Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy

[Use of Device-Assisted Enteroscopy in Small Bowel Disease: An Expert Consensus Statement by the Korean Association for the Study of Intestinal Diseases]

The introduction of device-assisted enteroscopy (DAE) in the beginning of the 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of small bowel diseases, DAE has the unique advantages of allowing the observation of the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how it is to be performed and what technical factors should be taken into consideration. In response to these needs, the Korean Association for the Study of Intestinal Diseases has developed an expert consensus statement on the performance of DAE by reviewing current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases

The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Diagnostic yield of inpatient capsule endoscopy

Background

Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2

Methods

We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE.

Results

131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE.

Conclusions

Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.

Clinical Outcomes of Negative Balloon-Assisted Enteroscopy for Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

Background

For patients with obscure gastrointestinal bleeding (OGIB), finding the bleeding site is challenging. Balloon-assisted enteroscopy (BAE) has become the preferred diagnostic modality for OGIB. The long-term outcome of patients with negative BAE remains undefined. The present study aimed to evaluate the long-term outcomes of patients with negative BAE results for OGIB and to clarify the effect of further investigations at the time of rebleeding with a systematic review and meta-analysis of the available cohort studies.

Methods

Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following indexes were analyzed: rebleeding rate after negative BAE, rebleeding rate after different follow-up periods, the proportion of patients who underwent further evaluation after rebleeding, the percentage of patients with identified rebleeding sources, and the percentage of patients with rebleeding sources in the small intestine. Heterogeneity was assessed using the I² test.

Results

Twelve studies that involved a total of 407 patients were included in the analysis. The pooled rebleeding rate after negative BAE for OGIB was 29.1% (95% CI: 17.2–42.6%). Heterogeneity was significant among the studies (I² = 88%; p < 0.0001). The Chi-squared test did not show a difference in rebleeding rates between the short and long follow-up period groups (p = 0.142). The pooled proportion of patients who underwent further evaluation after rebleeding was 86.1%. Among the patients who underwent further evaluation, rebleeding sources were identified in 73.6% of patients, and 68.8% of the identified rebleeding lesions were in the small intestine.

Conclusion

A negative result of BAE in patients with OGIB indicates a subsequently low risk of rebleeding. Further evaluation should be considered after rebleeding.

Use, Yield, and Risk of Device-assisted Enteroscopy in the United States: Results From a Large Retrospective Multicenter Cohort

INTRODUCTION

Since 2001, device-assisted enteroscopy (DAE) has revolutionized the diagnostic and therapeutic capabilities for managing small bowel pathology. Though commonly performed, there have been no recent large studies to assess the use, yield, and risks of DAE and none that include all 3 DAE modalities. We hypothesized that DAE is safe with high diagnostic and therapeutic yields achieved within reasonable procedure duration and here we present a large retrospective multicenter US study evaluating the use, yield, and complications of DAE.

METHODS

After obtaining institutional review board approval, electronic records were used to identify all DAE's performed for luminal small bowel evaluation in adult patients at 4 US referral centers (Duke University Medical Center, New York University Langone Medical Center, Louisiana State University Health Sciences Center, and University of Massachusetts Medical Center) from January 1, 2014 to January 1, 2019. Electronic medical records were reviewed to collect and analyze a variety of procedure-related outcomes. Using the data pooled across centers, descriptive statistics were generated for the patient and procedure-related characteristics and outcomes; relationships between characteristics and outcomes were explored.

RESULTS

A total of 1787 DAE's were performed over this 5-year period (392 at Duke University Medical Center, 887 at Louisiana State University Health Sciences Center, 312 at New York University Langone Medical Center, and 195 at University of Massachusetts Medical Center). Of these, there were 1017 (57%) double-balloon, 391 (29%) single-balloon, and 378 (21%) spiral enteroscopies. The mean age of patients undergoing DAE was 66 years and 53% of examinations were performed on women; 18% of patients in the cohort underwent >1 DAE over this time span. A total of 53% of examinations were performed for suspected small bowel bleeding, 31% were directly guided by video capsule endoscopy findings and 8% were performed for abnormal imaging. A total of 85% of examinations used an antegrade approach and DAE took a mean of 45 minutes to complete; 76% of examinations revealed abnormal findings, with vascular, inflammatory, and neoplastic findings seen in 49%, 17%, and 15% of the cohort, respectively. Older age was significantly associated with any abnormal finding, including arteriovenous malformations (P<0.0001); 50% of examinations included a therapeutic maneuver, most commonly argon plasma coagulation/cautery (43%). There were complications in 16 examinations (0.9%) including 2 perforations (0.1%), 6 cases with bleeding (0.3%) and 1 episode of pancreatitis (0.1%).

CONCLUSIONS

DAE is most commonly performed to evaluate suspected small bowel bleeding and is commonly directed by video capsule findings. DAE is safe, has a high diagnostic yield, with 76% of examinations showing abnormal findings, and frequently features therapeutic maneuvers. Advancing age is associated with abnormal findings on DAE.

Therapeutic Impact of Deep Balloon-assisted Small Bowel Enteroscopy on Red Blood Cell Transfusion

Objective Evaluate impact of balloon-assisted deep small bowel enteroscopy on red blood cell transfusion requirement in patients with obscure gastrointestinal (GI) bleeding.

Methods Retrospective study of patients, who underwent balloon-assisted deep enteroscopy with double-balloon enteroscopy (DBE) at two tertiary care academic centers (University of Wisconsin and Aurora St. Luke’s Medical Center) over a 55-month consecutive period. Sixty-nine patients with reliable blood transfusion records were identified during this time period. DBE was preceded by small bowel capsule endoscopy (CE) within 1 year in 38 cases. Transfusion requirements 6 months prior and postintervention were measured to see if DBE had any impact on the need for blood transfusions.

Results Sixty-nine patients (25 females and 44 males) were included. Mean age ± standard deviation (SD) was 63 ± 17 years. Wilcoxon signed rank test statistics were used to find the difference in the rate of blood transfusion. There was a statistically significant decrease in rate of packed red blood cell (pRBC) transfusion post DBE and endoscopic therapy with coagulation (p < 0.001). Argon plasma coagulation was used to ablate all arteriovenous malformations (AVMs) except in one (subepithelial lesion). Those that required > 5 units pRBC transfusions pre-DBE had the most benefit.

Conclusions Our study demonstrates that transfusion requirements are significantly reduced in those undergoing therapy with DBE and coagulation for obscure GI bleed.

Small Bowel Enteroscopy - A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication and on its diagnostic and therapeutic yields. A set of recommendations were issued accordingly.

Small bowel enteroscopy - A joint clinical guideline by the Spanish and Portuguese small-bowel study groups

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small-bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication, and its diagnostic and therapeutic yield. A set of recommendations was issued accordingly.

Capsule endoscopy for small-intestinal disorders: Current status

Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. In this review article, we focus on the current status of SBCE. Several platforms for SBCE are available worldwide. Third-generation SBCE (PillCam® SB3) has a high-resolution camera equipped with an adaptive frame rate system. Several software modes have been developed to reduce the reading time for capsule endoscopy and to minimize the possibility of missing lesions. The main complication of SBCE is capsule retention. Thus, the main contraindication for SBCE is known or suspected gastrointestinal obstruction unless intestinal patency is proven. Possible indications for SBCE are obscure gastrointestinal bleeding, Crohn's disease, small-intestinal polyps and tumors, and celiac disease. Colon capsule endoscopy (CCE) can observe inflamed colonic mucosa non-invasively, and allows for the continuous and non-invasive observation of the entire intestinal tract (pan-endoscopy). Recently, application of CCE as pan-enteric endoscopy for inflammatory bowel diseases (including Crohn's disease) has been reported. In the near future, reading for CE will be assisted by artificial intelligence, and reading CE videos for long periods will not be required.

Gastrointestinal diagnosis using non-white light imaging capsule endoscopy

Capsule endoscopy (CE) has proved to be a powerful tool in the diagnosis and management of small bowel disorders since its introduction in 2001. However, white light imaging (WLI) is the principal technology used in clinical CE at present, and therefore, CE is limited to mucosal inspection, with diagnosis remaining reliant on visible manifestations of disease. The introduction of WLI CE has motivated a wide range of research to improve its diagnostic capabilities through integration with other sensing modalities. These developments have the potential to overcome the limitations of WLI through enhanced detection of subtle mucosal microlesions and submucosal and/or transmural pathology, providing novel diagnostic avenues. Other research aims to utilize a range of sensors to measure physiological parameters or to discover new biomarkers to improve the sensitivity, specificity and thus the clinical utility of CE. This multidisciplinary Review summarizes research into non-WLI CE devices by organizing them into a taxonomic structure on the basis of their sensing modality. The potential of these capsules to realize clinically useful virtual biopsy and computer-aided diagnosis (CADx) is also reported.

The Clinical Usefulness of the PillCam Progress Indicator for Route Selection in Double Balloon Endoscopy

Objective The utility of capsule endoscopy (CE) findings in the route selection for double balloon endoscopy (DBE) has not been adequately discussed. The PillCam Progress Indicator in the RAPID 6.5 software program graphically demonstrates the progress of the capsule endoscope through the small-bowel. This study aimed to clarify the usefulness of the PillCam Progress Indicator in choosing the initial DBE route. Methods We retrospectively examined 50 consecutive patients with 50 target lesions detected on both CE and DBE at Hiroshima University Hospital from January 2011 to February 2018. In this study, we selected antegrade DBE on the basis of % Capsule Progress <50% as a clinical trial. The association between the PillCam Progress Indicator data and the DBE route to the target lesion was analyzed. Results The target lesion was reached via the initial DBE route in 96% (48/50) of cases. The cutoff values for selecting an antegrade route for DBE were 50% for % Capsule Progress and 42% for % SB Time. At the cutoff value, the sensitivity, specificity, and positive and negative predictive values for route selection were 100%, 91%, 93%, and 100% for % Capsule Progress and 96%, 91%, 93%, and 95% for % SB Time. Conclusion The PillCam Progress Indicator was useful for determining the appropriate initial DBE route.

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: A systematic review and meta-analysis

AIM

To compare the diagnostic accuracy of video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) in cases of obscure gastrointestinal bleeding (OGIB) of vascular origin.

METHODS

MEDLINE (via PubMed), LILACS (via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.

RESULTS

In the per-patient analysis, 17 studies (1477 lesions) were included. We identified 3150 exams (1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864 (58.5%) were diagnosed by VCE, and 613 (41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84% (95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was 92% (95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29 (95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20 (95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to 90%.

CONCLUSION

The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience

AIM

 The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting positive diagnostic yield, therapeutic yield, and readmission.

METHODS

 We conducted a retrospective cohort study of patients (n = 420) who underwent DBE at a tertiary care center between 2012 and 2016 at a tertiary referral center. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and t-test analyses were used to compare patient characteristics. Logistic regression was used to predict outcomes of interest.

RESULTS

 Of patients included in the study, 59 % were male with a mean age of 61.49 (SD = 15.15) Altered anatomy was noted in 14 %, while 5 % and 13 % of patients had end stage renal disease (ESRD) and current use of anticoagulation, respectively. The most common indication for DBE was obscure gastrointestinal bleed (OGIB) (33 %). Forty-nine patients had obscure and overt gastrointestinal bleeding (GIB) and 22 % had occult GIB with iron deficiency. The cohort's rate of positive diagnostic yield was 73 % and 35 % for therapeutic yield. The 30-day and 6-month readmission rates were both 11 %. A higher proportion of those readmitted were male (75 % vs 57 %, P  = 0.027) and had longer procedural time (38.68 vs 46.57, P  = 0.011). Likewise, occult GIB with iron deficiency anemia and iron deficiency alone (OR = 2.45, CI: 1.233 - 4.859, P  = 0.011), inpatient status (OR 2.42, CI 1.344 - 4.346, P  = 0.003), and longer procedural time (OR = 1.02, CI: 1.004 - 1.029, P  = 0.008) were associated positively with readmission.

CONCLUSION

 DBE procedures have relevant efficacy for both diagnostic and therapeutic yield while evaluating small bowel disease. Readmission rates are low and more in those with GI bleed and iron deficiency with longer index procedural times.

Outcomes of repeat balloon assisted enteroscopy in small-bowel bleeding

BACKGROUND/AIMS

 The rate of recurrent small-bowel bleeding (SBB) remains high despite the advent of balloon assisted enteroscopy (BAE). The study aims were to determine: (1) the diagnostic and therapeutic yields, and adverse event rate of repeat BAE in SBB, and (2) the predictors of a positive repeat BAE.

METHODS

 A retrospective review of a BAE database was conducted. Patients who had > 1 BAE for SBB were included. Primary outcomes were diagnostic yield, therapeutic yield, and adverse events of repeat BAE. Secondary outcomes were predictors of a positive repeat BAE.

RESULTS

 A total of 175 patients (55 % men; mean age 64.1 ± 16.3 years) were included. The diagnostic and therapeutic yields of repeat BAE were 55 % and 42 %, respectively. Repeat BAE adverse events occurred in 5 % with self-limited abdominal pain being most common. Patients with a positive repeat BAE were significantly older than the negative group (68.6 ± 13.9 vs. 60.9 ± 17.1; P  = 0.001) and were more likely to have cardiac comorbidities (OR 2.4, 95 %CI: 1.3 - 4.6; P  = 0.01), chronic kidney disease (OR 2.3, 95 %CI: 1.1 - 4.9; P  = 0.04), chronic obstructive pulmonary disease (OR 3.3, 95 %CI: 1.3 - 8.1; P  = 0.01), positive initial BAE (OR 3.6, 95 %CI: 1.9 - 6.8; P  < 0.001), and antegrade procedure (OR 3.3, 95 %CI: 1.7 - 6.1; P  < 0.001). On multivariate analysis, a positive initial BAE and antegrade route were the only significant predictive factors.

CONCLUSIONS

 Performing a repeat BAE for SBB appears safe and provided modest yields. A positive initial BAE and antegrade route were predictive of a positive repeat BAE.

The Use of Balloon-assisted Enteroscopy at a Large Volume Centre: A Retrospective Analysis

OBJECTIVES

Balloon-assisted enteroscopy (BAE) is increasingly used for the evaluation of small bowel disorders. We quantified local diagnostic and therapeutic yields of BAE in patients with suspected small bowel diseases.

METHODS

Adult patients undergoing BAE between January 2010 and July 2015 at McGill University Health Centre were included. Procedures were identified using a prospectively maintained database. Patients were excluded if procedure report was unavailable. Electronic medical records were reviewed. Analyses were restricted to patients who did not have a previous BAE.

RESULTS

BAE was performed in 453 patients, including 421 anterograde cases. Patients had a mean age of 61.0 ± 17.5 years. Most common indications for referral were obscure gastrointestinal bleeding (OGIB) (n=207, 45.7%), abnormal imaging (n=88, 19.4%), suspected small bowel neoplasia (SBN) (n=39, 8.6%) and Crohn's disease (CD) (n=31, 6.8%). A diagnosis was established in 216 procedures (47.7%). A pre-endoscopic indication of CD (odds ratio [OR]: 3.78; 95% Confidence Interval [CI], 1.60-8.90), OGIB (OR: 3.69, 95% CI, 2.03-6.71), suspected SBN (OR: 2.45; 95% CI, 1.06-5.65) and previous VCE (OR: 9.33; 95% CI, 3.24-26.90) were associated with abnormal findings. A therapeutic procedure was performed in 126 cases (28.3%). OGIB (OR: 7.00; 95% CI, 3.83-12.81), previous video capsule endoscopy (VCE) (OR: 7.86; 95% CI, 2.93-21.04) and suspected SBN (OR: 6.30; 95% CI, 2.58-21.04) were associated with performance of a therapeutic intervention. Complication rate was 1.6%, with bleeding in seven cases and one perforation.

CONCLUSIONS

In carefully selected patients, such as those with OGIB, Crohn's disease and previous VCE, BAE was a safe procedure that led to the identification of abnormal findings and therapeutic interventions.

Clinical Utility of Capsule Endoscopy and Double-Balloon Enteroscopy in the Management of Obscure Gastrointestinal Bleeding

BACKGROUND

Obscure gastrointestinal bleeding (OGIB) is a common but embarrassing problem for gastroenterologists. Most bleeding lesions associated with OGIB are present in the small intestine and sometimes cannot be identified due to the difficulty associated with physical accessibility. Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) have enabled in the process of diagnosing and have evolved to become approaches to treating OGIB.

SUMMARY

CE is a minimally invasive procedure and has a high diagnostic yield in patients with OGIB. DBE offers additional advantage of biopsy collection for pathological diagnosis and therapeutic intervention, but it should be noted that it sometimes causes severe adverse events such as acute pancreatitis, intestinal bleeding, and intestinal perforation. CE should be performed early in the workup course of OGIB. Positive CE findings enhance the diagnostic yield of subsequent DBE, and the effective therapeutic intervention improves the clinical outcomes of OGIB patients. On the contrary, there are no clear guidelines for further investigation of patients with negative CE findings at the present. Although patients in stable general condition may only require follow-up, repeated CE is useful to detect positive findings in patients with evidence of sustained bleeding and progressing anemia. We have revealed that repeated CE has higher positive finding rate than DBE in OGIB patients with negative CE findings in a preliminary study. Key Messages: CE and DBE have complementary roles in the management of OGIB, and the precise timing and proper sequence may be important for the approach to treating OGIB.

[When and how should small-bowel capsule endoscopy be used in children?]

Small-bowel capsule endoscopy (CE) has recently been used in children. During the past few years, an intense research activity has defined the advantages and limitations of CE. Its uses have been established in several small-bowel pathologies such as obvious or obscure digestive bleeding, Crohn disease, and hereditary polyposis. Although the absence of biopsy reduces the specificity of CE findings, small-bowel exploration using CE achieves better accuracy in detecting lesions than most radiological examinations. In children, swallowing problems and the risk of retention due to stenosis are the main concerns when using CE: these problems can be solved using endoscopic delivery of the capsule and luminal diameter calibration, respectively. This review focuses on the evidence making CE indispensable to small-bowel exploration.

Success of Minimally Invasive Transumbilical Single-Incision Laparoscopic Surgery (T-SILS) Plus Double-Balloon Endoscopy (DBE) for Pediatric Intestinal Angiodysplasia: A Case Report

We describe here a child with angiodysplasia of the small intestine, diagnosed by double-balloon endoscopy (DBE), who was treated with transumbilical single-incision laparoscopic surgery (T-SILS). A 9-year-old boy presented to another hospital with intermittent fresh melena of a duration of 5 months and 4 days. Anoscopy and gastric mucosal membrane scintigraphy were unsuccessful diagnostically, and he was referred to our hospital for further examination and treatment. Under general anesthesia, we performed DBE by an anal route, with the ileum assessed for a distance of about 150 cm from the ileocecal valve. Although no bleeding lesion was found in the colon, a flat elevated venous lake approximately 20 mm in size was observed 20 cm from the ileocecal valve, suggesting angiodysplasia of the small intestine. A tattoo was made under DBE, and wedge resection by T-SILS was performed 1 month later under general anesthesia. The excised specimen appeared as a flat, elevated venous lake approximately 20 mm in size. Histopathologic analysis revealed several dilated and distorted veins within the submucosa of the small intestine. The patient was diagnosed with angiodysplasia of the small intestine. His postoperative course was uneventful, and he remained free of recurrent gastrointestinal bleeding 18 months after the operation. This is the first case report showing the diagnosis, localization, and tattooing of an obscure gastrointestinal bleeding lesion of the small intestine by preoperative DBE and removal of the lesion by subsequent T-SILS in children.

Small Bowel Endoscopy

OPINION STATEMENT

The small bowel is a challenging area for endoscopic evaluation and therapy due to its length and angulated configuration. A small lumen diameter and segmental peristalsis made it a perfect fit for examination by a novel ingestible wireless camera in a capsule. The development of capsule endoscopy changed the diagnosis and management of bleeding lesions, ulcers, and tumors deep in the small bowel, allowing earlier diagnosis with excellent patient acceptance. Device-assisted enteroscopy revolutionized small bowel therapy, particularly management of bleeding, Peutz-Jeghers polyposis, and tumor marking for minimally invasive surgery. Small bowel stricture dilation in select patients is safe and effective. Tools for a spectrum of small bowel therapies are available but remain suboptimal to tackle lesions on angulated folds deep in the small bowel. Universal terminology to describe the endoscopic appearance of vascular lesions will facilitate studies of endoscopic and medical therapy. The future holds improvements in imaging, easier advancement through the small bowel, and therapeutic capacity. This review focuses on methods of small bowel endoscopy, therapy, and outcomes.

The Role of Capsule Endoscopy in Patients with Obscure Gastrointestinal Bleeding

Obscure gastrointestinal bleeding (OGIB) accounts for 5% of all gastrointestinal (GI) bleeding cases and is often caused by small bowel lesions. Capsule endoscopy (CE), which allows non-invasive visualization of the small bowel mucosa, has revolutionized the evaluation of OGIB. CE is preferred by both patients and physicians mainly because of its non-invasiveness, and is widely used as the first-line diagnostic modality for OGIB. The diagnostic yield of CE in OGIB has been reported to be in the range of 32% to 83%. Although no direct comparison has been made, a meta-analysis showed similar diagnostic yields between CE and double-balloon enteroscopy (DBE) for OGIB. However, CE could enhance the yield of subsequent DBE and serve as a guide for optimizing the insertion route for DBE. Even after negative CE, selected patients could benefit from second-look CE for OGIB. In terms of outcomes, a favorable clinical impact after CE has been reported in several studies. However, observations indicate that CE might not influence clinical outcomes directly, but rather play a role in selecting patients with OGIB who are likely to benefit from subsequent evaluation and intervention.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

Evaluation and outcomes of patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding or presence of iron deficiency anaemia after evaluation with a negative bidirectional endoscopy. OGIB accounts for 5% of gastrointestinal bleeding and presents a diagnostic challenge. Current modalities available for the investigation of OGIB include capsule endoscopy, balloon assisted enteroscopy, spiral enteroscopy and computed tomography enterography. These modalities overcome the limitations of previous techniques. Following a negative bidirectional endoscopy, capsule endoscopy and double balloon enteroscopy remain the cornerstone of investigation in OGIB given their high diagnostic yield. Long-term outcome data in patients with OGIB is limited, but is most promising for capsule endoscopy. This article reviews the current literature and provides an overview of the clinical evaluation of patients with OGIB, available diagnostic and therapeutic modalities and long-term clinical outcomes.

New insights to occult gastrointestinal bleeding: From pathophysiology to therapeutics

Obscure gastrointestinal bleeding is still a clinical challenge for gastroenterologists. The recent development of novel technologies for the diagnosis and treatment of different bleeding causes has allowed a better management of patients, but it also determines the need of a deeper comprehension of pathophysiology and the analysis of local expertise in order to develop a rational management algorithm. Obscure gastrointestinal bleeding can be divided in occult, when a positive occult blood fecal test is the main manifestation, and overt, when external sings of bleeding are visible. In this paper we are going to focus on overt gastrointestinal bleeding, describing the physiopathology of the most usual causes, analyzing the diagnostic procedures available, from the most classical to the novel ones, and establishing a standard algorithm which can be adapted depending on the local expertise or availability. Finally, we will review the main therapeutic options for this complex and not so uncommon clinical problem.

Evaluation and management of small-bowel tumors in the era of deep enteroscopy

In summary, small-intestine tumors are a rare phenomenon, but they are being discovered more frequently with newer diagnostic techniques. Prior studies of the small bowel were limited, making the diagnosis difficult. With the advent of CE and deep enteroscopy, gastroenterologists are finding these tumors at an earlier stage, thereby offering better management options for these patients. Although the incidence of small-bowel tumors has increased, the survival rates have remained the same. This may be a lag-time bias but could be a future area of research in this emerging field.

Non-small-bowel abnormalities identified during small bowel capsule endoscopy

AIM: To investigate the incidence of non-small-bowel abnormalities in patients referred for small bowel capsule endoscopy, this single center study was performed.

METHODS: Small bowel capsule endoscopy is an accepted technique to investigate obscure gastrointestinal bleeding. This is defined as bleeding from the digestive tract that persists or recurs without an obvious etiology after a normal gastroduodenoscopy and colonoscopy. Nevertheless, capsule endoscopy sometimes reveals findings outside the small bowel, i.e., within reach of conventional endoscopes. In this retrospective single center study, 595 patients undergoing capsule endoscopy between 2003 and 2009 were studied. The incidence of non-small bowel abnormalities was defined as visible abnormalities detected by capsule endoscopy that are located within reach of conventional endoscopes.

RESULTS: In 595 patients, referred for obscure gastrointestinal bleeding or for suspected Crohn’s disease, abnormalities were found in 306 (51.4%). Of these 306 patients, 85 (27.7%) had abnormalities within reach of conventional endoscopes; 63 had abnormalities apparently overlooked at previous conventional endoscopies, 10 patients had not undergone upper and lower endoscopy prior to capsule endoscopy and 12 had abnormalities that were already known prior to capsule endoscopy. The most common type of missed lesions were vascular lesions (n = 47). Non-small-bowel abnormalities were located in the stomach (n = 15), proximal small bowel (n = 22), terminal ileum (n = 21), colon (n = 19) or at other or multiple locations (n = 8). Ten patients with abnormal findings in the terminal ileum had not undergone examination of the ileum during colonoscopy.

CONCLUSION: A significant proportion of patients undergoing small bowel capsule endoscopy had lesions within reach of conventional endoscopes, indicating that capsule endoscopy was unnecessarily performed.

Long-term outcomes after single-balloon enteroscopy in patients with obscure gastrointestinal bleeding

BACKGROUND

Limited data exists on the long-term outcomes of patients with obscure gastrointestinal bleeding (OGIB) following single-balloon enteroscopy (SBE).

AIM

To examine the long-term outcomes of patients undergoing SBE for OGIB.

METHODS

Consecutive patients undergoing SBE for OGIB at a tertiary care center between 2008 and 2010 were retrospectively identified. Clinical data and SBE findings were extracted from the medical record. Recurrence of OGIB during follow-up through 2012 was assessed by a combination of chart review and telephone interviews.

RESULTS

One hundred and forty-seven patients were included in the study. The overall diagnostic yield of SBE was 64.6% (95/147 patients). Findings of SBE included vascular lesions (VLs, 53.7%), small bowel neoplasm (2.7%), inflammatory lesions (4.8%), and normal SBE (35.4%). One hundred and ten patients (56.4% female, mean age 70.6±11.3 years) were followed for an average 23.9 months after initial SBE. During follow-up, OGIB recurred in 39.5% of patients in whom a source of OGIB was identified on SBE and 55.9% of patients with normal findings on SBE. OGIB recurred in 47.6% of patients in whom small bowel VLs were treated endoscopically. None of the 13 patients in whom a non-VL lesion was identified as the source of bleeding on SBE experienced recurrent bleeding (p=0.019).

CONCLUSIONS

SBE is a safe and valuable method for managing patients with OGIB. More than 50% of patients experienced no recurrent bleeding during 2 years of follow-up after SBE. The long-term management of OGIB due to small bowel VLs remains challenging.

Prospective, randomized, double-blind, placebo-controlled trial of ulinastatin for prevention of hyperenzymemia after double balloon endoscopy via the antegrade approach

BACKGROUND

Double balloon endoscopy (DBE) allows the entire small intestine to be viewed using a combination of antegrade and retrograde approaches. Acute pancreatitis is a serious complication of antegrade DBE with no effective prophylactic treatment currently available. Ulinastatin has been shown to be effective for the prevention of pancreatitis following endoscopic retrograde cholangiopancreatography. We therefore assessed the efficacy of ulinastatin for hyperenzymemia after antegrade DBE.

PATIENTS AND METHODS

Forty-four patients were enrolled in this prospective, randomized, double-blind, placebo-controlled trial. Patients in the ulinastatin group received 150 000 U ulinastatin by i.v. drip infusion for 2 h from the start of the procedure. Serum concentrations of pancreatic amylase and lipase were measured before and 3 and 18 h after antegrade DBE.

RESULTS

The study was terminated after interim analysis. Of the 44 patients, 23 were randomized to ulinastatin and 21 to placebo.The groups were similar with regard to sex ratio, age, type of endoscope, insertion time, total procedure time, number of endoscope pull-back procedures, and baseline pancreaticamylase and lipase concentrations. Post-DBE hyperenzymemia was observed in 35.0% and 47.8% of patients in the placebo and ulinastatin groups, respectively. The higher frequency of hyperenzymemia in the ulinastatin group was unexpected, but the difference was not statistically significant. One patient in the placebo group (5.0%) and none in the ulinastatin group experienced acute pancreatitis, but the difference was not statistically significant.

CONCLUSION

The results of this trial suggest that ulinastatin does not prevent hyperenzymemia following antegrade DBE.

Endoscopic techniques for small bowel imaging

Advances in small bowel enteroscopy have led to an increase in the endoscopic evaluation and management of small bowel disorders. The entire small bowel can now be visualized in a noninvasive manner by capsule endoscopy, while therapeutic management can be performed with deep enteroscopy techniques, including balloon-assisted and spiral enteroscopy. Each of these enteroscopy tools has its unique advantages and disadvantages, which need to be taken into consideration during selection of the appropriate tool. Capsule endoscopy and deep enteroscopy are often used as complementary tests in the evaluation of small bowel disorders.

Endoscopic and radiographic evaluation of the small bowel in 2012

Traditionally, the diagnosis of small bowel disorders has been challenging secondary to the small intestine's length, tortuosity, and anatomic location. Recent technologic advancements in the field of enteroscopy and radiographic imaging have facilitated a more thorough endoscopic evaluation of patients with small bowel disease ranging from obscure gastrointestinal bleeding to inflammatory bowel disease and small bowel tumors. Such developments have made it possible to avoid invasive surgical procedures in certain clinical scenarios where they were previously the gold standard. In this review, we report an update on the diagnostic and management approach to patients with small bowel disease, emphasizing the advantages and limitations of the latest modalities now available to primary care physicians and gastroenterologists for evaluating patients with presumed disease of the small intestine.

Small bowel diagnostics: current place of small bowel endoscopy

The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Until the end of the last century, the small bowel follow through was the primary diagnostic tool for suspected small bowel disease. In recent years capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computerized tomography and magnetic resonance enteroclysis or enterography have facilitated the diagnosis, monitoring, and management of patients with small bowel diseases. These technologies are complementary, each with its advantages and limitations. In the present article, we will discuss the different options and indications for modern diagnostic methods for visualization of the small bowel. We also try to provide a clinical rationale for the use of these different diagnostic options in less established, newly emerging, indications for small bowel evaluation.

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.

Evaluating the role of small-bowel endoscopy in clinical practice: the largest single-centre experience

OBJECTIVE

There are few centres that offer all forms of small-bowel endoscopic modalities [capsule endoscopy (CE), push enteroscopy (PE), double-balloon enteroscopy (DBE) or single-balloon enteroscopy and intraoperative enteroscopy (IOE)]. Previous investigators have suggested that DBE may be more cost-effective as the first-line investigation. We evaluated the relationship among four modalities of small-bowel endoscopy in terms of demand, diagnostic yield, patient management and tolerability.

METHODS

Data were collected on patients who underwent PE and IOE since January 2002, CE since June 2002 and DBE since July 2006. These included age, sex, indication of referral, comorbidity, previous investigations and diagnosis obtained, including subsequent management change.

RESULTS

Demand for CE and DBE increased every year. A total of 1431 CEs, 247 PEs, 102 DBEs and 17 IOEs were performed over 93 months. The diagnostic yield was 88% for IOE compared with 34.6% for CE, 34.5% for PE and 43% for DBE (P<0.001). Management was altered by CE in 25%, by PE in 19% and by DBE in 33% of patients. However, 44% of patients who underwent DBE found the procedure difficult to tolerate. In 2009, for every 17 CEs performed, one patient underwent DBE locally.

CONCLUSION

This is the first series to report the clinical experience of four modalities of small-bowel endoscopy from a single centre. The use of CE as first-line investigation, followed by PE/DBE or IOE, is potentially both less invasive and tolerable.

Diagnostic yield of small bowel capsule endoscopy depends on the small bowel transit time

AIM: To investigate whether the small bowel transit time (SBTT) influences the diagnostic yield of capsule endoscopy (CE).

METHODS: Six hundred and ninety-one consecutive CE procedures collected in a database were analyzed. SBTT and CE findings were recorded. A running mean for the SBTT was calculated and correlated to the diagnostic yield with a Spearman’s correlation test. Subgroup analyses were performed for the various indications for the procedure.

RESULTS: There was a positive correlation between the diagnostic yield and SBTT (Spearman’s rho 0.58, P < 0.01). Positive correlations between diagnostic yield and SBTT were found for the indication obscure gastrointestinal bleeding (r = 0.54, P < 0.01), for polyposis and carcinoid combined (r = 0.56, P < 0.01) and for the other indications (r = 0.90, P <0.01), but not for suspected Crohn’s disease (r = -0.40).

CONCLUSION: The diagnostic yield in small bowel capsule endoscopy is positively correlated with the small bowel transit time. This is true for all indications except for suspected Crohn’s disease.

Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy

BACKGROUND AND AIM

In patients with obscure gastrointestinal (GI) bleeding, capsule endoscopy is widely used to determine the source of bleeding. However, there is currently no consensus on how to further evaluate patients with obscure GI bleeding with a non-diagnostic capsule endoscopy examination. This study aims to determine the diagnostic yield of dual-phase computed tomographic enterography (CTE) in patients with obscure GI bleeding and a non-diagnostic capsule endoscopy.

METHODS

Patients with obscure GI bleeding who were referred for capsule endoscopy were prospectively enrolled. Obscure GI bleeding was defined as overt if there was obvious GI bleeding; otherwise it was defined as occult. Patients with a non-diagnostic capsule endoscopy and no contraindications underwent a CTE.

RESULTS

Capsule endoscopy was performed in 52 patients; 26 patients (50%) had occult GI bleeding and 26 patients (50%) had overt GI bleeding. CTE was then performed in 25 of the 48 patients without a definitive source of bleeding seen on capsule endoscopy. The diagnostic yield of CTE was 0% (0/11) in patients with occult bleeding versus 50% (7/14) in patients with overt bleeding (P < 0.01). Using clinical follow up as the gold standard, for the 25 patients with a non-diagnostic capsule, CTE had a sensitivity of 33% (95% confidence interval 0.15, 0.56) and a specificity of 75% (95% confidence interval 0.22, 0.99).

CONCLUSIONS

In patients with a non-diagnostic capsule endoscopy examination, CTE is useful for detecting a source of GI bleeding in patients with overt, but not occult, obscure GI bleeding.

Use of Capsule Small Bowel Transit Time to Determine the Optimal Enteroscopy Approach

Background

Capsule small bowel transit time (SBTT) is used to select the most effective enteroscopy approach when targeting capsule endoscopy (CE) findings. Aim of this study was to determine if capsule SBTT can be used to guide the choice of enteroscopy technique for reaching CE abnormalities.

Methods

Single center, retrospective study involving 60 patients. Data were abstracted from medical records of patients with abnormal CE who proceeded to enteroscopy which included push enteroscopy (PE) single balloon enteroscopy (SBE) and double balloon enteroscopy (DBE).

Results

Ninety five findings were documented on CE with presumed identification of 56 (59%) of these abnormalities by enteroscopy. Majority were angioectasias on CE (42%) and enteroscopy (59%). Optimal cutoff values for selection of enteroscopy procedure were: 0-21% SBTT for PE (80% sensitivity, 74% specificity, 83% PPV); 0 - 36% SBTT for antegrade SBE (93% sensitivity, 40% specificity, 82% PPV); 0 - 57% SBTT for antegrade DBE (75% sensitivity, 80% specificity, 75% PPV); and 74 - 100% SBTT for retrograde DBE (88% sensitivity, 78% specificity, 78% PPV).

Conclusion

Capsule SBTT may be used to guide the selection of enteroscopy approach. PE, antegrade SBE, antegrade DBE and retrograde DBE are optimal when abnormalities on CE are seen at ≤ 21%, ≤ 36%, ≤ 57% and ≥ 74% SBTT respectively.

Outcome of patients who have undergone total enteroscopy for obscure gastrointestinal bleeding

AIM: To assess the diagnostic success and outcome among patients with obscure gastrointestinal bleeding who underwent total enteroscopy with double-balloon endoscopy.

METHODS: Total enteroscopy was attempted in 156 patients between August 2003 and June 2008 at Hiroshima University Hospital and achieved in 75 (48.1%). It is assessed whether sources of bleeding were identified, treatment methods, complications, and 1-year outcomes (including re-bleeding) after treatment, and we compared re-bleeding rates among patients.

RESULTS: The source of small bowel bleeding was identified in 36 (48.0%) of the 75 total enteroscopy patients; the source was outside the small bowel in 11 patients (14.7%) and not identified in 28 patients (37.3%). Sixty-one of the 75 patients were followed up for more than 1 year (27.2 ± 13.3 mo). Four (6.6%) of these patients showed signs of re-bleeding during the first year, but bleeding did not recur after treatment. Although statistical significance was not reached, a marked difference was found in the re-bleeding rate between patients in whom total enteroscopy findings were positive (8.6%, 3/35) and negative (3.8%, 1/26) (3/35 vs 1/26, P = 0.63).

CONCLUSION: A good outcome can be expected for patients who undergo total enteroscopy and receive proper treatment for the source of bleeding in the small bowel.

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.

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.

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.

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.

Diagnosis and management of mid-gastrointestinal bleeding by double-balloon endoscopy

The new methods of capsule endoscopy (CE) and double-balloon endoscopy (DBE) have revolutionized the diagnostic approach to middle (mid) gastrointestinal bleeding (MGIB) in recent years. DBE also has therapeutic options and enables us to treat the MGIB endoscopically. In this review, we discuss endoscopic diagnosis and management of three major categories of sources of MGIB - vascular lesions, ulcers/erosions and tumors/polyps.