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Damjanovska S, Isenberg G. Endoscopic Treatment of Small Bowel Bleeding. Gastrointest Endosc Clin N Am 2024; 34:331-343. [PMID: 38395487 DOI: 10.1016/j.giec.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Approximately 5% of all gastrointestinal (GI) bleeding originates from the small bowel. Endoscopic therapy of small bowel bleeding should only be undertaken after consideration of the different options, and the risks, benefits, and alternatives of each option. Endoscopic therapy options for small bowel bleeding are like those treatments used for other forms of bleeding in the upper and lower GI tract. Available endoscopic treatment options include thermal therapy (eg, argon plasma coagulation and bipolar cautery), mechanical therapy (eg, hemoclips), and medical therapy (eg, diluted epinephrine injection). Patients with complicated comorbidities would benefit from evaluation and planning of available treatment options, including conservative and/or medical treatments, beyond endoscopic therapy.
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Affiliation(s)
- Sofi Damjanovska
- Department of Medicine, University Hospitals Cleveland Medical Center/Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Gerard Isenberg
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center/Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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2
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Aso K, Yagi S, Yamada K, Kato D, Enomoto N, Nohara K, Kitagawa D, Takemura N, Kiyomatsu T, Kokudo N. Usefulness of indocyanine green fluorescence-guided small intestinal bleeding site identification in small bowel resection: a report of two cases and literature review. Clin J Gastroenterol 2023; 16:349-354. [PMID: 37046143 DOI: 10.1007/s12328-023-01787-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/13/2023] [Indexed: 04/14/2023]
Abstract
Small bowel bleeding that does not respond to conservative therapy requires surgical resection. However, identifying the bleeding sites intraoperatively is challenging. Indocyanine green (ICG) fluorescence imaging improves diagnosis of small bowel bleeding and surgical decision-making by visualizing blood flow. Herein, we reported two cases of small bowel bleeding that were successfully treated by using ICG to identify the bleeding sites and determine the extent of small bowel resection. The patients were a 46-year-old and a 75-year-old woman, both of whom presented with melena. Contrast-enhanced computed tomography and arteriography confirmed small bowel bleeding, and rebleeding occurred in both patients after transcatheter arterial embolization. Emergent surgeries were performed, and intraoperative selective angiography with ICG injections was conducted to identify obscure bleeding sites. ICG fluorescence identified all bleeding sites in both cases, and small bowel resections were successfully performed. The postoperative courses were uneventful, and both patients had a favorable postoperative course without recurrence of bleeding. ICG fluorescence imaging can safely identify the sites of intestinal bleeding and determine the appropriate extent of bowel resection.
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Affiliation(s)
- Kenta Aso
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Shusuke Yagi
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kazuhiko Yamada
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.
| | - Daiki Kato
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Naoki Enomoto
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kyoko Nohara
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Dai Kitagawa
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
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Lee J, Kim S, Kim D, Lee S, Ryu K. Three cases of jejunal tumors detected by standard upper gastrointestinal endoscopy: A case series. World J Clin Cases 2023; 11:962-971. [PMID: 36818621 PMCID: PMC9928703 DOI: 10.12998/wjcc.v11.i4.962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/27/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In patients with obscure gastrointestinal bleeding, re-examination with standard upper endoscopes by experienced physicians will identify culprit lesions in a substantial proportion of patients. A common practice is to insert an adult-sized forward-viewing endoscope into the second part of the duodenum. When the endoscope tip enters after the papilla, which is a marker for the descending part of the duodenum, it is difficult to endoscopically judge how far the duodenum has been traversed beyond the second part.
CASE SUMMARY We experienced three cases of proximal jejunal masses that were diagnosed by standard upper gastrointestinal endoscopy and confirmed with surgery. The patients visited the hospital with a history of melena; during the initial upper gastrointestinal endoscopy and colonoscopy, the bleeding site was not confirmed. Upper gastrointestinal bleeding was suspected; thus, according to guidelines, upper endoscopy was performed again. A hemorrhagic mass was discovered in the small intestine. The lesion of the first patient was thought to be located in the duodenum when considering the general insertion depth of a typical upper gastrointestinal endoscope; however, during surgery, it was confirmed that it was in the jejunum. After the first case, lesions in the second and third patients were detected at the jejunum by inserting the standard upper endoscope as deep as possible.
CONCLUSION The deep insertion of standard endoscopes is useful for the diagnosis of obscure gastrointestinal bleeding.
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Affiliation(s)
- Jaesun Lee
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
| | - Sunmoon Kim
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
| | - Daesung Kim
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
| | - Sangeok Lee
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon 35365, South Korea
| | - Kihyun Ryu
- Department of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon 35365, South Korea
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Guo Q. Intraoperative Endoscopic Interventions of Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2022; 32:817-827. [PMID: 36202518 DOI: 10.1016/j.giec.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastrointestinal endoscopy provides detailed information for diagnosis, differential diagnosis, and disease monitoring and delivers therapy for inflammatory bowel disease. Inflammatory bowel diseases are associated with complications such as strictures, gastrointestinal hemorrhage, fistula, perforation, and abscesses. Endoscopic intervention is a valid therapeutic modality for intestinal strictures and other morbidities. The multisegmental involvement of Crohn's disease, surgically altered bowel anatomy, and the postoperative extensive adhesions have made conventional diagnostic and therapeutic enteroscopy difficult. Intraoperative enteroscopy offers a feasible option for diagnosis and therapy. We report intraoperative enteroscopy in the management of small intestinal strictures and other intestinal morbidities.
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Affiliation(s)
- Qin Guo
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Erheng Road, Guangzhou, Guangdong Province, China.
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Tao Q, AL-Magedi AA, Wang Z, Xu W, Wu R. Intraoperative endoscopy through enterotomy for overt obscure gastrointestinal bleeding: A retrospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Meshikhes HA, Duhaileb MA, Alzahir AA, Almomen SA, Meshikhes AWN. Obscure Gastrointestinal Bleeding Due to Non-steroidal Anti-inflammatory Drug-Induced Colopathy. Cureus 2021; 13:e20278. [PMID: 35018270 PMCID: PMC8741528 DOI: 10.7759/cureus.20278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/21/2022] Open
Abstract
Obscure gastrointestinal (GI) bleeding poses a diagnostic challenge and is associated with high mortality. We report a case of life-threatening obscure GI bleeding precipitated by the ingestion of a non-steroidal anti-inflammatory drug (NSAID). The source of bleeding could not be identified preoperatively, and hence exploratory laparotomy was performed. An ileocaecal resection was undertaken based on the findings of the intraoperative enteroscopy. However, the bleeding recurred and repeated endoscopy examination identified the source to be multiple NSAID-induced ulcers that were scattered in the colo-rectum. The bleeding stopped spontaneously after a period of intensive supportive therapy and sulphasalazine enemas. This case highlights the diagnostic challenge of obscure GI bleeding. It also highlights the potentially life-threatening danger of GI bleeding secondary to NSAID-induced colopathy, even after a short course of treatment.
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Pal P, Tandan M, Kulkarni S, Reddy PM, Ramchandani M, Sekaran A, Shetty MG, Rebala P, Rao GV, Reddy DN. Is intraoperative enteroscopy still relevant in small bowel disorders in the era of capsule endoscopy and device-assisted enteroscopy? Real-world experience from a tertiary care hospital. J Gastroenterol Hepatol 2021; 36:3183-3190. [PMID: 34269477 DOI: 10.1111/jgh.15626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 06/03/2021] [Accepted: 07/13/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM With the advent of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), the indication of intraoperative enteroscopy (IOE) has become limited due to reported high morbidity/mortality. Most of the earlier studies on IOE were small/from pre-VCE/DAE era. We aimed to evaluate the impact of IOE in management of small bowel disorders (SBD) in post-VCE/DAE era. METHODS Patients with SBD undergoing IOE over last 15 years were evaluated retrospectively. Overall diagnostic/therapeutic yield, incremental diagnostic yield over preoperative investigations, and adverse events were noted. We also evaluated the number of cases in which IOE changed the management or guided surgical or endoscopic therapy. Rebleeding and recurrence were evaluated in patients with available follow-up data. RESULTS A total of 89 patients (59 male, 9-82 years) were included in the study. Overall diagnostic and therapeutic yield were 92.1% and 85.4%, respectively. Common findings of IOE were benign ulcers/strictures (30.1%), vascular lesions (26%), diverticula (15.1%), and tumors (13.7%). A total of 49.4% (44/89), 36% (32/89), and 20.2% (18/89) underwent VCE, DAE, or both, respectively, before IOE. Incremental diagnostic yield over preoperative work-up was 31.5% (28/89), and IOE changed the management in 37.1% (33/89) patients. IOE was used to guide surgery/endotherapy in 39.3% (35/89) patients. Recurrent gastrointestinal bleed occurred in 21.2% (14/66) patients. Morbidity and mortality rates were 20.2% (18/89) and 3.4% (3/89), respectively. CONCLUSIONS Intraoperative enteroscopy remains an essential technique to evaluate SBD and can detect new and additional lesions even after extensive preoperative evaluation. IOE is useful in guiding therapy in preoperatively identified lesions and can change management in a substantial proportion of patients. Hence, IOE has a definitive role in post-VCE/DAE era in carefully selected patients with SBD.
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Affiliation(s)
- Partha Pal
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Sujay Kulkarni
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Palle Manohar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Anuradha Sekaran
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Mahesh G Shetty
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Pradeep Rebala
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - G V Rao
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Kothari K, Patil M, Malipatel R, Devarbhavi H. Lessons of the month: Massive gastrointestinal bleeding in a young woman with idiopathic thrombocytopenic purpura (ITP). Clin Med (Lond) 2021; 21:e100-e102. [PMID: 33479087 DOI: 10.7861/clinmed.2020-0803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cytomegalovirus (CMV) is a ubiquitous pathogen, belongs to the herpes virus family and can infect the gastrointestinal (GI) system. The disease is usually noted in immunocompromised patients such as solid organ transplant recipients on immunosuppressive drugs, patients with malignancy receiving chemotherapy, patients with AIDS, patients on steroids for autoimmune disorders, and is rarely seen in immunocompetent individuals. In the GI system, CMV most commonly involves the colon, followed by oesophagus, stomach and, rarely, the small intestine. The GI manifestation of CMV infection is usually anorexia, diarrhoea, and blood in stools, abdominal pain and fever. Very rarely, CMV infection may present with a massive GI bleed. We report a case of 36-year-old pregnant woman with idiopathic thrombocytopenic purpura (ITP) who presented with massive GI bleeding following delivery, attributed to isolated CMV enteritis.
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Murphy B, Winter DC, Kavanagh DO. Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review. Front Surg 2019; 6:25. [PMID: 31157232 PMCID: PMC6532547 DOI: 10.3389/fsurg.2019.00025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Small bowel bleeding accounts for 5-10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.
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Affiliation(s)
- B. Murphy
- Department of Colorectal Surgery, University Hospital Tallaght, Dublin, Ireland
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - D. C. Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - D. O. Kavanagh
- Department of Colorectal Surgery, University Hospital Tallaght, Dublin, Ireland
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Abstract
Small bowel bleeding accounts for 5-10% of gastrointestinal bleeding. With the advent of capsule endoscopy, device-assisted enteroscopy, and multiphase CT scanning, a small bowel source can now be found in many instances of what has previously been described as obscure gastrointestinal bleeding. We present a practical review on the evaluation and management of small bowel bleeding for the practicing clinician.
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Urgesi R, Riccioni ME, Bizzotto A, Cianci R, Spada C, Pelecca G, Ricci RM, Costamagna G. Increased Diagnostic Yield of Small Bowel Tumors with Pillcam: The Role of Capsule Endoscopy in the Diagnosis and Treatment of Gastrointestinal Stromal Tumors (GISTs). Italian Single-Center Experience. TUMORI JOURNAL 2018; 98:357-63. [DOI: 10.1177/030089161209800313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for 1–3% of all gastrointestinal malignancies; they are, however, the most common gastric and small bowel mesenchymal tumors. The length and relative inaccessibility of the small bowel have long constrained the diagnosis of GISTs mainly presenting with chronic or intermittent bleeding as the sole clinical manifestation. Aim To report on the prevalence of small bowel GISTs in a prospectively recorded series of patients undergoing capsule endoscopy (CE). Patients and methods Between 2001 and 2007 five hundred patients were referred to our endoscopy unit for small bowel evaluation with capsule endoscopy. We retrospectively evaluated all charts. The main indications for CE were obscure-occult or obscure-overt bleeding. Two hundred eighty-nine patients underwent CE for either obscure-occult or obscure-overt bleeding and 211 for other indications. Patient outcome and care processes were measured by follow-up telephone interviews and chart review. Statistical computations were performed using Fisher's exact test and Student's t-test. Results CE identified a small bowel tumor in 20 patients (4.0%) and 9 tumors turned out to be GISTs (45.0%). Traditional endoscopic and radiological imaging failed to detect the GIST in all these cases. In one case a small bowel GIST was diagnosed by angiography and CE proved false negative. Overall, CE was able to diagnose a small bowel GIST in 9 out of 10 cases. All patients underwent surgical treatment and showed normalized hemoglobin levels at follow-up. The main limitation of this study is the small number of cases. Conclusions CE is an effective and sensitive diagnostic device compared with conventional radiology and plays an important role in the algorithm for the diagnostic work-up of suspected small bowel tumors.
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Affiliation(s)
- Riccardo Urgesi
- Digestive Endoscopy Unit, Catholic
University, Rome
- Division of Human Nutrition,
Department of Neuroscience, Tor Vergata University, Rome
- Gastroenterology Unit, Bel Colle
Hospital, Viterbo
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Manatsathit W, Khrucharoen U, Jensen DM, Hines OJ, Kovacs T, Ohning G, Jutabha R, Ghassemi K, Dulai GS, Machicado G. Laparotomy and intraoperative enteroscopy for obscure gastrointestinal bleeding before and after the era of video capsule endoscopy and deep enteroscopy: A tertiary center experience. Am J Surg 2017. [PMID: 28629608 DOI: 10.1016/j.amjsurg.2017.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND To evaluate roles of intraoperative endoscopy (IOE) in management of severe obscure GI bleeding (OGIB) before vs. after introduction of video capsule endoscopy (VCE) and deep enteroscopy (DE). METHODS We retrospectively reviewed prospectively collected data of patients undergoing IOE for severe OGIB in a tertiary referral center. RESULTS 52 patients had laparotomy/IOE for OGIB, 11 pre and 41 post VCE/DE eras. In the pre VCE/DE era, 36.4% (4/11) had preoperative presumptive diagnoses while in the post VCE/DE era presumptive diagnoses were made in 48.8% (20/41) (p = 0.18). Preoperative evaluation led to correct diagnoses in 18.2% (2/11) in the pre and 51.2% (21/41) in the post VCE/DE era (p = 0.09). Vascular lesions and ulcers were the most common diagnoses, but rebleeding was common. No rebleeding was found among patients with tumors, Meckel's diverticulum, and aortoenteric fistula. CONCLUSIONS Presumptive diagnoses in the post VCE/DE era were usually accurate. If VCE or DE are negative, the probability of negative IOE is high. Patients with tumors and Meckel's diverticulum were the best candidates for IOE.
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Affiliation(s)
- Wuttiporn Manatsathit
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, United States; CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States
| | - Usah Khrucharoen
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Dennis M Jensen
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States.
| | - O Joe Hines
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Thomas Kovacs
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Gordon Ohning
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Rome Jutabha
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Kevin Ghassemi
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Gareth S Dulai
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Gustavo Machicado
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
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Voron T, Rahmi G, Bonnet S, Malamut G, Wind P, Cellier C, Berger A, Douard R. Intraoperative Enteroscopy: Is There Still a Role? Gastrointest Endosc Clin N Am 2017; 27:153-170. [PMID: 27908515 DOI: 10.1016/j.giec.2016.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.
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Affiliation(s)
- Thibault Voron
- Department of General and Digestive Surgery, Georges Pompidou European AP-HP University Hospital, 20-40 rue Leblanc, 75908 Paris Cedex 15, France; Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France
| | - Gabriel Rahmi
- Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France; Department of Gastroenterology and Endoscopy, Georges Pompidou European AP-HP University Hospital, 20-40, rue Leblanc, 75908 Paris Cedex 15, France
| | - Stephane Bonnet
- Department of Digestive Surgery, Percy University Military Hospital, 101 Avenue Henri Barbusse, Clamart 92140, France
| | - Georgia Malamut
- Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France; Department of Gastroenterology and Endoscopy, Georges Pompidou European AP-HP University Hospital, 20-40, rue Leblanc, 75908 Paris Cedex 15, France
| | - Philippe Wind
- Department of Digestive Surgery, Avicenne AP-HP University Hospital, 125 Rue de Stalingrad, Bobigny 93000, France; UFR SMBH, Paris-Nord University, 74, rue Marcel Cachin, 93017 Bobigny cedex, France
| | - Christophe Cellier
- Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France; Department of Gastroenterology and Endoscopy, Georges Pompidou European AP-HP University Hospital, 20-40, rue Leblanc, 75908 Paris Cedex 15, France
| | - Anne Berger
- Department of General and Digestive Surgery, Georges Pompidou European AP-HP University Hospital, 20-40 rue Leblanc, 75908 Paris Cedex 15, France; Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France
| | - Richard Douard
- Department of General and Digestive Surgery, Georges Pompidou European AP-HP University Hospital, 20-40 rue Leblanc, 75908 Paris Cedex 15, France; Paris Descartes Faculty of Medicine, 15, rue de l'Ecole de Médecine, Paris 75006, France.
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Gurudu SR, Bruining DH, Acosta RD, Eloubeidi MA, Faulx AL, Khashab MA, Kothari S, Lightdale JR, Muthusamy VR, Yang J, DeWitt JM. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc 2017; 85:22-31. [PMID: 27374798 DOI: 10.1016/j.gie.2016.06.013] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023]
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15
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Chauhan SS, Manfredi MA, Abu Dayyeh BK, Enestvedt BK, Fujii-Lau LL, Komanduri S, Konda V, Maple JT, Murad FM, Pannala R, Thosani NC, Banerjee S. Enteroscopy. Gastrointest Endosc 2015; 82:975-90. [PMID: 26388546 DOI: 10.1016/j.gie.2015.06.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/11/2015] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging with CT and magnetic resonance enterography or direct visualization with wireless capsule endoscopy can provide valuable diagnostic information and direct therapy. Enteroscopy technology and techniques have evolved significantly and allow diagnosis and therapy deep within the small bowel, previously attainable only with intraoperative enteroscopy. Push enteroscopy, readily available in most endoscopy units, plays an important role in the evaluation and management of lesions located up to the proximal jejunum. Currently available device-assisted enteroscopy systems, DBE, SBE, and spiral enteroscopy each have their technical nuances, clinical advantages, and limitations. Newer, on-demand enteroscopy systems appear promising, but further studies are needed. Despite slight differences in parameters such as procedural times, depths of insertion, and rates of complete enteroscopy, the overall clinical outcomes with all overtube-assisted systems appear to be similar. Endoscopists should therefore master the enteroscopy technology based on institutional availability and their level of technical expertise.
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ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110:1265-87; quiz 1288. [PMID: 26303132 DOI: 10.1038/ajg.2015.246] [Citation(s) in RCA: 381] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/01/2015] [Indexed: 02/06/2023]
Abstract
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.
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Sánchez-Capilla AD, De La Torre-Rubio P, Redondo-Cerezo E. New insights to occult gastrointestinal bleeding: From pathophysiology to therapeutics. World J Gastrointest Pathophysiol 2014; 5:271-283. [PMID: 25133028 PMCID: PMC4133525 DOI: 10.4291/wjgp.v5.i3.271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/01/2014] [Accepted: 06/18/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15-34. [PMID: 24138285 DOI: 10.1111/apt.12527] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 09/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. AIM To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors. METHODS A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract. RESULTS Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively. CONCLUSIONS Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.
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Affiliation(s)
- S S Sami
- Nottingham Digestive Diseases Centre & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, UK
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Sidhu R, Sanders DS. Double-balloon enteroscopy in the elderly with obscure gastrointestinal bleeding: safety and feasibility. Eur J Gastroenterol Hepatol 2013; 25:1230-4. [PMID: 23751353 DOI: 10.1097/meg.0b013e3283630f1b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Double-balloon enteroscopy (DBE) is a novel endoscopic procedure to access the small bowel. There is paucity of data on its use in the elderly. OBJECTIVE The aim of this study was to assess the utility of DBE in patients with obscure gastrointestinal bleeding (OGB) in terms of safety and feasibility. MATERIALS AND METHODS A prospective review of consecutive patients who underwent DBE for OGB was conducted. Data were collected on demographics, dose of sedation/analgesia, diagnostic yield, and management and complications. Patients were divided into group 1, age of at least 70 years, and group 2, age less than 70 years. RESULTS A total of 148 DBE procedures were carried out for OGB. Group 1 (age≥70 years) comprised 27% (n=40) of the cohort with a mean age of 77 years (range 70-83 years). The mean age in group 2 (n=108) was 54 years, 44% women. The diagnostic yield in group 1 was 53 versus 35% in group 2 (P=0.06). Subsequent management was altered more frequently in group 1 (50 vs. 28%, P=0.01, odds ratio 2.6, 95% confidence interval 1.2-5.5). Sedation requirement was less in the elderly (median dose of midazolam, group 1: 4.5 mg versus group 2: 6 mg, P<0.001; fentanyl, group 1: 50 mcg vs. group 2: 75 mcg, P<0.001). There was no significant difference in complications between the two groups (0/40 vs. 1/108, P=0.54). On logistic regression, increasing age (P=0.008) was associated with a higher yield with DBE in all patients. CONCLUSION DBE is safe, has a high diagnostic yield and has a positive impact on patient management in the elderly.
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Affiliation(s)
- Reena Sidhu
- Department of Gastroenterology, Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK.
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Bonnet S, Douard R, Malamut G, Cellier C, Wind P. Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. Dig Liver Dis 2013; 45:277-84. [PMID: 22877794 DOI: 10.1016/j.dld.2012.07.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 06/25/2012] [Accepted: 07/06/2012] [Indexed: 12/11/2022]
Abstract
Obscure gastrointestinal bleeding has long been a diagnostic challenge because of the relative inaccessibility of small bowel to standard endoscopic evaluation. Intraoperative enteroscopy indications have been reduced by the development of deep enteroscopy techniques and video capsule endoscopy. In light of the current advances, this review aimed at evaluating the intraoperative enteroscopy technical aspects, study results and an ongoing role for intraoperative enteroscopy in obscure gastrointestinal bleeding management. Intraoperative enteroscopy allows complete small bowel exploration in 57-100% of cases. A bleeding source can be identified in 80% of cases. Main causes are vascular lesions (61%) and benign ulcers (19%). When a lesion is found, intraoperative enteroscopy allows successful and recurrence-free management of gastrointestinal bleeding in 76% of cases. The reported mortality is 5% and morbidity is 17%. The recurrence of bleeding is observed in 13-52% of cases. With the recent development of deep enteroscopy techniques, intraoperative enteroscopy remains indicated when small bowel lesions (i) have been identified by a preoperative work-up, (ii) cannot be definitively managed by angiographic embolization, endoscopic treatment or when surgery is required and (iii) cannot be localized by external examination during surgical explorations. Surgeons and endoscopists must exercise caution with intraoperative enteroscopy to avoid the use of a low yield, highly morbid procedure.
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Affiliation(s)
- Stéphane Bonnet
- Department of Digestive Surgery, Bégin University Military Hospital, Saint-Mandé, France
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21
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Small bowel diagnostics: current place of small bowel endoscopy. Best Pract Res Clin Gastroenterol 2012; 26:209-20. [PMID: 22704565 DOI: 10.1016/j.bpg.2012.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 03/08/2012] [Indexed: 01/31/2023]
Abstract
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.
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22
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Gerson LB. Small bowel endoscopy: cost-effectiveness of the different approaches. Best Pract Res Clin Gastroenterol 2012; 26:325-35. [PMID: 22704574 DOI: 10.1016/j.bpg.2012.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Accepted: 01/13/2012] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Lauren B Gerson
- Stanford University School of Medicine, Division of Gastroenterology and Hepatology, 450 Broadway Street, 4th Floor Pavilion C, MC: 6341, Redwood City, CA 94063, USA.
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Evaluating the role of small-bowel endoscopy in clinical practice: the largest single-centre experience. Eur J Gastroenterol Hepatol 2012; 24:513-9. [PMID: 22330235 DOI: 10.1097/meg.0b013e328350fb05] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Kochhar GS, Sanaka MR, Vargo JJ. Therapeutic management options for patients with obscure gastrointestinal bleeding. Therap Adv Gastroenterol 2012; 5:71-81. [PMID: 22282709 PMCID: PMC3263978 DOI: 10.1177/1756283x11409280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Gursimran S. Kochhar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - John J. Vargo
- Department of Gastroenterology and Hepatology Digestive Disease Institute Cleveland Clinic 9500 Euclid Avenue, Desk A-30 Cleveland, OH, USA
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Chen TH, Chiu CT, Lin WP, Su MY, Hsu CM, Chen PC. Application of double-balloon enteroscopy in jejunal diverticular bleeding. World J Gastroenterol 2010; 16:5616-20. [PMID: 21105196 PMCID: PMC2992681 DOI: 10.3748/wjg.v16.i44.5616] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of endoscopic diagnosis and therapy for jejunal diverticular bleeding.
METHODS: From January 2004 to September 2009, 154 patients underwent double-balloon enteroscopy (DBE) for obscure gastrointestinal bleeding. Ten consecutive patients with jejunal diverticula (5 males and 5 females) at the age of 68.7 ± 2.1 years (range 19-95 years) at Chang Gung Memorial Hospital, Academic Tertiary Referral Center, were enrolled in this study.
RESULTS: Of the 10 patients, 5 had melena, 2 had hematochezia, 2 had both melena and hematochezia, 1 had anemia and dizziness. DBE revealed ulcers with stigmata of recent hemorrhage in 6 patients treated by injection of epinephrine diluted at 1:10 000, Dieulafoy-like lesions in 4 patients treated by deploying hemoclips on the vessels, colonic diverticula in 2 patients, and duodenal diverticula in 3 patients, respectively. Of the 2 patients who underwent surgical intervention, 1 had a large diverticulum and was referred by the surgeon for DBE, 1 received endoscopic therapy but failed due to massive bleeding. One patient had a second DBE for recurrent hemorrhage 7 mo later, which was successfully treated with a repeat endoscopy. The mean follow-up time of patients was 14.7 ± 7.8 mo.
CONCLUSION: DBE is a safe and effective treatment modality for jejunal diverticular bleeding.
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Fisher L, Lee Krinsky M, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Cash BD, Decker GA, Fanelli RD, Friis C, Fukami N, Harrison ME, Ikenberry SO, Jain R, Jue T, Khan K, Maple JT, Strohmeyer L, Sharaf R, Dominitz JA. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 2010; 72:471-9. [PMID: 20801285 DOI: 10.1016/j.gie.2010.04.032] [Citation(s) in RCA: 202] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 04/19/2010] [Indexed: 02/06/2023]
Abstract
This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).(1) The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "we suggest," whereas stronger recommendations are typically stated as "we recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.
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Maaser C, Schmedt A, Bokemeyer M, Kannengiesser K, Ullerich H, Lügering A, Domagk D, Domschke W, Kucharzik T. Long-term efficacy and safety of double balloon enteroscopy--prospective and retrospective data from a single center study. Scand J Gastroenterol 2010; 45:992-9. [PMID: 20230304 DOI: 10.3109/00365521003710182] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Double balloon enteroscopy (DBE) has evolved as one of the most innovative and fast spreading endoscopic procedures in the last decade. With increasing experience of performing endoscopic procedures in the mid gut outside the operating room it is necessary to investigate the effectiveness of DBE regarding therapeutic consequences, long-term efficacy as well as safety. MATERIAL AND METHODS To address this we retrospectively analyzed all DBE performed over a period of 2 years at our department. Furthermore, in order to evaluate long-term effectiveness of DBE procedures we performed a follow-up analysis on all patients, whose DBE procedure was at least 6 months ago. In addition, 100 consecutive patients who underwent DBE were questioned regarding procedure associated complaints using a standardized questionnaire. RESULTS Retrospective analysis of all DBE procedures performed in our department before November 2006 (n = 545) revealed an overall diagnostic yield of 39.7% and a therapeutic yield of 31.1%. The overall number of major complications accounted to 0.9%. Follow-up analysis revealed a long-term effect of endoscopic interventions in more than 50%, while in those patients with an initially negative DBE long-term follow-up only revealed symptom explaining findings in 17% with the majority of the other patients being asymptomatic during follow-up. Regarding patient related complaints the prospective analysis showed that DBE procedures in general are well tolerated with the most common complaint being meteorism. CONCLUSIONS DBE showed to be a relatively safe and well tolerated procedure. However, more sensitive algorithms are needed to enhance the therapeutic results.
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Affiliation(s)
- Christian Maaser
- Department of Internal Medicine B, University of Muenster, Muenster, Germany.
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28
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Lin WP, Chiu CT, Su MY, Hsu CM, Sung CM, Chen PC. Treatment decision for potential bleeders in obscure gastrointestinal bleeding during double-balloon enteroscopy. Dig Dis Sci 2009; 54:2192-7. [PMID: 19051020 DOI: 10.1007/s10620-008-0591-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 10/17/2008] [Indexed: 01/10/2023]
Abstract
Double-balloon enteroscopy (DBE) is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. The aim is to describe how outcomes differ with patient setting (with DBE diagnosis and intervention, with DBE diagnosis but without intervention, and without DBE diagnosis), and thus demonstrate the value of endoscopic intervention when encountering potential bleeder during DBE. From November 2003 to January 2008, 90 patients with obscure gastrointestinal bleeding presented with DBE at our tertiary referral center. A total of 113 DBE procedures were carried out. Overall diagnostic yield was 75.6% (68/90). Endoscopic intervention was performed in 58 (85.3%) of the 68 patients with potential bleeder. The 90 patients were divided into three settings: with endoscopic diagnosis and intervention (n = 58), with endoscopic diagnosis but without intervention (n = 10), and without endoscopic diagnosis (n = 22). Rebleeding rates for the three groups were 22.4%, 60%, and 22.7%, respectively. For the 35 patients diagnosed with vascular lesions, the rebleeding rates in patients with and without endoscopic intervention, were 38.5% (10/26) and 66.7% (6/9), respectively. One (0.9%) severe adverse event occurred during the 113 procedures, and the patient died. DBE is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. DBE involves relatively safe procedures and has an acceptable complication rate. When potential bleeders are encountered during the procedure, especially for vascular lesions, therapeutic intervention should be attempted, since the intervention-related complication rate is acceptable, and such intervention can reduce the rebleeding rate and enhance the cost-effectiveness of DBE.
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Affiliation(s)
- Wei-Pin Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Kweishan, Taoyuan, Taiwan
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Abstract
Current options for the diagnosis and management of small bowel lesions include push enteroscopy (PE), video capsule endoscopy (VCE), single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), and intraoperative enteroscopy (IOE). IOE, the ultimate diagnostic and therapeutic modality for small bowel disorders, is a major surgical and endoscopic procedure. It should be reserved for cases that cannot be managed with others modalities because of the difficulties of the procedure and significant morbidity. The indication for IOE have diminished in recent years because of the development of VCE and DBE. IOE is reserved for patients with massive mid-gut bleeding, lesions not accessible by balloon enteroscopy, and lesions difficult or impossible to treat by balloon enteroscopy. There are special indications in Crohn disease and in Peutz-Jeghers syndrome. Our own results and a review of the literature are presented.
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Affiliation(s)
- Hans-Joachim Schulz
- Oskar-Ziethen-Hospital, Sana Clinic Lichtenberg, Medical Clinic I, Berlin University-Teaching Hospital (Charité), 10365 Berlin, Germany.
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30
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Abstract
The purpose of this article is to describe the available data regarding the short- and long-term outcomes associated with deep enteroscopy. Deep enteroscopy can be defined as the use of an enteroscope to examine small bowel distal to the ligament of Treitz or proximal to the distal ileum. The term deep enteroscopy includes double-balloon, single-balloon, and spiral enteroscopy. Comparisons are made with push enteroscopy and intraoperative enteroscopy, the major therapeutic endoscopic options available to the gastroenterologist before the introduction of deep enteroscopy. The article concludes with a discussion regarding complications associated with deep enteroscopy and cost-effectiveness of management strategies for obscure bleeding. Proposed changes to the current algorithm for management of obscure bleeding are suggested.
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Affiliation(s)
- Lauren B Gerson
- Division of Gastroenterology & Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305-5202, USA
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31
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Abstract
Small bowel endoscopy has made tremendous advances over the last 8 years. The introduction of capsule endoscopy, double-balloon enteroscopy, single-balloon enteroscopy and spiral overtube-assisted enteroscopy have completely removed the mystery in investigating the small intestine. These new procedures are challenging and timeconsuming to perform. A brief overview on the technical issues and complications related to these small bowel endoscopy procedures is presented.
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Affiliation(s)
- Simon K Lo
- Division of Digestive Diseases, Department of Medicine, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90048, USA
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32
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Roldán FP, Carro PG, García MCV, Yeste JP, Villarín AL. [Urgent intraoperative total enteroscopy with colonoscopy by means of a double enterotomy in a severe lower digestive tract haemorrhage]. Cir Esp 2009; 86:252-3. [PMID: 19552898 DOI: 10.1016/j.ciresp.2009.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2008] [Accepted: 03/31/2009] [Indexed: 10/20/2022]
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33
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Gerson LB, Flodin JT, Miyabayashi K. Balloon-assisted enteroscopy: technology and troubleshooting. Gastrointest Endosc 2008; 68:1158-67. [PMID: 19028224 DOI: 10.1016/j.gie.2008.08.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Accepted: 08/08/2008] [Indexed: 12/22/2022]
Affiliation(s)
- Lauren B Gerson
- Stanford University School of Medicine, Stanford, California, USA
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34
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Gerson L, Kamal A. Cost-effectiveness analysis of management strategies for obscure GI bleeding. Gastrointest Endosc 2008; 68:920-36. [PMID: 18407270 DOI: 10.1016/j.gie.2008.01.035] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 01/17/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage. METHODS We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period. RESULTS An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses. LIMITATIONS The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions. CONCLUSIONS An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.
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Affiliation(s)
- Lauren Gerson
- Division of Gastroenterology and Hepatology Stanford University School of Medicine, Stanford, California 94305-5202, USA
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DiSario JA, Petersen BT, Tierney WM, Adler DG, Chand B, Conway JD, Coffie JMB, Mishkin DS, Shah RJ, Somogyi L, Wong Kee Song LM. Enteroscopes. Gastrointest Endosc 2007; 66:872-80. [PMID: 17904135 DOI: 10.1016/j.gie.2007.07.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 02/06/2023]
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Raju GS, Gerson L, Das A, Lewis B. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007; 133:1697-717. [PMID: 17983812 DOI: 10.1053/j.gastro.2007.06.007] [Citation(s) in RCA: 404] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007.
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Affiliation(s)
- Gottumukkala S Raju
- Department of Medicine, University of Texas Medical Branch, Galveston, Galveston, Texas, USA
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Byeon JS. Double balloon endoscopy in obscure GI bleeding. Gastrointest Endosc 2007; 66:S69-71. [PMID: 17709037 DOI: 10.1016/j.gie.2007.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 05/16/2007] [Indexed: 12/22/2022]
Affiliation(s)
- Jeong Sik Byeon
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, Korea
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Abstract
Capsule endoscopy is a new technology that, for the first time, allows complete, non-invasive endoscopic imaging of the small bowel. The efficacy of capsule endoscopy in the diagnosis of suspected small bowel diseases has been established. Important applications for surgeons include observations of obscure gastrointestinal bleeding and small bowel neoplasms.
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Affiliation(s)
- Osman Ersoy
- Hacettepe University, School of Medicine, Department of Gastroenterology, Ankara 06100, Turkey
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Abstract
Obscure gastrointestinal (GI) bleeding is defined as visible or invisible GI blood loss, the source of which can not be identified by standard endoscopy (oesophagogastroduodenoscopy and colonoscopy). Nowadays, GI bleeding is divided into upper, mid- and lower bleeding. Mid-GI bleeding covers the section from the Treitz ligament to the ileocaecal valve. The new diagnostic methods of capsule endoscopy and double balloon enteroscopy have revolutionised the diagnostic approach in recent years. As a result, previous radiological and nuclear medicine techniques (small bowel X-ray, scintigraphy and angiography), but also endoscopic techniques, such as the push enteroscopy and intraoperative endoscopy, are becoming less important. After standard endoscopy and persistent blood loss it is advisable to first have these procedures repeated by an experienced examiner under optimal conditions. Nevertheless, no source of bleeding is identified by this method in 5% of cases. It is then recommended to use capsule endoscopy and, depending on the findings, double balloon enteroscopy with the option of intervention. In patients with unstable circulation an invasive procedure (intraoperative endoscopy) may be required.
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Affiliation(s)
- Ulrich Heil
- Klinik für Innere Medizin und Gastroenterologie, St.-Hildegardis-Krankenhaus, Katholisches Klinikum Mainz, Hildegardstrasse 2, 55131 Mainz, Germany.
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Saperas E. [Lower gastrointestinal bleeding: the great unknown]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:93-100. [PMID: 17335717 DOI: 10.1157/13099280] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lower gastrointestinal bleeding represents one-fourth of all gastrointestinal hemorrhages. The bleeding usually originates in the colon while less than 10% of cases originate in the small bowel. Colonoscopy is considered the initial procedure of choice due to its diagnostic efficacy, safety, and therapeutic potential. Mesenteric arteriography can be an alternative in patients with massive hemorrhage. Helical computed tomography of the abdomen with endovenous contrast can be useful but has not been directly compared with arteriography. When the results of gastroscopy and colonoscopy are negative, small bowel bleeding is suspected. Capsule endoscopy allows non-invasive examination of the entire small bowel. The diagnostic efficacy of this procedure is clearly superior to that of other conventional examinations and, compared with intraoperative endoscopy, capsule endoscopy has a sensitivity of 95% and a specificity of 75%. Double balloon enteroscopy is a new modality that also allows complete examination of the small bowel with the additional advantage of its therapeutic potential. Definitive diagnosis of the hemorrhagic site is essential for appropriate treatment. Endoscopic and angiographic advances are therapeutic alternatives to surgical resection. Endoscopic treatment is indicated in lesions with active bleeding or signs of recent hemorrhage. Arterial embolization can be a therapeutic alternative when arteriography shows active hemorrhage. Surgical treatment is reserved for patients with persistent bleeding in whom other options have failed.
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Affiliation(s)
- Esteban Saperas
- Unidad de Sangrantes, Servicio Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Schwartz GD, Barkin JS. Small-bowel tumors detected by wireless capsule endoscopy. Dig Dis Sci 2007; 52:1026-30. [PMID: 17380403 DOI: 10.1007/s10620-006-9483-8] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2006] [Accepted: 06/12/2006] [Indexed: 12/30/2022]
Abstract
Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.
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Affiliation(s)
- Gregory D Schwartz
- School of Medicine/Mt. Sinai Medical Center, Division of Gastroenterology, University of Miami, 4300 Alton Road, Miami Beach, FL 33140, USA
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Abstract
Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.
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Affiliation(s)
- Gregory D Schwartz
- School of Medicine/Mt. Sinai Medical Center, Division of Gastroenterology, University of Miami, 4300 Alton Road, Miami Beach, FL 33140, USA
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Abstract
Obscure gastrointestinal bleeding (OGIB) is defined as an intermittent or continuous loss of blood in which the source has not been identified after upper endoscopy and colonoscopy. It constitutes a diagnostic and therapeutic challenge for the general internist and the gastroenterologist. This article provides an overview of the etiology, clinical presentation, and diagnostic modalities of OGIB including push enteroscopy, double balloon enteroscopy, wireless capsule endoscopy, enteroclysis, angiography, bleeding scanning with labeled red blood cells, and surgery with intraoperative enteroscopy. Therapeutic modalities including iron replacement, combined hormones, octreotide acetate, therapeutic endoscopy, and surgery are also discussed. In addition, a rational approach to patients with OGIB according to the clinical presentation is presented herein.
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Affiliation(s)
- Ronald Concha
- Division of Gastroenterology, University of Miami, Miller School of Medicine/Mt. Sinai Medical Center, Miami Beach, FL 33140, USA
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Kopácová M, Bures J, Vykouril L, Hladík P, Simkovic D, Jon B, Ferko A, Tachecí I, Rejchrt S. Intraoperative enteroscopy: ten years' experience at a single tertiary center. Surg Endosc 2006; 21:1111-6. [PMID: 17103268 DOI: 10.1007/s00464-006-9052-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2006] [Revised: 06/18/2006] [Accepted: 06/23/2006] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND METHODS Intraoperative enteroscopy is an invasive technique for small bowel investigation. It enables us to investigate the entire small intestine and to treat pathological findings by endoscopic or surgical means at the same time. The investigation is invasive and that is why the proper indication is mandatory. RESULTS Forty-one intraoperative enteroscopies were performed at our center within a 10-year period. The procedure was diagnostic in 37/41 patients (90.2%); in 3 patients no pathology was found, and in 1 patient we found only previously diagnosed celiac disease. The investigation was therapeutic in 35/41 (85.4%) patients; 2 patients with small bowel ulcers did not require any intraoperative therapy. The pathological findings were arteriovenous malformations (found in 12 patients), small bowel NSAID-induced or Crohn's ulcers (8 patients)--ulcerations and arteriovenous malformations were simultaneously found in three patients; carcinoid of the small intestine (5 patients); Peutz-Jeghers syndrome (5 patients); bleeding polyps (2 gastrointestinal stromal tumors, 1 paraganglioma, and 1 lipoma--in 4 patients); Rendu-Osler-Weber disease (2 patients); multiple cavernous hemangiomas in blue rubber bleb nevus syndrome (1 patient); Henoch-Schönlein purpura (1 patient); aortoenteral fistula (1 patient); and retrograde intussusception of Meckel's diverticulum (1 patient). In five patients with Peutz-Jeghers syndrome, 6-22 hamartomas (median of 18 per session) were removed by means of endoscopic polypectomy during intraoperative enteroscopy. There were no major procedure-related complications in our series. CONCLUSIONS Intraoperative enteroscopy is accepted as the ultimate diagnostic procedure for complete investigation of the small bowel. Despite the introduction of double-balloon enteroscopy into clinical practice, intraoperative enteroscopy will be reserved for those cases where double-balloon enteroscopy cannot be performed or fails to investigate the entire small intestine, especially to prevent excessive bowel resection.
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Affiliation(s)
- M Kopácová
- 2nd Department of Medicine, Charles University in Praha, Faculty of Medicine at Hradec Králové, University Teaching Hospital, Sokolská 581, Hradec Králové, 500 05, Czech Republic.
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Wong RF, Tuteja AK, Haslem DS, Pappas L, Szabo A, Ogara MM, DiSario JA. Video capsule endoscopy compared with standard endoscopy for the evaluation of small-bowel polyps in persons with familial adenomatous polyposis (with video). Gastrointest Endosc 2006; 64:530-7. [PMID: 16996344 DOI: 10.1016/j.gie.2005.12.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Accepted: 12/06/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Video capsule endoscopy (VCE) may be useful for surveillance of small-bowel polyps in patients with familial adenomatous polyposis (FAP). OBJECTIVE To compare VCE to standard endoscopy for diagnosing small-bowel polyps in a defined segment of small bowel (proximal to a tattoo) and the entire examined small bowel. DESIGN Prospective. SETTING Single tertiary referral center. PATIENTS Participants with FAP (n = 32). The majority were selected for their high number of proximal small-bowel polyps and prior endoscopic tattoo placement in the proximal small bowel. INTERVENTIONS VCE (interpreted by 2 readers), push enteroscopy (PE), and lower endoscopy (LE) to count and measure small-bowel polyps. RESULTS In the defined segment, VCE detected a median of 10.0 (interquartile range [IQR], 5.0-19.0) and 9.0 (IQR, 6.0-16.0) polyps for each reader compared with a median of 41.0 (IQR, 19.0-64.0) polyps on PE (P = .002). Agreement between the 2 methods was fair (kappa = 0.34, 0.36). Agreement between VCE and PE was poor to fair (kappa = 0.10, 0.22) for estimating the size of the largest polyp and poor (kappa = -0.20, -0.27) for detecting large polyps (> or =1 cm). In the entire examined small bowel, VCE diagnosed a median of 38.0 (IQR, 10.5-71.5) and 54.0 (IQR, 13.0-100.0) polyps for each reader compared with a median of 123.0 (IQR, 38.5-183.0) for combination endoscopy (PE and LE) (P < .001). Agreement between the 2 methods was fair to moderate (kappa = 0.21, 0.56). LIMITATIONS Participants selected for high polyp burden, and results may not be applicable to all patients with FAP. CONCLUSIONS VCE underestimates the number of small-bowel polyps in persons with FAP and does not reliably detect large polyps.
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Affiliation(s)
- Robert F Wong
- Department of Internal Medicine, Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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Abstract
Capsule endoscopy has recently been introduced to explore endoscopically the whole small intestine, fulfilling a gap between examinations of the upper and lower gastrointestinal tract. The technique consists of a miniaturized endoscope, embedded in a swallowable capsule that is propulsed by peristalsis and achieves the journey to the right colon in five to eight hours. Images captured by the capsule are recorded on a hard drive worn in a belt by the patient. The main indication for capsule examination is the examination of the small bowel to find a bleeding lesion in patients with obscure bleeding. Several studies have shown that the diagnostic yield of capsule endoscopy is superior to that of push enteroscopy in this indication. Other possible indications are patients with suspected intestinal location of Crohn's disease, familial adenomatous polyposis, complicated coeliac disease and lesions due NSAIDs. The review contains information on the technical aspects of capsule endoscopy and discusses the indications. Issues of safety and tolerance are also discussed.
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Affiliation(s)
- Michel Delvaux
- Department of Internal Medicine and Digestive Pathology, Hôpitaux de Brabois Adultes, Tour Drouet, CHU de Nancy, F-54511 Vandoeuvre-les-Nancy, France.
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Abstract
Obscure GI bleeding is a relatively common problem facing internists, gastroenterologists, and surgeons in a typical clinical practice. The etiology is occasionally suggested by the patient's age, history, and medications. Management is complicated and typically requires a team-oriented approach, with input from the internist, gastroenterologist, radiologist, and surgeon alike. SBFT and enteroclysis seem to have a limited role, unless there is a high suspicion of a small bowel mass lesion or Crohn's disease. Scintigraphy may be performed in patients with active bleeding in whom endoscopy has failed oris contraindicated. Angiography may be used in patients with an early positive nuclear imaging or failed endoscopic therapy. Provocative angiography probably has a lower diagnostic yield than previously reported, and should be performed only in experienced centers. Helical CT is a new and potentially important option in patients with obscure bleeding, but is currently considered experimental. All patients with obscure GI bleeding should undergo repeat upper endoscopy and perhaps colonoscopy to rule out missed lesions. SBE seems to be complementary to capsule endoscopy, and it is unknown whether this should be performed before capsule endoscopy or only if capsule endoscopy yields a positive proximal small bowel finding. Double balloon enteroscopy seems promising, but the technique requires further study. Surgery should be reserved for patients who have a positive capsule endoscopy requiring surgical therapy or patients who have persistent GI bleeding requiring recurrent blood transfusions in whom all other modalities have failed. Treatment for vascularectasias, the most common cause of obscure GI bleeding, is currently inadequate,and typically requires a combination of multiple management approaches.
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Affiliation(s)
- Sauyu Lin
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
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Gerson LB, Van Dam J. Wireless capsule endoscopy and double-balloon enteroscopy for the diagnosis of obscure gastrointestinal bleeding. Tech Vasc Interv Radiol 2005; 7:130-5. [PMID: 16015557 DOI: 10.1053/j.tvir.2004.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Standard endoscopic examination (upper gastrointestinal endoscopy and colonoscopy) fails to detect the cause of gastrointestinal hemorrhage in approximately 5% of patients. Before the availability of wireless capsule endoscopy and double-balloon enteroscopy, imaging modalities for the small intestine distal to the ligament of Treitz included barium contrast examination and/or enteroclysis, push, passive, or intraoperative enteroscopy, technetium 99m labeled sulfur colloid scanning, angiography, and computed tomography, although the diagnostic yield of all of these imaging modalities was low. In 2001, wireless capsule endoscopy became available for the evaluation of patients with probable small intestinal hemorrhage. Advantages of wireless capsule endoscopy include that the procedure is noninvasive, requires no sedation, and does not expose the patient to ionizing radiation. In patients with obscure gastrointestinal hemorrhage, studies have demonstrated an additional 25 to 50% diagnostic yield using wireless capsule endoscopy when compared to other diagnostic modalities. The major limitations of capsule endoscopy were its inability to obtain a biopsy, precisely localize a lesion, or perform therapeutic endoscopy. In 2001, the double-balloon enteroscope was introduced. This new endoscopic technique provides the gastroenterologist with an opportunity for further evaluation and treatment of abnormalities detected on wireless capsule endoscopy or other small intestinal imaging studies.
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Affiliation(s)
- Lauren B Gerson
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
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Affiliation(s)
- Ian M Gralnek
- David Geffen School of Medicine at University of California-Los Angeles, Veterans Affairs Greater Los Angeles Healthcare System, USA.
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