Diagnostic yield and effect on clinical outcomes of push enteroscopy in suspected small-bowel bleeding

Magnetically assisted capsule endoscopy in suspected acute upper GI bleeding versus esophagogastroduodenoscopy in detecting focal lesions

BACKGROUND AND AIMS

Acute upper GI bleeding is common and requires investigation with EGD, but endotherapy is not always necessary. Magnetically assisted capsule endoscopy (MACE) uses a capsule steerable by an external magnet and allows examination of the upper GI tract and small bowel, but its role in acute upper GI bleeding has not been assessed.

METHODS

We conducted a prospective cohort study comparing the diagnostic yield of MACE and EGD in patients with suspected acute upper GI bleeding. Patient tolerance, mucosal visibility by MACE, and frequency of small-bowel bleeding were assessed. Whether or not MACE could safely predict discharge of patients was also determined.

RESULTS

Thirty-three patients were included for analysis (median age, 60 years; 75.8% male). MACE detected more focal lesions (peptic, vascular, and fresh/altered blood without a clear source) than EGD (40 versus 25, respectively, P = .02) but statistical significance was not reached for significant lesions (considered to be the bleeding source; 14 vs 13, respectively, P = 1). Capsule endoscopy identified an additional cause for bleeding in the small bowel in 18%. Visualization by MACE was excellent in most areas; views of the esophagus, gastroesophageal junction, fundus, and duodenal bulb were suboptimal. MACE was better tolerated than unsedated EGD and correctly identified patients who were safe for discharge.

CONCLUSIONS

MACE had higher diagnostic yield for focal lesions and was better tolerated than EGD. It also correctly predicted safe discharge for patients with acute upper GI bleeding. (Clinical trials registration number: NCT02690376.).

Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease

Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.

A comparison between capsule endoscopy and double balloon enteroscopy using propensity score-matching analysis in patients with previous obscure gastrointestinal bleeding

BACKGROUND

Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB.

PATIENTS AND METHODS

We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE.

RESULTS

The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p < .01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43-12.6; p < .01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p < .01).

CONCLUSIONS

Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.

Exploring the Small Bowel: Update on Deep Enteroscopy

Deep enteroscopy allows for the diagnosis and treatment of small bowel disorders that historically required operative intervention. There are a variety of endoscopic platforms using balloons and rotational overtubes to facilitate small bowel intubation and even allow for total enteroscopy. Obscure gastrointestinal bleeding is the most common indication for deep enteroscopy. By visualizing segments of the small bowel not possible through standard EGD or push enteroscopy, deep enteroscopy has an established high rate of identification and treatment of bleeding sources. In addition to obscure bleeding, other common indications include diagnosis and staging of Crohn's disease, evaluation of findings on capsule endoscopy and investigation of possible small bowel tumors. Large endoscopy databases have shown deep enteroscopy to be not only effective but safe. Recent research has focused on comparing the diagnostic rates, efficacy, and total enteroscopy rates of the different endoscopic platforms.

A Smart Capsule System for Automated Detection of Intestinal Bleeding Using HSL Color Recognition

There are no ideal means for the diagnosis of intestinal bleeding diseases as of now, particularly in the small intestine. This study investigated an intelligent intestinal bleeding detection capsule system based on color recognition. After the capsule is swallowed, the bleeding detection module (containing a color-sensitive adsorptive film that changes color when absorbing intestinal juice,) is used to identify intestinal bleeding features. A hue-saturation-light color space method can be applied to detect bleeding according to the range of H and S values of the film color. Once bleeding features are recognized, a wireless transmission module is activated immediately to send an alarm signal to the outside; an in vitro module receives the signal and sends an alarm. The average power consumption of the entire capsule system is estimated to be about 2.1mW. Owing to its simplicity, reliability, and effectiveness, this system represents a new approach to the clinical diagnosis of intestinal bleeding diseases.

Enteroscopy

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.

Is Endoscopic Therapy Effective for Angioectasia in Obscure Gastrointestinal Bleeding?: A Systematic Review of the Literature

GOAL

We aimed to summarize pooled rebleeding rates of angioectasia after therapeutic endoscopy, and compare these to historical control (no intervention) rates.

BACKGROUND

Obscure gastrointestinal bleeding continues to be challenging to diagnose and treat; in America, small bowel angioectasias are the most common cause. Technology advances led to higher diagnostic yield for these lesions; however, therapeutic impact of endoscopy remains unclear.

STUDY

A PubMed search (June 1, 2006 to September 19, 2013) with 2 independent reviews sought articles reporting rebleeding rates of symptomatic angioectasia without therapy (natural history) and after endoscopic treatment. This study list was added to studies in the 2007 American Gastroenterological Association systematic review. Data on number of patients who underwent endoscopic therapy, type of therapy used, number of patients who experienced rebleeding, and follow-up time were extracted. Rebleeding data were pooled and weighted averages were reported with 95% confidence intervals (CI).

RESULTS

Twenty-four articles (n=490 patients) with data on endoscopic therapy for angioectasia and 6 natural history cohorts (n=130) receiving no therapy for angioectasia were eligible. Of the endoscopic therapy patients, 121 at push enteroscopy and 427 at balloon-assisted enteroscopy; 209/490 (42.7%; 95% CI, 38%-47%) rebled. Of the control (no therapy) patients, 64/130 (49.2%; 95% CI, 40%-58%) rebled. Number needed to treat is estimated at 15 to 16.

CONCLUSIONS

Rebleeding rate after endoscopic therapy for symptomatic small bowel angioectasia may be comparable to that expected without therapy. Endoscopic therapy may be ineffective; if effective, the needed to treat is estimated to be high. Controlled studies, with intervention-stratified and etiology-stratified outcomes are needed.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

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

Emergency single-balloon enteroscopy in overt obscure gastrointestinal bleeding: Efficacy and safety

We aimed to evaluate the impact of emergency single-balloon enteroscopy (SBE) on the diagnosis and treatment for active overt obscure gastrointestinal bleeding (OGIB).

METHODS

SBE procedures for OGIB were retrospectively reviewed and sub-divided according to the bleeding types: active-overt and inactive-overt bleeding. The patient's history, laboratory results, endoscopic findings and therapeutic interventions were registered. Emergency SBE was defined as an endoscopy that was performed for active-overt OGIB, within 24 hours of clinical presentation.

RESULTS

Between January 2010 and February 2013, 53 SBEs were performed in 43 patients with overt OGIB. Seventeen emergency SBEs were performed in 15 patients with active overt-OGIB procedures (group A), which diagnosed the bleeding source in 14: angiodysplasia (n = 5), ulcers/erosions (n = 3), bleeding tumors (gastrointestinal stromal tumor (GIST), n = 3; neuroendocrine tumor, n = 1), and erosioned polyps (n = 2). Endoscopic treatment was performed in nine patients, with one or multiple hemostatic therapies: argon plasma coagulation (n = 5), epinephrine submucosal injection (n = 5), hemostatic clips (n = 3), and polypectomy (n = 2). Twenty-eight patients with inactive bleeding (group B) were submitted to 36 elective SBEs, which successfully diagnosed 18 cases. The diagnostic yield in group A (93.3%) was significantly higher than in group B (64.3%)-Fisher's exact test, p = 0.038.

CONCLUSION

This study revealed an important role of emergency SBE in the diagnosis of bleeding etiology in active overt OGIB.

Evaluation and outcomes of patients with obscure gastrointestinal bleeding

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

Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review

BACKGROUND & AIMS

Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies.

METHODS

We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality.

RESULTS

We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (-8.96/y), compared with iron therapy (-1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01).

CONCLUSIONS

In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.

Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis

OBJECTIVES

Gastrointestinal angiodysplastic lesions (GIADs) are defined as pathologically dilated communications between veins and capillaries. The objective of this systematic review and meta-analysis was to determine the efficacy of available treatment modalities for GIADs.

METHODS

We identified eligible studies by searching through PubMed, SCOPUS, and Cochrane central register of controlled trials. We searched for clinical trials examining the efficacy of endoscopic, pharmacologic, or surgical therapy for GIADs. Data were pooled using a random-effects model, and the effect of response to medical or surgical therapy was reported as odds ratios with 95% confidence intervals (CIs). Data and quality indicators were extracted by two authors from 22 studies, including 831 individuals with GIADs. The analysis included 623 patients treated with endoscopic therapy, 63 with hormonal therapy, 72 patients with octreotide, and 73 status post aortic valve replacement surgery.

RESULTS

Hormonal therapy, based on two case-control studies, was not effective for bleeding cessation (odds ratio: 1.0, 95% CI: 0.5-1.96). On the basis of 14 studies including patients with gastric, colonic, and small-bowel GIADs, endoscopic therapy was effective as initial therapy, but the pooled recurrence bleeding rate was 36% (95% CI: 28-44%) over a mean (±s.d.) of 22±13 months. The event rate for re-bleeding increased to 45% (95% CI: 37-52%) when studies including only small-bowel GIADs were included (N=341). In four studies assessing the efficacy of somatostatin analogs, the pooled odds ratio was 14.5 (95% CI: 5.9-36) for bleeding cessation. In two studies assessing the role of aortic valve replacement (AVR) in 73 patients with Heyde's syndrome, the event rate for re-bleeding was 0.19 (95% CI: 0.11-0.30) over a mean follow-up period of 4 years postoperatively.

CONCLUSIONS

Over one-third of patients with GIADs experienced re-bleeding after endoscopic therapy. Somatostatin analogs and AVR for Heyde's syndrome appeared to be effective therapy for GIADs.

Leitsymptome und Differenzialdiagnostik

Die Vorstellung eines Kindes mit akuten Bauchschmerzen erfolgt meist kurz nach Schmerzbeginn, nicht selten nachts und zu Zeiten eingeschränkter Diagnostik. Erschwert ist die Diagnosefindung durch fehlende Verbalisierung der Schmerzen bei Kleinkindern und Säuglingen sowie durch vage und wenig präzise Angaben zu Schmerzcharakter und Lokalisation bei älteren Kindern.

Distribution of bleeding gastrointestinal angioectasias in a Western population

AIM: To define which segments of the gastrointestinal tract are most likely to yield angioectasias for ablative therapy.

METHODS: A retrospective chart review was performed for patients treated in the Louisiana State University Health Sciences Center Gastroenterology clinics between the dates of July 1, 2007 and October 1, 2010. The selection of cases for review was initiated by use of our electronic medical record to identify all patients with a diagnosis of angioectasia, angiodysplasia, or arteriovenous malformation. Of these cases, chart reviews identified patients who had a complete evaluation of their gastrointestinal tract as defined by at least one upper endoscopy, colonoscopy and small bowel capsule endoscopy within the past three years. Patients without evidence of overt gastrointestinal bleeding or iron deficiency anemia associated with intestinal angioectasias were classified as asymptomatic and excluded from this analysis. Thirty-five patients with confirmed, bleeding intestinal angioectasias who had undergone complete endoscopic evaluation of the gastrointestinal tract were included in the final analysis.

RESULTS: A total of 127 cases were reviewed. Sixty-six were excluded during subsequent screening due to lack of complete small bowel evaluation and/or lack of documentation of overt bleeding or iron deficiency anemia. The 61 remaining cases were carefully examined with independent review of endoscopic images as well as complete capsule endoscopy videos. This analysis excluded 26 additional cases due to insufficient records/images for review, incomplete capsule examination, poor capsule visualization or lack of confirmation of typical angioectasias by the principal investigator on independent review. Thirty-five cases met criteria for final analysis. All study patients were age 50 years or older and 13 patients (37.1%) had chronic kidney disease stage 3 or higher. Twenty of 35 patients were taking aspirin (81 mg or 325 mg), clopidogrel, and/or warfarin, with 8/20 on combination therapy. The number and location of angioectasis was documented for each case. Lesions were then classified into the following segments of the gastrointestinal tract: esophagus, stomach, duodenum, jejunum, ileum, right colon and left colon. The location of lesions within the small bowel observed by capsule endoscopy was generally defined by percentage of total small bowel transit time with times of 0%-9%, 10%-39%, and 40%-100% corresponding to the duodenum, jejunum and ileum, respectively. Independent review of complete capsule studies allowed for deviation from this guideline if capsule passage was delayed in one or more segments. In addition, the location and number of angioectasias observed in the small bowel was further modified or confirmed by subsequent device-assisted enteroscopy (DAE) performed in the 83% of cases. In our study population, angioectasias were most commonly found in the jejunum (80%) followed by the duodenum (51%), stomach (22.8%), and right colon (11.4%). Only two patients were found to have angioectasias in the ileum (5.7%). Twenty-one patients (60%) had angioectasias in more than one location.

CONCLUSION: Patients being considered for endoscopic ablation of symptomatic angioectasias should undergo push enteroscopy or anterograde DAE and re-inspection of the right colon.

Double-balloon enteroscopy for obscure gastrointestinal bleeding: A single center experience in China

AIM: To evaluate the diagnostic value of double-balloon enteroscopy (DBE) for obscure gastrointestinal bleeding (OGIB).

METHODS: The data about 75 OGIB patients who underwent DBE in January 2007-June 2009 in our hospital were retrospectively analyzed.

RESULTS: DBE was successfully performed in all 75 patients without complication. Of the 75 patients, 44 (58.7%) had positive DBE findings, 22 had negative DBE findings but had potential bleeding at surgery and capsule endoscopy, etc. These 66 patients were finally diagnosed as OGIB which was most commonly caused by small bowel tumor (28.0%), angiodysplasia (18.7%) and Crohn’s disease (10.7%). Lesions occurred more frequently in proximal small bowel than in distal small bowel (49.3% vs 33.3%, P = 0.047).

CONCLUSION: DBE is a safe, effective and accurate procedure for the diagnosis of OGIB.

Moussa virus: a new member of the Rhabdoviridae family isolated from Culex decens mosquitoes in Côte d'Ivoire

Characterization of arboviruses at the interface of pristine habitats and anthropogenic landscapes is crucial to comprehensive emergent disease surveillance and forecasting efforts. In context of a surveillance campaign in and around a West African rainforest, particles morphologically consistent with rhabdoviruses were identified in cell cultures infected with homogenates of trapped mosquitoes. RNA recovered from these cultures was used to derive the first complete genome sequence of a rhabdovirus isolated from Culex decens mosquitoes in Côte d'Ivoire, tentatively named Moussa virus (MOUV). MOUV shows the classical genome organization of rhabdoviruses, with five open reading frames (ORF) in a linear order. However, sequences show only limited conservation (12-33% identity at amino acid level), and ORF2 and ORF3 have no significant similarity to sequences deposited in GenBank. Phylogenetic analysis indicates a potential new species with distant relationship to Tupaia and Tibrogargan virus.

Treatment decision for potential bleeders in obscure gastrointestinal bleeding during double-balloon enteroscopy

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.

Outcomes associated with deep enteroscopy

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

Enteroscopy in the diagnosis and management of obscure gastrointestinal bleeding

Capsule endoscopy and balloon-assisted enteroscopy, have revolutionized our approach to the diagnosis and management of patients with obscure gastrointestinal bleeding, largely replacing intraoperative enteroscopy and conventional barium studies. Despite its limitations, capsule endoscopy may well be the most reasonable initial diagnostic strategy to evaluate most patients with obscure gastrointestinal bleeding, leaving balloon-assisted enteroscopy in reserve as a complementary tool. This article reviews the data on enteroscopy, with particular emphasis on the use of capsule endoscopy and balloon-assisted enteroscopy for the diagnosis and management of patients with obscure gastrointestinal bleeding.

Cost-effectiveness analysis of management strategies for obscure GI bleeding

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

A prospective, single-blind trial comparing wireless capsule endoscopy and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding

BACKGROUND

Wireless capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are new methods enabling diagnostic endoscopy of the entire small intestine. However, which of the two is superior is unclear. We therefore prospectively compared the clinical efficacy of CE and DBE.

METHODS

We prospectively examined 32 patients with obscure gastrointestinal bleeding. CE preceded DBE by 1-7 days, and all patients underwent DBE twice, by antegrade and retrograde approaches, to evaluate the entire small intestine. Physicians evaluating the results of CE and DBE were blind to the results of the other method. We evaluated diagnosis, diagnostic yield of the two methods, and clinical outcomes.

RESULTS

CE revealed abnormal findings in 29 (90.6%) of 32 patients. CE definitively or probably detected the sources of bleeding in 23 (71.9%) of the 32 patients, including angioectasias (eight), erosions (seven), ulcers (five), tumor (one), and hemorrhagic polyps (two). DBE definitely or probably detected the sources of bleeding in 21 (65.6%) of the 32 patients, including angioectasias (seven), erosions (four), ulcers (five), tumor (one), hemorrhagic polyps (two) and diverticula (two). CE yielded more abnormal findings than DBE (CE 90.6%, DBE 65.6%) (P = 0.032), although there were no significant differences in diagnostic yield between the methods. We were able to perform additional treatment or biopsy with DBE in 13 patients, including coagulation therapy (ten), endoscopic mucosal resection (one), biopsy (seven), and extraction of retained CE (two).

CONCLUSIONS

Our results demonstrate the superiority of CE in detecting abnormal lesions, and the superiority of DBE in endoscopic management.

A multicenter randomized comparison of the Endocapsule and the Pillcam SB

BACKGROUND

Video capsule endoscopy has been shown to be the single most effective endoscopic procedure for identifying the source of obscure GI bleeding (OGIB).

OBJECTIVE

Our purpose was to report on the Food and Drug Administration pivotal trial in which the Endocapsule (EC) (Olympus America, Allentown, Pa) was compared with the Pillcam SB (PSB) (Given Imaging, Yoqneam, Israel) in patients with OGIB.

DESIGN

A novel trial design was used in which the EC and the PSB were swallowed by the same patient 40 minutes apart, in randomized order.

SETTING

Four academic medical centers.

PATIENTS

Patients with OGIB aged 18 to 85 years who had either been transfused or who had a hematocrit of <31% in males or <28% in females.

INTERVENTIONS

Both video capsules were swallowed in random order. Videos from the PSB were read locally for patient management. All videos were then read by at least 2 independent readers for normal versus abnormal categorization, a diagnosis, capsule transit time, reading time, and a subjective assessment of image quality.

MAIN OUTCOME MEASUREMENT

Categorization of videos as either normal or abnormal.

RESULTS

Data from 51 of 63 enrolled patients were analyzed. Nine patients were excluded for technical reasons and 3 for protocol violations. Twenty-four videos were read as normal and 14 as abnormal from both capsules. Disagreement occurred in 13. No adverse events were reported for either capsule. Overall agreement was 38 of 51 (74.5%) with a kappa of 0.48, P = .008.

LIMITATIONS

Although ingestion order was randomized, the videos could not be read blind owing to a different shape of the image margin.

CONCLUSIONS

(1) Both devices were safe and had a comparable diagnostic yield within the range previously reported. (2) There was a subjective difference in image quality favoring the EC. (3) This study design provided unique information about capsule movement in the small intestine and the lack of electromechanical interference between 2 different capsules.

Tratamento de hemorragia intestinal grave decorrente de hipertensão porta, por meio de esplenectomia subtotal e anastomose esplenorrenal proximal

OBJETIVO: Um dos maiores desafios no tratamento da hipertensão porta é o sangramento de varizes intestinais. O objetivo deste artigo é apresentar um novo tratamento para hemorragia entérica grave provocada por hipertensão porta cirrótica, utilizando a esplenectomia subtotal combinada com derivação esplenorrenal proximal. TÉCNICA: Uma paciente de 64 anos apresentou sangramento intenso proveniente de varizes em alça jejunal em Y de Roux, para derivação biliodigestiva, após lesão coledociana, complicada com cirrose hepática. O procedimento consistiu em esplenectomia subtotal, preservando o pólo superior do baço, suprido apenas pelos vasos esplenogástricos, e anastomose término-lateral da veia esplênica, em sua extremidade proximal, à veia renal esquerda. RESULTADOS: Esse procedimento foi seguro, sem sangramento maior, dificuldade técnica ou complicação. No acompanhamento de 30 meses, a paciente não teve novos episódios de sangramento, a cirrose não avançou e, atualmente, encontra-se bem, sob controle. CONCLUSÃO: A esplenectomia subtotal combinada com derivação esplenorrenal proximal é uma boa alternativa operatória para tratar hemorragia proveniente de varizes intestinais, decorrentes de hipertensão porta.

Subtotal splenectomy and central splenorenal shunt for treatment of bleeding from Roux en Y jejunal loop varices secondary to portal hypertension

PURPOSE

To present subtotal splenectomy and splenorenal shunt as a surgical option to treat severe bleeding from a Roux en Y jejunal loop varices secondary to portal hypertension.

METHOD

A 64-year-old white woman presented severe episodes of bleeding from varices inside a Roux en Y jejunal loop secondary to portal hypertension due to cirrhosis. Subtotal splenectomy was performed with preservation of the upper splenic pole supplied by the splenogastric vessels. This procedure was combined with a central splenorenal shunt to divert part of portal blood to systemic flow.

RESULTS

This procedure was safely performed with no complications. A 2-year post-operative follow-up of the patient has been uneventful. No re-bleeding occurred during this period and she returned to her normal life.

CONCLUSION

Subtotal splenectomy combined with central splenorenal shunt seems to be a safe procedure useful for the treatment of enteral bleedings due to portal hypertension.

Push enteroscopy in the era of capsule endoscopy

GOALS

To evaluate the diagnostic yield of push enteroscopy in relation to indication and compare the yield in patients who had capsule endoscopy followed by push enteroscopy against capsule endoscopy naive patients.

BACKGROUND

With the advent of capsule endoscopy the role of push enteroscopy needs to be reevaluated.

STUDY

Patients who underwent push enteroscopy from January 2002 to May 2006 were included.

RESULTS

One hundred fifty-five patients underwent push enteroscopy: 93 females, average age 55 years. There were 74 cases where both push enteroscopy (PE) and capsule endoscopy (CE) were performed. Indications for PE were iron deficiency anemia (n=51), overt bleeding (n=31), suspected celiac disease (n=32), refractory celiac disease (n=19), assessment for Crohn's disease (n=10), and miscellaneous (n=12). In 148 patients, an average length of 70 cm of small bowel was examined (range 30 to 130 cm). PE was unsuccessful in 7 patients due to anatomic strictures or patient distress. The overall diagnostic yield was 30% with the highest yield in overt bleeding when compared with other subgroups (P<0.001). Nine percent of lesions were within the reach of a standard endoscope. Comparison of the diagnostic yield in patients who had CE followed by PE against CE naive patients was 41% versus 47%, respectively (P<1). There were no cases where push enteroscopy recognized a lesion that had not been already detected by capsule endoscopy.

CONCLUSIONS

Push enteroscopy has the greatest diagnostic yield in patients with overt bleeding when compared with other referral indications. PE should be used as an adjuvant to CE for therapeutic intervention.

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

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

Clinical utility of double-balloon enteroscopy for small intestinal bleeding

Until the development of wireless capsule endoscopy (CE) and double-balloon enteroscopy (DBE), it was extremely difficult to examine the entire small intestine. To assess the usefulness of DBE for diagnosing suspected small intestinal bleeding, we retrospectively compared the diagnoses and treatments of cases before and after its introduction at one hospital. Between September 2003 and December 2005, 21 consecutive patients with suspected small intestinal bleeding underwent DBE at Tokai University Hospital (group A), and subsequently 2 were excluded from the study after being diagnosed with bleeding from a diverticulum and an angiodysplasia in the ascending colon, respectively. For comparison, inpatients who were negative for gastrointestinal bleeding on colonoscopy and gastroscopy between May 1998 and August 2003 were reviewed and 27 consecutive patients who had not undergone DBE were selected as the control group (group B). All patients had been diagnosed negative for a source of bleeding on more than one colonoscopy and gastroscopy. There were no significant differences between the two groups in terms of age, gender, history of blood transfusion, blood hemoglobin value on admission, or symptoms. The diagnostic yield of DBE in identifying the source of bleeding was 78.9%: six cases of small intestinal ulcers, five cases of angiodysplasia, two cases of hard submucosal tumor (SMT), one case of small pulsating SMT, and one case of small intestinal cancer. DBE was also used to successfully treat three cases of angiodysplasia with argon plasma coagulation. In the control group, conventional investigations, including enteroclysis, angiography, Meckel scan, scintigraphy with technetium-labeled red blood cells, and/or push enteroscopy, were performed in 88.9%, 29.6%, 29.6%, 55.6%, and 25.9%, respectively. The overall diagnostic yield of the conventional approaches was only 11.1% (P < 0.01), comprising a Meckel's diverticulum, a polyp, and an angiodysplasia. We conclude that DBE can be used to diagnose suspected small intestinal bleeding and to treat some cases, such as angiodysplasia.

How helpful is capsule endoscopy to surgeons?

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.

Capsule endoscopy changes patient management in routine clinical practice

Our objective was to evaluate the diagnostic yield and effect of capsule endoscopy on patient management in routine clinical practice. Three hundred examinations were performed (176 females; mean age, 51 years), with a median follow-up of 17 months. Indications included overt bleeding (n=55), anemia (n=104), suspected Crohn's disease (n=68), celiac disease (n=35), suspected functional symptoms (n=23), polyposis (n=5), and miscellaneous (n=10). The overall diagnostic yield was 39%, but it was notably higher in overt bleeders, 66%, compared to 46% in the anemia group (P<0.025), 32% in the suspected Crohn's group (P<0.001), and 17% in the functional group (P<0.001). As a result of capsule endoscopy, management was altered in 26% of patients. This study shows that capsule endoscopy has both a high diagnostic yield and an impact on subsequent patient management. These data further support the role of capsule endoscopy in routine clinical practice.

[Lower gastrointestinal bleeding: the great unknown]

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.

Wireless capsule endoscopy in children: a study to assess diagnostic yield in small bowel disease in paediatric patients

BACKGROUND AND AIM

Small bowel disease in the paediatric population is varied and to date has relied on indirect l modalities such as small bowel follow-through with attendant radiation exposure. Wireless capsule endoscopy (WCE) has the potential to provide a safer and more effective means of investigating the paediatric small bowel. The aim of our study was to prospectively assess the diagnostic yield of WCE compared with standard investigation in children with suspected small bowel disease.

METHODS

Twenty-eight consecutive patients, median age 12.5 y (range, 9.4-15.9) with suspected small bowel disease were investigated with WCE. This included 16 patients with suspected small bowel Crohn disease (CD) (10 newly diagnosed; 6 known cases), 6 with obscure or occult gastrointestinal bleeding (GIB), 3 with Peutz-Jegher polyposis (PJP), 2 with protein-losing enteropathy and 1 with recurrent abdominal pain. All of the patients had preceding upper gastrointestinal endoscopy (OGD) and ileocolonoscopy, and 24 had a barium meal and follow-through (BMFT). Images were downloaded and analysed and results compared with the endoscopic and radiological findings.

RESULTS

Three patients were unable to swallow the capsule (1 CD, 1 PJP and 1 GIB). Two of these patients (1 GIB, 1 PJP) had the capsule placed in the stomach endoscopically and completed the WCE uneventfully thereafter. In 3 patients (CD group) the capsule remained in the stomach and/or proximal duodenum and no small bowel images were obtained. Hence, 24 patients had successful completion of the WCE through the small bowel, 23 of whom had clinically relevant findings identified. In all patients with CD who had successful WCE studies (12/16), small bowel disease was identified (11/12 active disease, 1/12 chronic disease). A possible small bowel bleeding source was identified in all 6 patients with GIB. Two patients with GIB also underwent push enteroscopy and 1 of these had a bleeding source identified. The 2 patients with protein-losing enteropathy had extensive patchy lymphangiectasia of the jejunum and ileum, not detected at OGD. The patient with abdominal pain had an intussusception of the upper jejunum. The 2 PJP patients had small bowel polyps identified, which were not detected at BMFT. WCE was more sensitive for small bowel pathology than both BMFT (19 vs 5; 26% sensitivity compared with WCE) and endoscopic investigations (23 vs 10; 43.4% sensitivity compared with WCE). Two patients with CD had delayed capsule transit.

CONCLUSIONS

WCE led to a positive alteration in management in 18/24 (75%) of patients whose small bowel was examined by WCE and in 18/28 (64.3%) who were admitted to the study. WCE was safe, well tolerated, and more sensitive than radiological and standard endoscopic modalities in the detection of small bowel CD distribution, GIB source, and presence of polyps in children.

Ileus secondary to wireless capsule enteroscopy

Wireless capsule enteroscopy, being a novel, painless investigative technique, is reported to be significantly superior to push enteroscopy in its ability to find bleeding abnormalities in the small intestine. Here we report a case of acute jejunal obstruction following wireless capsule endoscopy. The patient had a 1-month history of gastrointestinal bleeding of unknown source. Further evaluation including gastroscopy and colonoscopy, angiography and computed tomography (angio-CT), and radio-labeled erythrocytes scan failed to reveal a source of bleeding. Therefore, wireless capsule enteroscopy was performed. Before capsule endoscopy, there was no clinical or imaging evidence of strictures or stenosis. At readmission it could be shown that there were two inflamed strictures of the small intestine. The capsule was detected at a stricture of the small intestine detected by abdominal ultrasonography and conventional computed tomography. The patient underwent a medical treatment with steroidal and other anti-inflammatory drugs for a total of 23 days and was discharged without complaints. Acute laparotomy after readmission with jejunal ileus proofed the capsule occluding two highly inflamed jejunal stenosis caused by Crohn disease. The present case demonstrates the potential for complications when wireless capsule enteroscopy is performed in the presence of intestinal strictures. Any history of inflammatory bowel disease, abdominal irradiation, cancer, obstruction, and abdominal surgery must be elicited in detail and may exclude the use of wireless capsule enteroscopy.

A patient with long-standing iron-deficient anemia

BACKGROUND

A 36-year-old Chinese woman presented with cutaneous lupus and was incidentally found to have iron-deficient anemia. She had a history of iron-deficient anemia 13 years previously, for which extensive investigations were carried out; the results of which were all normal. The patient also had pulmonary tuberculosis at that time, for which she received a full course of treatment. She required periodic blood transfusions and iron supplements to maintain her hemoglobin levels. She was subsequently discharged to a family clinic for follow-up until the current presentation.

INVESTIGATIONS

Upper endoscopy, colonoscopy, barium meal follow-through, small-bowel enema, (99m)Tc-labeled red-cell scan and double-balloon enteroscopy.

DIAGNOSIS

Iron-deficient anemia due to obscure gastrointestinal bleeding caused by two small-bowel hemangiomas.

MANAGEMENT

Laparoscopic surgery.

Capsule endoscopy versus push enteroscopy for evaluation of obscure gastrointestinal bleeding with 1-year outcomes

Because of the low diagnostic yield of standard radiologic tests for identifying sources of obscure gastrointestinal bleeding in the small intestine, we compared wireless video capsule endoscopy with push enteroscopy and small-bowel follow-through. Patients referred to Mayo Clinic, Scottsdale, Arizona, between August and December 2001 for evaluation of obscure gastrointestinal bleeding were potential candidates. Eligible patients had previously inconclusive endoscopy, colonoscopy, small-bowel follow-through, and other radiologic studies. Participants underwent capsule endoscopy and enteroscopy (within 24 hr). The primary end point was localization of any bleeding source, with 1-year telephone follow-up. Capsule endoscopy yielded positive findings in 10 of 20 patients (11 men; mean age, 69 years), 6 of whom had negative enteroscopy and small-bowel follow-through. No patient with negative findings on capsule endoscopy had positive findings on enteroscopy and small-bowel follow-through. At follow-up, 19 patients reported fewer transfusions, gastrointestinal procedures, and hospitalizations. Capsule endoscopy identified more lesions and improved outcomes.

The utility of capsule endoscopy and its role for diagnosing pathology in the gastrointestinal tract

BACKGROUND

Capsule endoscopy (CE) is a new device that enables visualization of areas of the small bowel that were previously inaccessible through other noninvasive procedures. The purpose of this study is to evaluate this new diagnostic tool and its efficacy in finding occult GI tract pathology.

METHODS

A single-institution retrospective review was completed on patients undergoing CE from January 2002 to September 2004. Data evaluated included indications for CE, results of previous studies, CE findings, and complications of the CE study.

RESULTS

A total of 702 CE studies in 652 patients were performed during the study period. Suspicious GI bleeding presenting as anemia, guaiac positive stools, or history of gross bleeding were the most common reasons to perform CE (75.8%). Other indications included abdominal pain (11.5%), diarrhea (3.1%), or others (9.5%). In studies performed for GI bleeding (N = 532), a source was found in 49.3% of CE studies. Arteriovenous malformation (AVM) was the most common reported finding (43.9%), followed by ulcer (24.1%), colon or gastric pathology (14.1%), mass/tumor (9.1%), and stricture (6.9%). Patients with abdominal pain (n = 81) had findings 46.9% of the time including edema/ulcer (47.4%), stricture (10.5%), mass/tumor (26.3%), gastric pathology (10.5%), AVM (2.6%), or sprue (2.6%). Patients with diarrhea (n = 22) had findings 45.5% of the time including edema/ulcer (75%), mass/tumor (12.5%), or sprue (12.5%). A total of 66 patients underwent operative exploration after a CE study at this institution either because of the observed findings or for other reasons. There were 12 (1.7%) CE studies in which the capsule was retained and required surgical removal. Pathology at the retention site included benign strictures or adhesions (n = 9, 75%), Crohn's stricture (n = 1, 8.3%) carcinoid tumor (n = 1, 8.3%), and villous adenoma (n = 1, 8.3%).

CONCLUSIONS

CE is an accurate study to locate abnormalities in the GI tract that may have either been missed by previous diagnostic studies or cannot be observed through other non-invasive means. When used for diagnostic challenges such as GI bleeding with no apparent source, CE can be helpful in guiding surgical decisions in patients and thus should be integrated as part of the diagnostic workup.

A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding

OBJECTIVE

Obscure gastrointestinal bleeding from jejunal and ileal lesions remains undiagnosed using traditional imaging techniques (radiologic, endoscopic). This prospective study compares the diagnostic detection rate of small-bowel lesions using wireless video capsule endoscopy (VCE) with the detection rate using double-balloon enteroscopy (DBE) in patients with obscure gastrointestinal bleeding (OGIB). Tolerance, adverse events, endoscopic interventions, and prognosis were described as secondary aims.

METHODS

Thirty-five consecutive patients with obscure gastrointestinal bleeding were evaluated (22 males and 13 females; mean age 63.2 yr; range, 19-86 yr). The detection rates of the Given M2A wireless VCE and DBE were compared.

RESULTS

Small-bowel abnormalities were detected using VCE in 28 (80%) of the 35 patients with OGIB, compared with 21 (60%) of the 35 patients using DBE (p = 0.01). Both examinations were well tolerated, but VCE was more acceptable to patients. No major adverse event occurred after either examination. Biopsies (n = 27), argon plasma coagulation (n = 19), tattoo injection (n = 8), and polypectomy (n = 2) were feasible with DBE when indicated in 27 of the 35 patients (77%). During a median (range) follow-up period of 5 (2-12) months, 26 (74%) patients remained clinically stable and did not require blood transfusions after DBE procedures. Eighteen (51%) of those who remained clinically stable had received APC therapy.

CONCLUSIONS

High detection rates of the causes of OGIB are feasible with VCE and DBE. Although the detection rate of VCE was superior, our results indicate that the procedures are complementary; an initial diagnostic imaging employing VCE might be followed by therapeutic and interventional DBE.

Investigation of the small bowel in gastrointestinal bleeding--enteroscopy and capsule endoscopy

The last frontier in luminal endoscopy has been conquered. Bleeding lesions in the small intestine can present a frustrating clinical problem, but recent advances have made investigating the small bowel easier and less invasive. Capsule endoscopy and double balloon enteroscopy are two new technologies that promise to lower the barrier to evaluation of the entire small intestine. Recent studies show that capsule endoscopy improves outcomes in patients who have OGIB. Although outcome studies regarding double balloon enteroscopy have not been performed, the opportunity to treat lesions throughout the small bowel without resorting to surgery is a tremendous advance. These improvements suggest that the corner may have been turned in the diagnosis and management of small bowel bleeding. Perhaps to the next generation of gastroenterologists, small bowel bleeding will not be obscure.

Wireless capsule endoscopy and double-balloon enteroscopy for the diagnosis of obscure gastrointestinal bleeding

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.

Capsule endoscopy for the diagnosis and follow-up of blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome is a rare disorder characterised by cutaneous and gastrointestinal vascular malformations. A 31-year-old man came under our observation with obscure gastrointestinal bleeding. Hemangiomas on his back and the multiple bluish vascular lesions in the distal ileum revealed by capsule endoscopy led to the diagnosis of blue rubber bleb nevus syndrome. The patient was treated with octreotide to prevent rebleeding. During the 12 months of treatment he had no gastrointestinal bleeding episodes or anaemia. Then repeat capsule endoscopy showed that the small bowel vascular lesions were unchanged. Capsule endoscopy may be a useful tool for diagnosing and monitoring the effects of therapy in patients with blue rubber bleb nevus syndrome.

Double balloon enteroscopy-the last blind-point of the gastrointestinal tract

Technical challenges have obstructed the diagnosis and treatment of small intestine disease. An innovative form of enteroscopy-the double balloon method-permits visualization of the complete small intestine, to-and-fro examination of an area of interest, and biopsy and endoscopic procedures which are safer, faster, and less painful than earlier methods. From October 2003 to May 2004, a total of 10 patients with obscure gastrointestinal bleeding received 12 enteroscopic examinations, 8 per oral and 4 per rectal examinations, while 2 patients received per oral enteroscopy first and further per rectal procedures 2 days later. Two cases with intestinal submucosal tumors were discovered by per oral enteroscopy, one with a 5-cm SMT with reddish mucosa at the jejunum and another with a 4-cm SMT and surface ulceration, in which the biopsy showed GIST. Both patients received an operation later. Four patients were found to have intestinal angiodysplasia in jejunum(per oral) and one in ileum (per rectal), and after local therapy bleeding stopped. Multiple angiodysplasias were observed in a patient who was operated on for active bleeding from the ileum after Indian ink tattooing. The two patients who received per oral and per rectal procedures did not display definite small intestinal lesions. All patients underwent the procedures satisfactorily without any complications, and the examination times varied from 90 to 360 min. Double balloon enteroscopy permits deep insertion of an endoscope into the small intestine without excessive stretching of the intestinal tract. This method can use either an oral or an anal approach. To-and-fro observation of almost the complete small intestine is possible, as are interventions.

Push enteroscopy alters management in a majority of patients with obscure gastrointestinal bleeding

INTRODUCTION

Although enteroscopy has been increasingly used to investigate occult or obscure bleeding, little is known about its impact on patient management. The aim of the present paper was to evaluate both the diagnostic yield and the impact of push enteroscopy on the management of patients referred to a tertiary Australian institution.

METHODS

Data were collected prospectively in all patients undergoing push enteroscopy at Royal Adelaide Hospital. Fifty-five patients were investigated for obscure gastrointestinal (GI) bleeding (25 women, mean age 65.6 years), the cause of which remained unknown despite previous gastroscopy and colonoscopy. The patients were divided into two groups: occult-obscure (anemia without macroscopic blood loss) and overt-obscure (macroscopic bleeding). Findings at enteroscopy, therapeutic procedures, and complications were recorded. Patients were followed to establish the impact of the procedure on subsequent management and clinical outcome.

RESULTS

Enteroscopy demonstrated a potential site of bleeding in 38 patients (69%), and 38% of lesions found were within the reach of the gastroscope. The most common lesions were small intestinal angiodysplasia. Seventy-five percent of patients with positive findings had alterations to their management. After subsequent treatment, 62% were no longer anemic and there was a significant reduction in rebleeding (P < 0.05) and transfusion requirements (P < 0.05) compared to patients with negative findings. The procedure was well tolerated and complications were rare.

CONCLUSION

Enteroscopy has a positive impact on patient management and clinical outcome in a majority of patients with obscure gastrointestinal bleeding.

Predictive factors of positive findings in patients explored by push enteroscopy for unexplained GI bleeding

BACKGROUND

The diagnostic yield of push enteroscopy (PE) in patients with unexplained overt GI bleeding is about 30%. The aim of this study was to assess for predictive factors of positive findings.

METHODS

A total of 182 patients referred to two endoscopic centers (European Georges Pompidou Hospital [Paris, France] and Erasmus Hospital [Brussels, Belgium]) for unexplained overt GI bleeding (melena [57%], hematochezia [26%], or hematochezia associated with melena [17%]) were included in this retrospective study. Predictive factors associated with positive findings at upper PE were studied by using uni- and multivariate analysis.

RESULTS

The overall diagnostic yield of upper PE was 34% (62/182), but lesions were found beyond the second duodenum in 25% of the patients (45/182). Factors significantly associated with positive findings at upper PE were the following. (1) In univariate analysis: the presence of melena, Hb level <7 g/dL, blood transfusion >4 units per patient, chronic renal failure, disorder of hemostasis or effective anticoagulant treatment, history of intestinal arteriovenous malformation, and age > 65 years. (2) In multivariate analysis: chronic renal failure and presence of melena. If only jejunal lesions were considered, chronic renal failure was the only predictive factor associated with positive findings at upper PE in multivariate analysis. The severity of GI bleeding did not reach statistical significance ( p = 0.06). Delay between GI bleeding and PE, number of previous standard endoscopies and previous episodes of bleeding were not associated with positive findings in upper PE.

CONCLUSIONS

In patients with unexplained overt GI bleeding, upper PE has a higher diagnostic yield in patients with chronic renal failure and patients with melena (vs. hematochezia).

Clinical outcomes of enteroscopy using the double-balloon method for strictures of the small intestine

AIM: To evaluate the clinical outcome of enteroscopy, using the double-balloon method, focusing on the involvement of neoplasms in strictures of the small intestine.

METHODS: Enteroscopy, using the double-balloon method, was performed between December 1999 and December 2002 at Jichi Medical School Hospital, Japan and strictures of the small intestine were found in 17 out of 62 patients. These 17 consecutive patients were subjected to analysis.

RESULTS: The double-balloon enteroscopy contributed to the diagnosis of small intestinal neoplasms found in 3 out of 17 patients by direct observation of the strictures as well as biopsy sampling. Surgical procedures were chosen for these three patients, while balloon dilation was chosen for the strictures in four patients diagnosed with inflammation without involvement of neoplasm.

CONCLUSION: Double-balloon enteroscopy is a useful method for the diagnosis and treatment of strictures in the small bowel.