.

Diagnostic yield of double-balloon endoscopy in patients with obscure GI bleeding

BACKGROUND

Double-balloon endoscopy (DBE) is a new method that allows visualization, tissue sampling, and therapeutic intervention of a variety of pathologies throughout the small-intestinal tract.

OBJECTIVE

In the present study, we evaluated the diagnostic yield of DBE and its impact on the final diagnosis, treatment, and clinical outcome of patients with obscure GI bleeding (OGIB).

DESIGN AND SETTING

A hospital-based cross-sectional, follow-up study.

PATIENTS

We studied 108 consecutive patients (66 men and 42 women) referred to our hospital from July 2003 to February 2007 for the evaluation of OGIB: 13 patients with overt-ongoing bleeding, 76 with overt-previous bleeding, and 19 with occult OGIB.

MAIN OUTCOME MEASUREMENTS

Diagnostic yield, a final diagnosis, treatment, and clinical outcome were all analyzed in each group.

RESULTS

DBE diagnostic rates for patients with overt-ongoing, overt-previous, and occult bleeding were 100.0%, 48.4% and 42.1%, respectively. The difference in diagnostic yields between the overt-ongoing group and the 2 other groups was statistically significant (P < .005). The most common sources of bleeding were ulcers and tumor lesions. Small-intestinal lesions were identified in 52 of 108 patients; of which 36 patients (69.2%) were biopsied and 49 patients (94.2%) received treatment. Eight patients (7.4%) had recurrent bleeding during the mean follow-up period of 28.5 months. Sensitivity, specificity, and positive and negative predictive values of DBE in the diagnoses of small-intestinal lesions in patients with OGIB were 92.7%, 96.4%, 98.1%, and 87.1%, respectively. No serious complications were encountered.

CONCLUSIONS

DBE was proven to be a very useful diagnostic tool and had a therapeutic impact in the majority of patients with OGIB. The best candidates for the procedure were patients with overt-ongoing bleeding.

Is small-bowel radiography necessary before double-balloon endoscopy?

OBJECTIVE

Small-bowel radiography may be replaced by enteroscopy in the diagnosis of small-intestine lesions. We retrospectively elucidated the diagnostic yield of small-bowel radiography performed before double-balloon endoscopy.

MATERIALS AND METHODS

One hundred twenty-four patients who underwent double-balloon endoscopy during the period 2004-2006 were classified into those with abnormal radiographic findings (n = 45), normal radiographic findings (n = 31), and no small-bowl radiographs (n = 48). The classification was based on the use of small-bowel radiography and the diagnosis before double-balloon endoscopy. The indications for, approaches to, and diagnostic yields of double-balloon endoscopy were compared for the three groups. The diagnostic yield of small-bowel radiography was considered positive when any sign of pathologic change in the small bowel was identified. The diagnostic yield of double-balloon endoscopy was considered positive when endoscopic or biopsy findings explained the clinical manifestations.

RESULTS

The group with abnormal findings on small-bowel radiography was younger (15-86 years) and less frequently had obscure bleeding (8.9%) than the group with normal findings on small-bowel radiography (age, 17-84 years; frequency of obscure bleeding, 45.2%) (p = 0.01) or the group without small-bowel radiographs (age, 15-91 years; frequency of obscure bleeding, 64.6%) (p < 0.0001). The positive diagnostic yield of double-balloon endoscopy was highest in the group with abnormal findings on small-bowel radiography (71.1%), followed by the group with no small-bowel radiographs (45.8%) and the group with normal findings on small-bowel radiography (35.5%) (p = 0.0002). Among patients who did undergo small-bowl radiography, the accuracy of the technique was 68.4%, the positive predictive value was 71.1%, and the negative predictive value was 64.5%. The positive diagnostic yields of small-bowel radiography and double-balloon endoscopy were not statistically different (59.2% for small-bowel radiography, 56.6% for double-balloon endoscopy; p > 0.1).

CONCLUSION

The diagnostic accuracy of double-balloon endoscopy seems to improve if the procedure is preceded by small-bowel radiography.

Clinical features predicting the detection of abnormalities by double balloon endoscopy in patients with suspected small bowel bleeding

BACKGROUND AND AIM

Although double balloon endoscopy (DBE) has demonstrated a high diagnostic yield in suspected small bowel bleeding, it is not known whether DBE is of equal value to all patients with suspected small bowel bleeding or of greater benefit in selected subgroups. We aimed to determine whether any clinical features predict an increased likelihood of finding a lesion in patients with suspected small bowel bleeding.

METHODS

We retrospectively analyzed clinical features of 43 consecutive patients (M : F = 26:17, age 13-82 years) who underwent DBE because of suspected small bowel bleeding. Data associated with DBE procedure were collected prospectively. Predictive factors for the detection of a lesion were determined by comparison of clinical features between patients with positive DBE findings and those with negative findings.

RESULTS

Potential bleeding sources were discovered in 30 patients (69.8%) out of 43. Duration of bleeding was longer in patients with positive DBE findings than in those with negative findings (195 +/- 311 vs 18 +/- 17 days, P = 0.015). Number of bleeding episodes was higher in patients with positive DBE findings (2.2 +/- 1.2 vs 1.3 +/- 0.5, P = 0.011). The odds ratio for the detection of bleeding focus on DBE for patients with two or more bleeding episodes, relative to those with only one current bleeding episode was 5.67 (95% CI: 1.12-28.81, P = 0.036) in multivariate analysis.

CONCLUSION

DBE may be the most useful in patients with suspected small bowel bleeding if they have a history of frequent bleeding episodes over a long period.

Ileo-ileal invagination--a cause of recurrent mid-gastrointestinal bleeding: diagnostic and endoscopic therapy by means of push-and-pull enteroscopy

The types of lesions that cause bleeding in the small bowel are similar to those found in other areas in the gastrointestinal tract, such as vascular malformations, ulcers and inflammatory lesions, neoplasms and other less common lesions like Meckel's diverticulum. This report describes three patients with suspected mid-gastrointestinal bleeding with no significant past medical history. Before presenting to our unit the diagnostic work-up such as oesophagogastroduodenoscopy, colonoscopy and radiological small bowel imaging such as conventional enteroclysis or magnet resonance imaging enteroclysis had been performed without detecting any bleeding source. Capsule endoscopy suspected an angiodysplasia in the terminal ileum in one patient, in the other two patients a polyp in the region of the ileum as the potential bleeding source was diagnosed. In all three patients, a polyp with an ulcerated tip was found with the anal push-and-pull enteroscopy. An endosocpic resection was performed in all three cases without complication with the exception of one. In this patient a perforation occured 3 days after resection and was treated surgically without further complications. Histology revealed in all three cases, a polypoid diaphragmatic invagination of the small bowel with a vast area of chronic ulceration on the tip of this pseudopolyp with infiltration of the muscularis propria. In summary, the present paper describes the rare cases of erosive pseudopolyps after ileo-ileal invagination treated with endoscopic resection by means of push-and-pull enteroscopy.

Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis

BACKGROUND & AIMS

The aim of this study was to compare the diagnostic yield of capsule endoscopy (CE) with double-balloon enteroscopy (DBE) in small-bowel (SB) disease using meta-analysis.

METHODS

We performed a search of studies comparing CE with DBE in SB disease. Data on diagnostic yield of CE and DBE were extracted, pooled, and analyzed. The weighted incremental yield (IY(W)) (yield of CE--yield of DBE) of CE over DBE and 95% confidence intervals (95% CIs) for pooled data were calculated using a fixed-effect model (FEM) for analyses without, and a random-effect model (REM) for analyses with, significant heterogeneity.

RESULTS

Eleven studies compared CE and DBE; the pooled overall yield for CE and DBE was 60% (n = 397) and 57% (n = 360), respectively (IY(W), 3%; 95% CI, -4% to 10%; P = .42; FEM). Ten studies reported vascular findings; the pooled yield for CE and DBE was 24% (n = 371) and 24% (n = 364), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .88; REM). Nine studies reported inflammatory findings; the pooled yield for CE and DBE was 18% (n = 343) and 16% (n = 336), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .89; FEM). Nine studies reported polyps/tumors; the pooled yield for CE and DBE was 11% (n = 343) and 11% (n = 336), respectively (IY(W), -1%; 95% CI, -5% to 4%; P = .76; FEM).

CONCLUSIONS

CE and DBE have comparable diagnostic yield in SB disease, including obscure gastrointestinal bleeding. CE should be the initial diagnostic test because of its noninvasive quality, tolerance, ability to view the entire SB, and for determining the initial route of DBE. Because of its therapeutic capabilities, DBE may be indicated in patients with a positive finding on CE requiring a biopsy or therapeutic intervention, if suspicion for a SB lesion is high despite a negative CE, and in patients with active bleeding.

Initial experience with double-balloon enteroscopy at a U.S. center

BACKGROUND

Double-balloon enteroscopy (DBE) allows direct visualization and intervention in the entire small intestine. Concerns include long procedure times and a long learning curve after training.

OBJECTIVES

To analyze the initial experience of a single endoscopist when using DBE; assess resource utilization, safety, clinical utility, and the learning curve.

DESIGN

Prospective study.

SETTING

Tertiary-referral center.

PATIENTS

A total of 137 consecutive patients with bleeding or other small-intestine disorders.

MAIN OUTCOME MEASURES

Clinical impact at the time of DBE and changes in the procedure time and extent with experience.

RESULTS

Two hundred DBE procedures were performed without major complications. For 115 oral DBEs, the mean (SD) procedure duration was 101 +/- 35 minutes and length of examined small intestine was 220 +/- 80 cm, with no significant change with experience. For 85 anal DBEs, the mean (SD) procedure duration was 96 +/- 33 minutes, and the length examined was 124 +/- 60 cm; the length examined increased with experience, but the duration did not decrease. The percentage of patients in which a DBE had a helpful clinical impact rose from 58% in the first 50 DBEs, to 86% in the last 50 of 200 DBEs. The total enteroscopy rose from 8% in the first 50 DBEs, to 63% in the last 50 of 200 DBEs.

LIMITATIONS

No follow-up data on outcomes.

CONCLUSIONS

DBEs required significant time and did not always allow for a total enteroscopy. DBEs were safe and helpful in the management of most patients. An experienced endoscopist may perform a safe and useful DBE after limited training, but the development of expertise may require more than 100 to 150 DBE procedures.

Antiglycan antibodies as serological markers in the differential diagnosis of inflammatory bowel disease

BACKGROUND

The objective of the study was to evaluate the diagnostic accuracy of recently developed antiglycan serological tests in clinical practice for the diagnosis of Crohn's disease.

METHODS

This study was a cohort analysis of both clinical and biochemical parameters of patients with diagnosed inflammatory bowel disease compared with those in a control population. Antiglycan antibodies were determined using commercially available enzyme immunoassays. The setting was the outpatient unit of the gastroenterology department of a large, tertiary-care referral academic hospital. Participants were 214 consecutive patients, enrolled over a 5-month period, including 116 with Crohn's disease and 53 with ulcerative colitis, as well as 45 with other gastrointestinal diseases and 51 healthy controls.

RESULTS

Anti-Saccharomyces cerevisiae antibodies showed the best performance (54% sensitivity and 88%-95% specificity for Crohn's disease). Among patients with negative anti-Saccharomyces antibodies, 19 (34%) had high titers of at least another tested antiglycan antibody. Anti-Saccharomyces and anti-laminaribioside antibodies were associated with disease involving the small bowel and with penetrating or stricturing phenotype. Anti-laminaribioside was significantly higher in patients with a familial history of inflammatory bowel disease.

CONCLUSIONS

The new proposed serological markers are significantly associated with Crohn's disease, with low sensitivity but good specificity. About one third of anti-Saccharomyces-negative patients may be positive for at least 1 of those markers. Antiglycan antibodies appear to be associated with characteristic localization and phenotype of the disease.

Prospective evaluation of small bowel preparation with bisacodyl and sodium phosphate for capsule endoscopy

AIM: To determine the effect of Prepacol^®, a combination of sodium phosphate and bisacodyl, on transit and quality of capsule endoscopy (CE).

METHODS: Fivety two consecutive patients were included in this prospective study. CE was performed following a 12 h fasting period. Twenty six patients were randomized for additional preparation with Prepacol^®. The quality of CE was assessed separately for the proximal and the distal small bowel by 3 experienced endoscopists on the basis of a graduation which was initially developed with 20 previous CE.

RESULTS: Preparation with Prepacol^® accelerated small bowel transit time (262 ± 55 min vs 287 ± 97 min), but had no effect on the quality of CE. Visibility was significantly reduced in the distal compared to the proximal small bowel.

CONCLUSION: The significantly reduced visibility of CE in the distal small bowel allocates the need for a good preparation. Since Prepacol^® has no beneficial effect on CE the modality of preparation and the ideal time of application remains unclear. Further standardized examinations are necessary to identify sufficient preparation procedures and to determine the impact of the volume of the preparation solution.

Vascular lesions of the gastrointestinal tract

Classification of vascular abnormalities of the gastrointestinal tract on the basis of anatomy and pathophysiology has recently been suggested. Angiodysplasia, an example of an arteriovenous lesion, may cause either acute or chronic bleeding. Diagnosis may be difficult. High-quality standard endoscopy, capsule endoscopy, and double-balloon enteroscopy are most efficacious. Therapy using argon plasma coagulation is currently preferred. Pharmacological therapy has been employed, but a final conclusion about its efficacy cannot yet be drawn. Dieulafoy lesion, an arterial type of vascular abnormality, is rare but serious. It can be responsible for severe haemorrhage. Mechanical endoscopic methods are the most efficacious. Gastric antral vascular ectasia (GAVE), a capillary lesion, can be safely biopsied; it coincides with several diseases (including liver cirrhosis), may cause chronic iron-deficiency anaemia, and is best treated by argon plasma coagulation. Haemangiomas, benign neoplastic lesions, usually occur as part of other specific syndromes; they are difficult to manage due to the multiplicity and size of the lesions.

Obscure gastrointestinal bleeding: role of videocapsule and double-balloon enteroscopy

Capsule endoscopy (CE), which allows the non-invasive visualisation of mucosa throughout the entire small bowel, has revolutionised the exploration of small-bowel diseases, and particularly the evaluation of obscure gastrointestinal bleeding (OGIB) after a negative initial evaluation, including gastroscopy and colonoscopy. CE has a high negative predictive value and a higher diagnostic yield than all other modalities, such as radiology (small-bowel X-rays or computed tomography scan) or push enteroscopy. CE may be the preferred initial diagnostic choice in OGIB because of its non-invasive quality and better tolerance. Double-balloon enteroscopy, also known as push-and-pull enteroscopy, has recently been developed. It has made it possible not only to explore the small bowel but also to carry out therapeutic interventions deep in the small bowel without the need for surgical laparotomy. This exploration should be considered as a second-line exploration for OGIB in patients with a positive finding on CE requiring endoscopic follow-up for histology or intervention, and in patients in whom suspicion of a small-bowel lesion is high despite a negative CE.

Occult intestinal haemorrhage due to lipoma of the small bowel detected with the combined use of the new endoscopic techniques. A report of two cases

We report two unusual cases of occult intestinal bleeding due to lipoma of the small bowel. Both the patients underwent several inconclusive endoscopic and radiological procedures before the diagnosis of these lesions that was possible using video capsule endoscopy and double balloon enteroscopy. In the first case, the finding of capsule endoscopy was confirmed using enteroscopy, allowing us to diagnose the ileal mass. In the second and more recent case, we used double balloon enteroscopy for the further characterisation and management of the ileal lipoma. Lipoma is a very rare cause of intestinal bleeding and we describe the management and the outcome of our patients.

Double-balloon endoscopy: who needs it?

OBJECTIVE

Double-balloon endoscopy (DBE) made the small bowel accessible to inspection and therapy in its entirety. However, DBE is a time-consuming procedure that requires a highly skilled endoscopist, several nurses and--more often than not--anesthesiological support. This makes the selection of patients for DBE a pivotal point. The mainstay of this screening examination of the small bowel is capsule endoscopy (CE). The aim of this study was to describe the results of this screening procedure and the subsequent DBE in patients with suspected mid-gastrointestinal bleeding (MGIB).

MATERIAL AND METHODS

Patients referred for CE from March 2004 to September 2006 were evaluated retrospectively. If CE revealed pathology suitable for DBE, the procedure was then carried out. All referred patients were followed-up at the end of the period with regard to final diagnosis and symptom resolution.

RESULTS

A total of 83 patients were referred for suspected MGIB. Indications for DBE were found in 26 patients (31%). A total of 34 DBEs (27 oral, 7 anal) were performed. Insertion length for the oral and anal DBE was 200 cm (range 40-500 cm) beyond the ligament of Treitz and 137 cm (range 10-200 cm) beyond the ileocecal valve, respectively. In 2 out of 4 patients where insertion was attempted, a total inspection of the small bowel was possible (50%). The diagnostic yield was 77% (CI: 58-89%) with a therapeutic yield of 73% (CI: 54-86%). None of the 57 patients for whom there was no indication for DBE required DBE within the next 12 months.

CONCLUSIONS

CE can be applied as a screening procedure for DBE and allows for an approximately two-thirds reduction in the need for DBE as well as enabling a choice to be made between the oral and anal route.

Double balloon endoscopy associated pancreatitis: A description of six cases

AIM: To perform a single-center analysis of all double balloon endoscopy (DBE) related cases of pancreatitis identified prospectively from a recorded DBE-complication database.

METHODS: From November 2003 until January 2007, 603 DBE procedures were performed on 412 patients, with data on complications recorded in a database. The setting was a tertiary care center offering DBE. DBE was performed from the antegrade or retrograde route. Outcome measurements included age, gender, medication, indication, DBE-endoscope type, insertion depth, procedure duration, findings, interventions, post-procedural abdominal pain, and post-procedural hospitalization.

RESULTS: This is the largest single-center study reporting on post-DBE pancreatitis prospectively. Six patients (1.0%) developed post-DBE pancreatitis, all after antegrade DBE. There was no association with gender, duration of the procedure or type of endoscope. The mean age was 51.9 years (range 25-78). Four patients had severe pancreatitis. Of these, two had inflammatory signs in the body-tail region, one had pancreatitis in the tail region, and the total pancreas was involved in one.

CONCLUSION: The incidence of post-DBE pancreatitis in our series is higher than previously reported. We found no relation with DBE-endoscope type. The inflammatory changes occurred in the body-tail region of the pancreas, suggesting that post-DBE pancreatitis is caused by repetitive mechanical strain on the pancreas.

Prevalence of non-steroidal anti-inflammatory drug-induced enteropathy determined by double-balloon endoscopy: a Japanese multicenter study

OBJECTIVE

Capsule endoscopy has shown that non-steroidal anti-inflammatory drugs (NSAIDs) can damage the small intestine. The aim of this study was to determine the prevalence of NSAIDs enteropathy in subjects indicated for double-balloon endoscopy (DBE).

MATERIAL AND METHODS

The Japanese Study Group for Double-Balloon Endoscopy (JSG-DBE) established a database for the practical use of DBE in the Japanese population during a 2-year period from 2004 to 2005. Using this database, we identified subjects who had been taking NSAIDs within a month prior to DBE (NSAIDs group) and those free from NSAIDs use (control group). The clinical background and DBE findings were compared between the two groups.

RESULTS

Among 1035 patients registered in the JSG-DBE database, 61 subjects were classified as the NSAIDs group and 600 served as the control group. Patients in the NSAIDs group were older (62+/-18 versus 51+/-19 years, p<0.0001) and gastrointestinal bleeding was a more frequent indication for DBE (79% versus 44%, p<0.001) compared with in the control group. Non-specific mucosal breaks were detected by DBE in 31 patients in the NSAIDs group (51%) and 29 patients in the control group (5%, p <0.0001). Aspirin was less frequently prescribed and cardiovascular disease was a less frequent indication for NSAIDs use in patients with mucosal breaks than in those without breaks.

CONCLUSIONS

In the cases indicated for enteroscopy, NSAIDs enteropathy occurred in half of the patients taking NSAIDs. Aspirin seems to be less harmful to the small intestine than other NSAIDs.

Hyperamylasemia of uncertain significance associated with oral double-balloon enteroscopy

BACKGROUND

Double-balloon enterocopy (DBE) is still under evaluation, including its yield and safety aspects.

OBJECTIVE

Our purpose was to consider the relationship between DBE and hyperamylasemia.

DESIGN

Single-center prospective study.

SETTING

Tertiary referral hospital, conducted from March to October 2006.

PATIENTS

Thirty-five oral DBEs were carried out in 31 patients (17 men, 14 women). Serum amylase, lipase, C-reactive protein (CRP), and urine amylase were taken before the procedure and 4 and 24 hours after the investigation. Abdominal pain was evaluated with a 3-step scale.

MAIN OUTCOME MEASUREMENTS

Only 1 patient had acute pancreatitis after DBE.

RESULTS

An elevation of amylase levels after the procedure was found in 51.4% and abdominal pain or nausea or vomiting in 34.3%, but 8.6% of these patients had no hyperamylasemia after DBE. CRP was determined in 25 procedures and the serum lipase level in 14 of these 25 DBEs; elevation of both factors after the procedure was found in 36%. The CRP level was elevated in 60% after the procedure. We found a positive correlation between abdominal pain and serum lipase level (r = 0.72, P = .0032) and negative correlation between abdominal pain and age (r = -0.445, P = .0076). Significant hyperamylasemia seems to be associated with longer duration of DBE (borderline statistically significant, P = .045; 95% CI for difference of means 0.985-82.306).

LIMITATIONS

Nonblinded nonrandomized study.

CONCLUSIONS

Hyperamylasemia after DBE seems to be rather common, mainly in the longest examinations. Although association of significant hyperamylasemia and acute pancreatitis is possible, it is not obligatory.

American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding

This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007.

Current status of double balloon endoscopy--indications, insertion route, sedation, complications, technical matters

BACKGROUND

The recent development of double balloon endoscopy (DBE) has revolutionized enteroscopy. This system allows for endoscopic scrutiny and treatment of the entire small bowel, but general consensus has not yet been reached regarding procedural guidelines.

METHODS

We have been using the DBE system since June 2003, at Nippon Medical School Hospital, Tokyo, Japan, where 163 patients have undergone 265 DBE examinations. This study presents a detailed analysis of the current status of DBE examination at our institution, with particular focus on indications, contraindications, sedation, choice of insertion route, complications, and relevant technical points.

OBSERVATIONS

The most common indication for DBE was obscure GI bleeding. Patients were placed under conscious or deep sedation and their vital signs were monitored throughout the examination. The choice of either an oral or anal insertion route was determined on the basis of clinical symptoms or any previous examination data. When analyzing the entire small bowel, we began via the anal route and marked the intestine with India ink at the furthest insertion point lying closest to the oral route. We then switched our approach to the oral route, and confirmed total enteroscopy when the enteroscope reached the India-ink mark. With regard to complications, we encountered 1 case of acute pancreatitis and 2 cases of aspiration pneumonia after examination.

CONCLUSIONS

The DBE system allows for full investigation of the pathology of the small intestine and timely endoscopic treatment. However, for the DBE system to achieve more widespread acceptance, it is critical that we establish a universal method for its safe and efficient use.