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

Analysis of the causes and clinical characteristics of jejunoileal hemorrhage in China: a multicenter 10 year retrospective survey

Background

A retrospective study was performed to assess the causes, diagnostic methods for, and clinical features of, jejunoileal hemorrhage in Shandong province, China and to derive recommendations for management of this condition from these data.

Methods

We performed a retrospective systematic collection of data from between January 1999 and December 2008 in seven cities in Shandong province, China, identified 72 patients with jejunoileal hemorrhage and analyzed the relevant clinical data.

Results

Overall, tumors were the most common cause of jejunoileal hemorrhage (42 patients, 58.3%). The causes of this condition were significantly different (P < 0.05) in male and female patients. In male patients, the commonest factors were tumor (52.2%), enteritis (17.4%) and angiopathy (15.2%). However, in female patients, tumors accounted for a greater proportion of cases (18/26, 69.2%). In 38 cases (52.8%) the diagnosis was made by intraoperative enteroscopy or laparotomy, in 14 by capsule endoscopy and in the remainder by radiological methods. The most frequent presentation was melena (62.7%), followed by maroon stools (26.9%) and hematochezia (9.0%). Of the 72 patients,laparotomy is the main treatment method.

Conclusion

Tumor, enteritis and angiopathy and diverticular disease are the most common causes of jejunoileal hemorrhage in Shandong province, China. The main clinical manifestations are bloody stools, most commonly in the form of melena, with or without abdominal pain. We recommend that female patients over the age of 40 with jejunoileal hemorrhage accompanied by abdominal pain should undergo urgent further assessment because of the strong probability of jejunoileal tumor.

Small bowel endoscopy: cost-effectiveness of the different approaches

Obscure gastrointestinal haemorrhage is defined the presence of overt or occult bleeding in the setting of a normal endoscopic examination of the upper and lower gastrointestinal tracts. While obscure bleeding is not common, the evaluation and management of these patients often incurs considerable expense. Potential options for small bowel evaluation include traditional radiographic studies, push enteroscopy, video capsule endoscopy, deep enteroscopy, tagged red blood cell scans, angiography, and enterography examinations with either computed tomography and/or magnetic resonance imaging. The decision regarding which modality to employ depends on the cost of the procedure, its effectiveness in rendering a diagnosis, and the potential for administration of therapy. This article will discuss determination of costs associated with technology for small bowel imaging, quality of life data associated with chronic GI haemorrhage, and available cost-effectiveness studies comparing the options for small bowel exploration.

Advances in modern enteroscopy therapeutics

Advances in modern enteroscopy have been largely due to endoscope development but also through the improved availability of endoscopic accessories along with improved understanding in their application. Device assisted enteroscopy began with the double balloon system in 2001 and was quickly followed by single balloon enteroscopy and spiral enteroscopy. These tools revolutionised deep small bowel endoscopy and allowed for the delivery of virtually all known therapeutic endoscopy intervention to almost all segments of the small bowel. This review covers the types of interventions in regards to indications, methods and their safety profiles as well as reviewing the various device assisted endoscopes available and their attributes.

Small bowel endoscopy for obscure GI bleeding

Advancements in small bowel endoscopy have revolutionized the investigation and management of obscure GI bleeding. Capsule endoscopy and double balloon endoscopy, followed more recently by single balloon endoscopy and spiral enteroscopy, have progressed into established technologies that have now become integrated within clinical practice. As such, small bowel endoscopy research has matured to focus less on immediate endoscopic findings and ever increasingly on important clinical outcomes with long-term follow-up. The purpose of this paper is to review the role of small bowel endoscopy in obscure GI bleeding, while providing insights that may help guide clinicians in their decision-making.

Obscure and occult gastrointestinal bleeding: comparison of different imaging modalities

Patients with persistent, recurrent, or intermittent bleeding from the gastrointestinal (GI) tract for which no definite cause has been identified by initial esophagogastroduodenoscopy, colonoscopy, or conventional radiologic evaluation are considered to have an obscure GI bleeding (OGIB). The diagnosis and management of patients with OGIB is challenging, often requiring extensive and expensive workups. The main objective is the identification of the etiology and site of bleeding, which should be as rapidly accomplished as possible, in order to establish the most appropriate therapy. The introduction of capsule endoscopy and double balloon enteroscopy and the recent improvements in CT and MRI techniques have revolutionized the approach to patients with OGIB, allowing the visualization of the entire GI tract, particularly the small bowel, until now considered as the "dark continent" . In this article we review and compare the radiologic and endoscopic examinations currently used in occult and OGIB, focusing on diagnostic patterns, pitfalls, strengths, weaknesses, and value in patients' management.

Diagnostic yield of capsule endoscopy for gastric diseases

BACKGROUND AND AIM

Capsule endoscopy (CE) for the stomach has not yet been in practical use. Likewise as in colon, CE for colorectal cancer screening, the less invasive nature of CE may be suitable for gastric screening. The aim of this study is to estimate a diagnostic yield of CE for gastric diseases.

METHODS

This study involved 55 patients who participated in other clinical studies regarding obscure overt gastrointestinal bleeding or iron deficiency anemia. All patients underwent esophagogastroduodenoscopy and CE within 2 weeks. Sensitivity and specificity of CE for diffuse and localized gastric lesions were calculated, respectively.

RESULTS

Gastroscopy revealed 38 diffuse lesions (14 antral gastritis, 19 pangastritis, and 5 diffuse antral vascular ectasia) and 25 localized lesions (14 erosions, 2 cancers, and 9 polyps). CE had a higher sensitivity for gastric diffuse lesions compared with localized lesions. For diffuse lesions, sensitivity and specificity of CE were 70% and 82%, respectively. For localized lesions, sensitivity and specificity of CE were 28% and 63%, respectively. All cancers could not be detected by CE.

CONCLUSIONS

Currently, the diagnostic yield of CE for gastric diseases is not high enough for gastric screening. Additional improvements including preparations, position change, or the invention of new technologies are required.

New vision in video capsule endoscopy: current status and future directions

Now, more than 10 years after the approval of video capsule endoscopy (VCE), the technology has become an essential component in the management of several clinical conditions. Currently, two capsules are approved in the USA for visualizing the small bowel mucosa, one capsule is authorized for oesophageal assessment and several others are in use or under evaluation worldwide. New investigations have focused on optical improvements, advances in intestinal cleansing and risk reduction strategies to optimize VCE methodologies in clinical care. Established indications diagnosed using VCE include unexplained gastrointestinal bleeding, small bowel Crohn's disease (in adults and children >10 years old), localization of small bowel tumours and a broad range of miscellaneous abnormalities. Investigations are ongoing to determine the utility of VCE in colon cancer screening, assessment of oesophageal disorders and diagnosis of coeliac disease. Active research is in progress into ways to improve the efficacy of VCE recording interpretation, prolong imaging time and further enhance optics and imaging methods. To expand the potential utility of VCE, novel devices that can manoeuvre within or insufflate the gut lumen, tag or biopsy suspect lesions, or target drug delivery to specific sites are in development. To facilitate these advances, consortia have been organized to promote innovative VCE technologies.

Out-of-reach obscure bleeding: single-balloon enteroscopy to diagnose and treat varices in hepaticojejunostomy after pediatric liver transplant

Obscure gastrointestinal (GI) bleeding is defined as bleeding from the GI tract that persists or recurs, with no obvious etiology, after esophagogastroduodenoscopy (EGD), colonoscopy, and radiologic evaluation of the small bowel. We present the case of a 17-yr-old girl who for two years had been suffering from recurrent episodes of melena and/or enterorrhagia. Fifteen yr earlier she had undergone a split-liver transplant with Roux-en-Y biliary reconstruction. A series of endoscopic and radiologic investigations had failed to find the source of the bleeding. Suspecting the presence of ectopic varices, we decided to perform single-balloon enteroscopy (SBE). We observed and aspirated a large amount of fresh red blood in the afferent loop until we found the hepaticojejunostomy. On the edge of the biliary-enteric anastomosis we observed a vascular lesion 5 mm in diameter. Judging this ectopic varix to be the source of bleeding, we placed two endoclips. The second clip placement caused varix rupture with a consequent massive hemorrhage, emergently and successfully treated with cyanoacrylate sclerotherapy. No episodes of rebleeding were observed, and no complications occurred during the entire hospital stay, and after six months of follow-up. This report highlights the importance of afferent loop examination in patients with obscure GI bleeding who have undergone liver transplant with Roux-en-Y biliary reconstruction.

Endoscopic evaluation and management of gastrointestinal bleeding in patients with ventricular assist devices

The optimal diagnostic approach and yield for gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) are unknown. We explored the etiology of bleeding and yield of upper and lower endoscopy, balloon-assisted enteroscopy, and video capsule endoscopy in the evaluation of GIB in patients with VADs. Methods. All VAD patients with overt gastrointestinal bleeding and drop in hematocrit from April 1, 2000 to July 31, 2008 were retrospectively reviewed. The endoscopic evaluation of each episode was recorded. Overall yield of EGD, colonoscopy, balloon-assisted, and video capsule endoscopy were evaluated. Results. Thirty-six bleeding episodes occurred involving 20 patients. The site of GIB was identified in 32/36 episodes (88.9%), and the etiology of bleeding was determined in 30/36 cases (83.3%). Five VAD patients underwent VCE. The VCE exams demonstrated a high yield with 80% of exams identifying the etiology of GIB. Endoscopic intervention was successful in 8/9 attempts. No adverse events were recorded. Two patients required surgical intervention for GIB. Conclusion. Upper, lower, video capsule, and balloon-assisted enteroscopies are safe and demonstrate a high yield in the investigation of gastrointestinal bleeding in VAD patients. Medical centers caring for VAD patients should employ a standardized protocol to optimize endoscopic evaluation and intervention.

Iron deficiency anaemia: a review of diagnosis, investigation and management

Iron deficiency anaemia (IDA) is the most common form of anaemia worldwide. In men and postmenopausal women the commonest cause of IDA is blood loss from lesions in the gastrointestinal tract, making it a common cause of referral to gastroenterologists. Causes of IDA relate either to blood loss or iron malabsorption. After confirmation with laboratory tests, gastrointestinal evaluation is almost always indicated to exclude gastrointestinal malignancy. Specific patient groups such as premenopausal women, patients with low-normal ferritin and iron-deficient patients without anaemia may need an individualized approach. A small proportion of patients have recurrent or persistent IDA despite negative standard endoscopies. These patients with obscure gastrointestinal bleeding usually require evaluation of the small bowel with capsule endoscopy or double balloon enteroscopy. Treatment should involve prompt iron replacement plus diagnostic steps directed towards correcting the underlying cause of IDA. Oral iron replacement is cheap and effective, but parenteral (intravenous) therapy may be required due to intolerance, noncompliance or treatment failure with oral therapy.

Advances in small bowel imaging

The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Within the past 10 years, advances have led to an explosion of technologies that facilitate examination of the entire small intestine. Wireless video capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computer tomography (CT) and magnetic resonance (MR) enterography have facilitated the diagnosis, monitoring, and management of patients with small intestinal diseases. These technologies are complementary, each with its advantages and limitations. Capsule endoscopy provides a detailed view of the mucosal surface and has excellent patient acceptance, but does not allow therapeutics. Deep enteroscopy allows careful inspection of the mucosa and therapeutics, but is time consuming and invasive. Enterography (CT or MR) allows examination of the small bowel wall and surrounding structures. The initial best test for detecting small intestinal disease depends on clinical presentation and an astute differential diagnosis.

Therapeutic management options for patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.

Utility of preoperative small-bowel endoscopy for hemorrhagic lesions in the small intestine

PURPOSE

We evaluated a small group of patients with hemorrhagic lesions in the small intestine diagnosed preoperatively by video capsule endoscopy (VCE) and/or double-balloon endoscopy (DBE), who underwent surgery in our hospital.

METHODS

The subjects were 20 patients with hemorrhagic lesions in the small intestine diagnosed preoperatively by VCE and/or DBE, who underwent surgery between April 2004 and December 2008.

RESULTS

VCE, DBE, and computed tomography were performed in 12, 17, and 20 patients, respectively. Eleven patients also had a biopsy taken during DBE, resulting in a definitive diagnosis in eight. Because of the risk of hemorrhage during DBE in five patients, a biopsy was not taken and the sites of the lesion were marked in these patients. Twenty patients underwent surgery, and the diagnoses were small-intestinal cancer in eight, gastrointestinal stromal tumor in seven, arteriovenous malformation in two, and Crohn's disease, angioectasia, and leiomyoma in one each. The interval between the onset of symptoms and surgery was less than 50 days for six patients, 50-100 days for two, 100-200 days for five, and more than 200 days for seven.

CONCLUSION

Preoperative small-bowel endoscopy proved useful for diagnosing the cause of hemorrhagic lesions in the small intestine.

Roux-en-Y loop varices in children with portal hypertension after liver transplantation: an unusual cause of "obscure" gastrointestinal bleeding

PHALT may result from graft dysfunction, portal vein thrombosis, arterio-venous fistulas and can lead to GIB, commonly from bleeding esophageal varices. We present three children with GIB requiring multiple blood transfusions that were diagnosed with RY Loop bleeding. Routine EGD, colonoscopy, and CE failed to reveal the bleeding source. However, enteroscopy revealed large varices at the site of hepaticojejunostomy anastomosis in all. Our experience demonstrates that RY loop varices in children with PHALT are a rare and treatable cause of obscure GI bleeding.

Colonoscopy Leads to A Diagnosis of A Jejunal Gastrointestinal Stromal Tumour (GIST)

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal (GI) tract, but are the least common of small intestinal malignant neoplasms. While GI bleeding is the most common clinical presentation of GISTs, intussusception and obstruction are uncommon, as GISTs rarely grow into the lumen. We describe an unusual case of a 50-year-old male who presented with intermittent obscure, overt GI bleeding requiring multiple hospital admissions and blood transfusions. His work-up included abdominal CT imaging, small bowel follow-through, gastroscopies, push enteroscopy, colonoscopies, and anterograde and retrograde double-balloon enteroscopies. Complicating his presentation were colonic angiodysplasias and the development of recurrent venous thromboembolism requiring anticoagulation. Within an hour after an apparently uncomplicated colonoscopy, he developed an acute abdomen secondary to a jejunal intussusception, which led to a laparoscopic small bowel resection and the diagnosis of a jejunal GIST. Given his GIST had no high-risk features, ongoing surveillance with abdominal CT imaging was arranged. This case illustrates the complex presentation and diagnostic difficulty of a jejunal GIST causing obscure, overt GI bleeding and this is the first reported case of a jejunal intussusception following colonoscopy. Due to its submucosal location, multiple endoscopic approaches had failed to diagnose the GIST prior to surgery.

Impact of inpatient status and gender on small-bowel capsule endoscopy findings

BACKGROUND

Video capsule endoscopy (VCE) is most commonly performed in the outpatient setting to evaluate obscure GI bleeding.

OBJECTIVE

To determine the impact of gender and inpatient status on VCE findings.

DESIGN

Retrospective study.

SETTING

Two tertiary medical centers and a VA medical center.

PATIENTS

A total of 167 inpatients and 540 outpatients undergoing 707 VCE examinations for obscure GI bleeding.

INTERVENTIONS

VCE study.

MAIN OUTCOME MEASUREMENTS

Patient age, sex, indication for VCE, gastric and small-bowel transit times, significant VCE findings including detection of blood in the lumen and major lesions outside the small bowel, and presence of comorbid conditions.

RESULTS

Significant VCE findings were identified more frequently during inpatient VCE examinations (48% vs 37%, P = .009). Endoscopic placement, nongastric passage, and incomplete studies to the cecum were more common for inpatient VCE examinations. Gastric transit time, but not small-bowel transit time, was longer in inpatient VCE studies. Inpatient VCE examinations were more common in male patients (73% vs 61%, P = .004) and patients with overt bleeding (83% vs 46%, P < .05). The overall diagnostic VCE rate was higher for male patients because of a higher prevalence of angiodysplastic lesions and major findings outside the small bowel.

LIMITATIONS

Retrospective study. Lack of information regarding timing of VCE study, most recent episode of obscure bleeding, and comorbidity data for outpatients.

CONCLUSION

The overall diagnostic yield was higher for inpatient VCE examinations. Male patients were more likely to demonstrate significant findings on both inpatient and outpatient VCE studies because of a higher prevalence of angiodysplastic lesions and findings outside the small bowel.

Outcomes after symptomatic capsule retention in suspected small bowel obstruction

BACKGROUND AND AIM

Capsule endoscopy (CE) has been proven to be a sensitive and a safe tool for the examination of the small bowel. However, careful patient selection is required to avoid complications, primarily capsule retention. The aims of this study were to evaluate the rate of capsule retention in patients with suspected chronic small bowel obstruction and to analyze the role and the impact of subsequent surgical intervention.

METHODOLOGY

Fifteen patients referred for CE with a clinical picture suggestive of chronic small bowel obstruction and with negative imaging studies were retrospectively analyzed.

RESULTS

Capsule retention occurred in three (20%) patients who developed symptoms of subacute obstruction and subsequently underwent surgery. Radiation enteritis, Crohn's disease, and an ileal tumor were demonstrated as the causes of the capsule retention in these patients. Surgical removal of the retained capsule was performed and the underlying small bowel disease was treated.

CONCLUSION

Capsule retention is a frequent complication of CE in patients with symptoms of chronic small bowel obstruction. Surgery, with the removal of the retained capsule, is proven to be beneficial in identifying the location of, and treating, the underlying disease in these patients.

CT-enterography may identify small bowel tumors not detected by capsule endoscopy: eight years experience at Mayo Clinic Rochester

BACKGROUND

Capsule endoscopy (CE) is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases. However, small bowel tumors (SBT) are sometimes missed by CE. Preliminary studies suggest that CT-enterography (CTE) may play a role in detecting SBT.

AIMS

The purpose of this study was to compare the performance of CE and CTE in detecting SBT METHODS: This was a single center, retrospective study. Patients treated at the Mayo Clinic Rochester between January 2000 and December 2008 with a discharge diagnosis of SBT and negative initial esophagogastroduodenoscopy (EGD) and colonoscopy were identified through a search of the electronic medical records. Among 103 identified patients, 41 had undergone CE, CTE or both, and comprised our study group. The exact binomial sensitivity of CE and CTE in detecting SBT was calculated. Demographic characteristics, clinical presentation, results of diagnostic tests, and tumor characteristics were recorded for each patient.

RESULTS

CTE and CE detected 38/41 (sensitivity 92.7%; 95% CI 80.1-98.5) and 8/27 (sensitivity 29.6%; 95% CI 13.8-50.2) of the SBT identified at Mayo Clinic Rochester, respectively. Seventeen patients had both CTE and CE. In this subgroup of patients, CTE detected SBT in 16/17 (sensitivity 94.1; 95% CI 72.7-99.9) and CE in 6/17 (sensitivity 35.3%; 95% CI 13.3-59). The matched paired difference in the sensitivity of two techniques in detecting SBT was statistically significant (P = 0.004).

CONCLUSION

CTE may identify SBT not diagnosed by CE.

[Gastrointestinal bleeding: the role of radiology]

Gastrointestinal bleeding represents a diagnostic challenge both in its acute presentation, which requires the point of bleeding to be located quickly, and in its chronic presentation, which requires repeated examinations to determine its etiology. Although the diagnosis and treatment of gastrointestinal bleeding is based on endoscopic examinations, radiological studies like computed tomography (CT) angiography for acute bleeding or CT enterography for chronic bleeding are becoming more and more common in clinical practice, even though they have not yet been included in the clinical guidelines for gastrointestinal bleeding. CT can replace angiography as the diagnostic test of choice in acute massive gastrointestinal bleeding, and CT can complement the endoscopic capsule and scintigraphy in chronic or recurrent bleeding suspected to originate in the small bowel. Angiography is currently used to complement endoscopy for the treatment of gastrointestinal bleeding.

Single-balloon push-and-pull enteroscopy system: does it work? A single-center, 3-year experience

BACKGROUND

The last decade has seen significant advances in the evaluation of the small bowel. Several endoscopic techniques have been developed in recent years: capsule endoscopy (CE), double-balloon enteroscopy (DBE), and, more recently, the single-balloon enteroscopy (SBE). The aim of this study was to evaluate diagnostic and therapeutic impact, safety, and feasibility of the SBE procedure after a 3-year experience.

METHODS

A total of 73 SBE procedures were performed from July 2006 to July 2009. The starting insertion route (oral or anal) of SBE was chosen according to the estimated location of the suspected lesions based on the clinical presentation and, in 48 patients, on the findings of CE. A total of 70 patients with obscure gastrointestinal bleeding (31), suspected malabsorption syndrome (12), polyposis syndromes (11), suspected Crohn's disease (9), and suspected gastrointestinal tumors (7) were recruited.

RESULTS

The SBE was not carried out in four patients because of technical problems. Multiple angiodysplasias were found and treated in 9 patients; Peutz-Jeghers syndrome, familial adenomatous polyposis (FAP), and multiple polypectomies were carried out in 8 patients; endoscopic tattoos were performed in 2 patients due to the large diameter of the polyps; and multiple biopsies was performed in only one patient. SBE diagnosed Crohn's disease in four patients, malabsorption syndromes in two, lymphangiectasia in two, eosinophilic enteritis in one, melanoma in one, and nonspecific inflammation in eight. A total of seven small-bowel tumors were diagnosed (all were tattooed). In 23/70 patients the exam was negative. No major complications occurred.

CONCLUSION

Single-balloon enteroscopy seems to be safe, useful, and highly effective in the diagnosis and therapy of several small-bowel diseases.

Prevalence of gastric cancer versus colorectal cancer in Asians with a positive fecal occult blood test

AIM

Prior studies have reported conflicting results on the yield of esophagogastroduodenoscopy (EGD) in patients with a positive fecal occult blood test (FOBT). Our aim was to compare the yield between EGD and colonoscopy performed in a racially diverse population with a positive FOBT.

METHODS

A retrospective, cross-sectional study of FOBT positive patients who underwent EGD and colonoscopy from January 1, 1999 to November 1, 2008. Endoscopic lesions deemed responsible for GI bleeding were identified.

RESULTS

Two hundred and eighty-seven patients met entry criteria, among which, 63% were Asian and 81% were immigrants to the U.S. Forty-four patients had EGD findings deemed responsible for a positive FOBT, the most common being esophagitis (25.0%) and gastric ulceration (15.9%). Forty-two patients had colonoscopic findings likely responsible for a positive FOBT with the most frequent lesion being colonic polyps ≥9 mm in diameter (76.2%). Prevalence of lower and upper GI tract lesions responsible for positive FOBT was similar (14.6% vs. 15.3%, p = 0.2). There was no association between a patient reporting upper GI symptoms, or the presence of anemia and the detection of upper GI tract lesions on endoscopy. Gastric adenocarcinoma (n = 3) was as prevalent as colorectal adenocarcinoma (n = 4). All three patients with gastric adenocarcinomas were Asian (prevalence 1.6%).

CONCLUSIONS

In our racially diverse population evaluated for a positive FOBT, gastric adenocarcinoma was as prevalent as colorectal adenocarcinoma; however, gastric adenocarcinoma was limited to Asian patients. EGD and colonoscopy should be considered in the evaluation of patient populations similar to ours, particularly Asian immigrants.

Ketamine and midazolam sedation for pediatric gastrointestinal endoscopy in the Arab world

AIM: To evaluate the safety and effectiveness of intravenous ketamine-midazolam sedation during pediatric endoscopy in the Arab world.

METHODS: A retrospective cohort study of all pediatric endoscopic procedures performed between 2002-2008 at the shared endoscopy suite of King Abdullah University Hospital, Jordan University of Science & Technology, Jordan was conducted. All children were > 1 year old and weighed > 10 kg with American Society of Anesthesiologists class 1 or 2. Analysis was performed in terms of sedation-related complications (desaturation, respiratory distress, apnea, bradycardia, cardiac arrest, emergence reactions), adequacy of sedation, need for sedation reversal, or failure to complete the procedure.

RESULTS: A total of 301 patients (including 160 males) with a mean age of 9.26 years (range, 1-18 years) were included. All were premedicated with atropine; and 79.4% (239/301) had effective and uneventful sedation. And 248 (82.4%) of the 301 patients received a mean dose of 0.16 mg/kg (range, 0.07-0.39) midazolam and 1.06 mg/kg (range, 0.31-2.67) ketamine, respectively within the recommended dosage guidelines. Recommended maximum midazolam dose was exceeded in 17.6% patients [34 female (F):19 male (M), P = 0.003] and ketamine in 2.7% (3 M:5 F). Maximum midazolam dose was more likely to be exceeded than ketamine (P < 0.001). Desaturation occurred in 37 (12.3%) patients, and was reversible by supplemental oxygen in all except 4 who continue to have desaturation despite supplemental oxygen. Four (1.3%) patients had respiratory distress and 6 (2%) were difficult to sedate and required a 3rd sedative; 12 (4%) required reversal and 7 (2.3%) failed to complete the procedure. None developed apnea, bradycardia, arrest, or emergence reactions.

CONCLUSION: Ketamine-midazolam sedation appears safe and effective for diagnostic pediatric gastrointestinal endoscopy in the Arab world for children aged > 1 year and weighing > 10 kg without co-morbidities.

Therapeutic and interventional endoscopy for gastrointestinal bleeding

INTRODUCTION

Gastrointestinal (GI) bleeding remains a common clinical problem encountered by every emergency room and trauma physician. Endoscopy remains the main approach to the diagnosis and therapy of GI bleeding.

OBJECTIVES

To present the modern endoscopic approach for GI bleeding.

METHODS

Narrative review based on our expertise and inclusion of classic articles dealing with interventional and therapeutic GI endoscopy.

RESULTS

GI hemorrhage is now classified as upper, middle, and lower GI bleeding. Upper GI bleeding is defined as hemorrhage originating from the oropharynx to the ligament of Treitz (or papilla of Vater), middle GI bleeding occurs distal to the papilla of Vater to the terminal ileum, and lower GI bleeding is defined as bleeding distal to the ileocecal valve, including the entire colon and anorectum. Endoscopic methods used to diagnosed and treat GI bleeding include esophagogastroduodenoscopy, duodenoscopy, capsule endoscopy, double- and single-balloon enteroscopy, spiral enteroscopy, and colonosocopy.

CONCLUSIONS

This is the first review paper dedicated to endoscopic therapy for bleeding involving any part of the luminal GI tract (i.e., esophagus, stomach, small bowel, and colon). Modern endoscopy permits the investigation and treatment of the majority of conditions affecting the entire hollow GI tract.

Review article: the diagnosis and investigation of obscure gastrointestinal bleeding

BACKGROUND

Obscure gastrointestinal bleeding (OGIB) is a commonly encountered clinical problem in gastroenterology and is associated with significant morbidity and mortality. The investigation and management of OGIB has changed dramatically over the past decade with the advent of newer gastroenterological and radiological technologies.

AIM

To review the current evidence on the diagnosis and investigation of OGIB.

METHODS

We searched the PubMed database (1985-2010) for full original articles in English-language journals relevant to the investigation of OGIB. The search terms we used were 'gastrointestinal bleeding' or 'gastrointestinal hemorrhage' or 'small bowel bleeding' each in combination with 'obscure', or 'capsule endoscopy', or 'enteroscopy' or 'enterography' or 'enteroclysis'.

RESULTS

Capsule endoscopy (CE) or double balloon enteroscopy (DBE) should be first line investigations. They are complimentary procedures with comparable high diagnostic yields. DBE is also able to provide therapeutic intervention. Newer technologies such as single balloon and spiral enteroscopy are currently being evaluated. Radiological and nuclear medicine investigations, such as CT enterography and CT enteroclysis, are alternative diagnostic tools when CE or DBE are contraindicated. Repeating the gastroscopy and/or colonoscopy may be considered in selective situations. An algorithm for investigation of obscure bleeding is proposed.

CONCLUSIONS

The development of capsule endoscopy and double balloon enteroscopy has transformed the approach to the evaluation and management of obscure gastrointestinal bleeding over the past decade. Older diagnostic modalities still play a complementary, but increasingly selective role.

A prospective evaluation of adult men with iron-deficiency anemia in Korea

OBJECTIVE

Iron-deficiency anemia (IDA) is the most common nutritional deficiency worldwide. However, the information concerning various causes of IDA in adult men is still insufficient. The aim of our study was to evaluate adult men with IDA.

METHODS

We prospectively studied 206 adult men with IDA. All subjects had a direct history taken and underwent a physical examination. Esophagogastroduodenoscopy was performed in most patients, and colonoscopy was conducted if no lesion causing IDA was found or the fecal occult blood test was positive.

RESULTS

The history of prior gastrectomy and blood-letting cupping therapy that probably had caused IDA were reported in 24 (11.7%) and 11 (5.3%) patients, respectively. In terms of potential causes of IDA, 68 (33.0%) patients were found to have upper gastrointestinal disorders (34 peptic ulcers, 17 erosive gastritis, 16 gastric cancers, and one gastrointestinal stromal tumor). Colonoscopy showed 42 (20.4%) clinically relevant lesions that probably caused IDA: colon cancer (five patients), colon polyps (14 patients), ulcerative colitis (one patient), and hemorrhoids (22 patients). One small bowel tumor was detected at small bowel series. Concerning malignant lesions that were responsible for IDA, 22 malignant lesions were found in patients of 50 years or older, accounting for 16.8% (22 of 131 patients), while only one (1.3%) early gastric cancer was found in the younger patients.

CONCLUSION

This study demonstrated that gastrointestinal blood loss is the main cause of IDA in adult men, and that there is a high rate of malignancy in men older than 50 years, emphasizing the need for a complete, rigorous gastrointestinal examination in this group of patients. Considering blood-letting cupping therapy, there is a need to consider culture-specific procedures as a possible cause of IDA.

Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding

PURPOSE

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.

RESULTS

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).

CONCLUSION

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.

Bleeding lesions within reach of conventional endoscopy in capsule endoscopy examinations for obscure gastrointestinal bleeding: is repeating endoscopy economically feasible?

BACKGROUND

Most tertiary gastroenterology centers currently offer an open-access capsule endoscopy (CE) service, including patients with obscure gastrointestinal bleeding. However, CE may identify lesions missed by conventional endoscopy.

AIMS

To determine the incidence of bleeding lesions missed by the preceding gastroscopy/colonoscopy that were revealed by CE and compare potential differences in the rate of identifying such lesions in patients that we investigated as opposed to those investigated elsewhere.

METHODS

We prospectively reviewed data from patients subjected to CE for obscure bleeding. We analyzed all cases where a source of bleeding was located in the stomach, duodenum, or colon.

RESULTS

A total of 317 consecutive patients were subjected to CE for obscure gastrointestinal bleeding within 28 months. Prior to CE examination, 174 patients had gastroscopy and colonoscopy in our institutions and 143 were referrals, all with negative endoscopic investigation. We identified 11 (3.5%) cases where the source of bleeding was found in the stomach (n = 4) or the cecum (n = 7). There was a significant difference of extra small intestinal lesions diagnosed by CE between referrals (9/143, 6.3%) and endoscopic investigation performed in our institutions (2/174, 1.15%), (p = 0.026). The estimated cost of re-endoscoping in our institution all CE referrals would be 50,050 euro (143 patients × 350 euro), to avoid unnecessary CE examinations (9 patients × 600 euro = 5,400 euro).

CONCLUSIONS

Reading the whole CE video is important, because small-bowel CE may identify lesions responsible for obscure bleeding missed by the preceding gastroscopy and colonoscopy. Repeating conventional endoscopy by experts before CE is not a cost-effective approach.

Do clinical characteristics predict the presence of small bowel angioectasias on capsule endoscopy?

BACKGROUND AND AIMS

Angioectasias (AVMs) are the most common vascular anomaly of the gastrointestinal (GI) tract, and these lesions are often associated with obscure gastrointestinal bleeding (OGIB). It is unknown if the presence of upper and/or lower gastrointestinal AVMs are predictive of small bowel AVMs. The aims of this study are to define the small bowel segmental distribution of AVMs and to identify the factors predicting the presence of small bowel AVMs among a cohort of patients with a known history of AVMs in the upper and/or lower GI tracts who are undergoing capsule endoscopy (CE) for OGIB.

METHODS

We performed a retrospective cohort analysis of 1,125 patients undergoing CE at our institution between 11/1/2001 and 8/31/2007. Inclusion criteria were: (1) complete esophagoduodenoscopy (EGD), CE, and colonoscopy, (2) OGIB indication for CE, and (3) history of ≥ 1 AVM on EGD and/or colonoscopy that was previously treated in the past or deemed not to be a clinically significant source of bleeding. Exclusion criteria were: (1) history of radiation therapy to the GI tract, and (2) presence of a congenital or systemic disease associated with GI AVMs. Data were extracted on: (1) age; (2) gender; (3) presence of diabetes, (4) presence of hypertension, (5) presence of aortic stenosis, (6) history of non-steroidal anti-inflammatory therapy, (7) history of anticoagulant therapy, (8) hemoglobin, platelet, and INR values prior to CE; (9) baseline serum creatinine; and (10) presence and GI tract segmental location of AVMs. Multivariate logistic regression was used to identify independent predictors of small bowel AVMs.

RESULTS

1,125 patients underwent EGD, CE, and colonoscopy. One hundred and fourteen patients had a history of ≥ 1 AVM on EGD and/or colonoscopy and met inclusion and exclusion criteria. The mean age was 69 years, and 63% of patients were women. 37% of patients were found to have ≥ 1 jejunal AVM and 15% were found to have ≥ 1 ileal AVM. In multivariate analysis, age ≥ 65 (OR 2.62, P = 0.05) and the presence of AVMs on EGD (OR 4.61, P = 0.02) were predictive of jejunal AVMs. AVMs on colonoscopy alone were not predictive of jejunal or ileal AVMs. No factors were found to predict the presence of ileal AVMs.

CONCLUSIONS

Patients with AVMs on EGD have an increased risk of jejunal AVMs on CE, particularly if they are elderly. Future studies should validate these findings in a prospective cohort.

A prospective evaluation of iron deficiency anemia in the GI endoscopy setting: role of standard endoscopy, videocapsule endoscopy, and CT-enteroclysis

BACKGROUND

Iron deficiency anemia (IDA) is a frequently encountered condition in clinical practice. After conventional endoscopy, the cause of anemia remains unknown in up to 40% of patients.

OBJECTIVE

To evaluate prospectively the diagnostic efficacy of a systematic endoscopic approach to IDA and to compare the diagnostic yield of videocapsule endoscopy (VCE) and CT-enteroclysis in endoscopy-negative patients.

DESIGN

Consecutive patients with IDA were enrolled prospectively.

SETTING

Open-access endoscopy within an academic hospital.

PATIENTS

This study involved 189 patients with IDA, including 98 women and 91 men; mean (±standard deviation) age 68 years±16.6 years.

INTERVENTION

Patients with IDA underwent gastroscopy and colonoscopy plus ileoscopy. Endoscopy-negative patients were further blindly evaluated by both CT-enteroclysis and VCE.

MAIN OUTCOME MEASUREMENTS

Diagnostic yield of conventional endoscopy; diagnostic yield of VCE versus CT-enteroclysis.

RESULTS

Endoscopy results were positive in 144 of 189 patients (76.2%). CT-enteroclysis and VCE allowed a diagnosis in 37 of 45 endoscopy-negative patients (82.2%). Overall, VCE was superior to CT-enteroclysis (77.8% vs 22.2%; P<.001), in particular when flat lesions were found.

LIMITATIONS

Single-center study.

CONCLUSION

A systematic approach to IDA, which includes standard endoscopy, VCE, and CT-enteroclysis allows an overall diagnostic rate of 95.7%; however, CT-enteroclysis should be limited to cases of nondiagnostic VCE.

Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis

BACKGROUND AND AIM

Uncertainty remains about the best test to evaluate patients with obscure gastrointestinal bleeding (OGIB). Previous meta-analyses demonstrated similar diagnostic yields with capsule endoscopy (CE) and double balloon enteroscopy (DBE) but relied primarily on data from abstracts and were not limited to bleeding patients. Many studies have since been published. Therefore, we performed a new meta-analysis comparing CE and DBE focused specifically on OGIB.

METHODS

A comprehensive literature search was performed of comparative studies using both CE and DBE in patients with OGIB. Data were extracted and analyzed to determine the weighted pooled diagnostic yields of each method and the odds ratio for the successful localization of a bleeding source.

RESULTS

Ten eligible studies were identified. The pooled diagnostic yield for CE was 62% (95% confidence interval [CI] 47.3-76.1) and for DBE was 56% (95% CI 48.9-62.1), with an odds ratio for CE compared with DBE of 1.39 (95% CI 0.88-2.20; P = 0.16). Subgroup analysis demonstrated the yield for DBE performed after a previously positive CE was 75.0% (95% CI 60.1-90.0), with the odds ratio for successful diagnosis with DBE after a positive CE compared with DBE in all patients of 1.79 (95% CI 1.09-2.96; P = 0.02). In contrast, the yield for DBE after a previously negative CE was only 27.5% (95% CI 16.7-37.8).

CONCLUSIONS

Capsule endoscopy and double balloon enteroscopy provide similar diagnostic yields in patients with OGIB. However, the diagnostic yield of DBE is significantly higher when performed in patients with a positive CE.

Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial

BACKGROUND

Balloon endoscopy has been accepted as an effective tool for examining the small intestine. Two types of balloon endoscopy, single and double, are commercially available. The difference in performance between these 2 types of balloon endoscopy has not yet been elucidated.

OBJECTIVE

To compare the yield of single-balloon endoscopy (SBE) and double-balloon endoscopy (DBE).

DESIGN

Single-center, randomized, controlled trial.

SETTING

University hospital in Tokyo, Japan.

PATIENTS

Patients with suspected small-bowel disease.

INTERVENTIONS

SBE and DBE.

MAIN OUTCOME MEASUREMENTS

Outcomes were the total enteroscopy rate, diagnostic yield, complication rate, and clinical outcomes. Analysis was done by intent to treat.

RESULTS

The study started in April 2008 and was terminated in April 2010 because of an obvious disadvantage for the SBE group. Thirty-eight patients were enrolled in the study; 18 patients were assigned to the SBE group and 20 to the DBE group. The total enteroscopy rate was 0% in the SBE group and 57.1% in the DBE group (P = .002). In terms of complications, the DBE group had 1 patient with Mallory-Weiss syndrome, and the SBE group had 1 patient with hyperamylasemia. There was no difference in the overall diagnosis rate between the SBE and DBE groups (61.1% vs 50.0%, P = .49). There was no difference in therapeutic outcome between the SBE and DBE groups (27.8% vs 35.0%, P = .63).

LIMITATIONS

Relatively small number of study patients.

CONCLUSIONS

Total enteroscopy is more easily performed with DBE than with SBE.

Small bowel video capsule endoscopy in Crohn’s disease: What have we learned in the last ten years?

Since its introduction in 2001, capsule endoscopy (CE) has become the most important advance in the study of small bowel disease, including Crohn’s disease (CD). This technique has been demonstrated to be superior to all other current forms of radiological investigation in detecting mucosal abnormalities of small bowel nonstricturing CD. CE has proven to be extremely useful in diagnosing CD in patients with inconclusive findings from ileocolonoscopy and x-ray-based studies. Almost half of all patients with CD involving the ileum also present lesions in proximal intestinal segments, with the small bowel being exclusively involved in up to 30% of all CD cases. Despite the widespread use of CE, several questions concerning the utility of this technique remain unanswered. The lack of commonly agreed diagnostic criteria for defining CD lesions with the aid of CE may have had an influence on the variation in diagnostic results for CE reported in the literature. The utility of CE in monitoring CD and in guiding therapy has also been proposed. Furthermore, CE could be a useful second-line technique for patients with an established diagnosis of CD and unexplained symptoms. Finally, as no threshold for CD diagnosis has been agreed upon, a severity scale of mucosal disease activity has not been universally followed. None of the available activity indexes based on CE findings has been independently validated. This article discusses several cutting-edge aspects of the usefulness of CE in CD 10 years after its introduction as a sensible method to study the small intestine.

The role of endoscopic imaging of the small bowel in clinical practice

Enteroscopy, defined as direct visualization of the small bowel (SB) with the use of a fiberoptic or wireless endoscope, has progressed considerably over the past several years. Technological advancements in the field have facilitated endoscopic evaluation of the SB. This comprehensive clinical review summarizes the latest modalities available to aid gastroenterologists in exploring the SB for evaluation of obscure gastrointestinal bleeding, tumors, inflammatory bowel disease, and celiac disease. Previous physical limitations in equipment that made a complete evaluation of the SB difficult have all but disappeared with the advent of capsule endoscopy, balloon-assisted enteroscopy, and spiral enteroscopy.

Is portal hypertensive enteropathy an important additional cause of blood loss in portal hypertensive patients?

OBJECTIVE

Recently, mucosal changes of small bowel were defined by developing new imaging techniques including capsule endoscopy (CE) in portal hypertensive patients. However, the clinical impact of these changes is unknown. In this study, we aimed to determine the additional cause of blood loss in portal hypertensive patients.

MATERIAL AND METHODS

A total of 444 portal hypertensive patients, hospitalized in our clinic between 2005 and 2007, were evaluated. Patients with obscure bleeding were enrolled to this prospective case-control study. CE was performed in 21 patients who met inclusion criteria. Gastroscopy, colonoscopy and computerized tomography/small bowel enema were performed in all patients.

RESULTS

Fourteen cirrhotic and seven noncirrhotic portal hypertensive patients were enrolled to this study. Mean age of patients was 47.9±15.6 years, and 13 of 21 were male. Small bowel varices were found in 7 patients (1 active bleeding) and other mucosal abnormalities in 10 patients (vascular ectasia, erosion and edema, 1 active bleeding). Although two of them were normal, jejunal malignant mass was found in two patients (1 active bleeding). Of 21 patients, 19 (90.5%) patients had portal hypertensive abnormalities (including varices). However, ileal varices rate was 57.1% (4 patients) in noncirrhotic portal hypertensive patients and 21.4% (3 patients) in cirrhotics.

CONCLUSION

Ninety percent of patients had portal hypertensive abnormalities in small bowel and one-third of them had small bowel varices. Small bowel varices and vascular ectasia were the main causes of obscure bleeding in portal hypertensive patients.

Video capsule endoscopy: what is the future?

Video capsule endoscopy (VCE) that was launched 10 years ago has become a first-line procedure for examining the small bowel, especially in the case of obscure gastrointestinal bleeding. Other major indications include Crohn disease (CD), celiac disease, and intestinal polyposis syndrome. In the case of small bowel diseases, the use of VCE must be integrated in a global diagnostic and therapeutic approach. More recently, wireless endoscopy has been adapted for examining the colon, opening up larger perspectives for colorectal cancer screening or colon examination. Technologic modifications of the second-generation colon capsule increase the sensitivity of this method for detecting polyps. Other new developments, including remote magnetic manipulation, power management, drug delivery capsule, microbiopsy capsule, and adaptation of technologies such as chromoendoscopy, are sure to enhance the capabilities of wireless endoscopy in gastrointestinal disorders.

Cost estimation of small bowel capsule endoscopy based on "real world" data: inpatient or outpatient procedure?

BACKGROUND

Although capsule endoscopy is the cornerstone for the evaluation of the small bowel in patients with obscure GI bleeding data about costs are lacking.

AIM

To evaluate, from a third party payer point of view, whether performing capsule endoscopy as an outpatient instead of an inpatient procedure can reduce costs.

MATERIALS AND METHODS

The data source is a multicentre survey collecting data for 2921 patients; 1486 of them underwent capsule endoscopy for obscure GI bleeding or chronic unexplained iron-deficiency anaemia as inpatients (814 with positive, 211 with inconclusive and 461 with negative result). We estimated costs of inpatient procedures based on the diagnosis related groups (DRG) system, while those of outpatient procedures on reimbursement provided in five Italian regions.

RESULTS

We estimated that the cost for each inpatient undergoing capsule endoscopy is about € 1775.90. Assuming that all these patients had undergone the same procedure as outpatients, € 175.00-741.00 per patient (depending on the reimbursement and/or on diagnosis related group codes applied) would have been saved.

CONCLUSIONS

Our estimate suggests that, from the third party payer's perspective and using the diagnosis related group reimbursement system, shifting capsule endoscopy from inpatient to outpatient procedure, would be potentially cost saving at least for patients referred for obscure GI bleeding or chronic unexplained anaemia.

Primary balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding: findings and outcome of therapy

GOALS

The aim of this study was to evaluate the diagnostic and therapeutic outcome of a primary balloon-assisted enteroscopy (BAE) approach in obscure gastrointestinal bleeding (OGIB) patients.

BACKGROUND

In the diagnostic approach of OGIB, both wireless capsule endoscopy (WCE) and BAE are used. The advantage of the primary wireless capsule endoscopy approach is its noninvasiveness. The main advantage of the primary BAE approach is the excellent diagnostic accuracy and the possibility to perform treatment during the same procedure.

STUDY

A retrospective analysis of our BAE database with patients evaluated for OGIB was performed. BAE data, findings, and follow-up were obtained and evaluated.

RESULTS

One hundred and thirty-two patients (81 male, mean age 62 (11-88) years) were included. In 60 (45%) patients with follow-up, a likely cause for OGIB was found in the small bowel during BAE: angiodysplasia or vascular malformations in 42 (70%), ulcerative lesions in 7 (12%), tumors in 3 (5%), and other findings in 8 (13%) patients. Follow-up was available in 118 (89%) patients; mean time of follow-up was 18 (1-47) months. Thirty-eight (76%) patients with findings at BAE received endoscopic treatment, 27 (71%) of them improved, but anemia also improved spontaneously in 34 patients (63%) with normal findings during BAE. The total number of angiodysplasia per patient was not related to the outcome after treatment.

CONCLUSIONS

The primary BAE approach in OGIB patients has an acceptable diagnostic yield. Therapy seems successful at mid-term follow-up. A high frequency of spontaneous resolution of anemia in patients with normal findings during BAE was observed.

A comparative evaluation of single-balloon enteroscopy and spiral enteroscopy for patients with mid-gut disorders

BACKGROUND

Single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) are recently described device-assisted techniques in endoluminal evaluation of the small bowel. No studies comparing SBE and SE in patients with suspected small-bowel disorders have previously been reported.

OBJECTIVE

The aims of this study were to compare SBE and SE in terms of diagnostic yield, procedure time, depth of maximal insertion, and complications.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care referral center.

PATIENTS

A retrospective analysis was performed on all patients at our institution undergoing anterograde SBE or SE between 2007 and 2009. Patients with altered anatomy or prior small-bowel surgery were excluded.

INTERVENTION

Deep enteroscopy.

MAIN OUTCOME MEASUREMENT

Diagnostic yield.

RESULTS

During the study period, 92 patients underwent 105 procedures (52 SBE, 53 SE). The most common indication for small-bowel endoscopy was obscure GI bleeding (n = 42). The diagnostic yield was not statistically different between SBE and SE (59.6% and 43.4%, respectively, P = .12). The overall diagnostic yield in patients with obscure GI bleeding was 67%. There was no significant difference between mean SBE and SE procedure times (53 minutes [range 15-99 minutes] vs 47 minutes [range 20-125 minutes], respectively; P = .2). The mean depth of maximal insertion beyond the ligament of Treitz for SE was significantly higher than that for SBE (301 cm [range 175-400 cm] vs 222 cm [range 110-400 cm], respectively; P < .001). Perforation occurred in one SBE procedure.

LIMITATIONS

Retrospective design and nonstandardized gas insufflation.

CONCLUSION

This is the first report comparing SE and SBE. Although SE yielded greater depth of maximal insertion than SBE, both techniques had similar diagnostic yields and procedure times. In addition, both techniques were safe and were particularly useful in patients with obscure GI bleeding.