Capsule endoscopy vs. push enteroscopy: which one should we perform first?

Spiral enteroscopy and push enteroscopy

Spiral enteroscopy is a new technique for endoscopic evaluation of the small bowel. Currently, more than 3000 cases have been performed worldwide. The Discovery SB device has been approved by the Food and Drug Administration and has been granted a CE mark. The technique is safe and effective for management and detection of small bowel pathology. Recent studies of spiral enteroscopy have demonstrated diagnostic yield, total time of procedure, and depth of insertion that compare favorably with double and single balloon enteroscopy. The strengths of spiral enteroscopy are rapid advancement in the small bowel and controlled, stable withdrawal that facilitates therapy. Future studies will be needed to compare competing technologies. Push enteroscopy is a readily available, safe and effective technique for detecting and treating proximal gut pathology. If performed without an overtube, complications are rare. Use of a dedicated push enteroscope with an overtube is generally reserved for specific indications in which a moderate increase in depth of insertion into the small bowel is required. When capsule endoscopy and deep small bowel enteroscopy are not available, push enteroscopy is a reasonable option with low risk and moderate yield. Push enteroscopy will remain an important part of the armamentarium of the modern endoscopist.

Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?

BACKGROUND AND AIMS

The position of capsule endoscopy (CE) relative to push enteroscopy (PE) in the diagnostic algorithm of obscure gastrointestinal bleeding is unclear, as previous studies involved the use of both techniques in all patients. We therefore conducted a trial in which patients were randomized to undergo one or other exploration.

METHODS

All consecutive patients referred for obscure gastrointestinal bleeding were randomized between CE and PE as the first-line exploration. The alternative method was only used if the first-line method revealed no definite bleeding source, or if required for clinical reasons during follow-up.

RESULTS

CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001).

CONCLUSIONS

CE has a higher diagnostic yield than PE in obscure gastrointestinal bleeding, and a strategy based on CE as first-line exploration avoids unnecessary explorations.