Video push enteroscopy in the investigation of small bowel disease: defining clinical indications and outcomes

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.

Obscure recurrent gastrointestinal bleeding: a revealed mystery?

OBJECTIVE

Nowadays, capsule endoscopy (CE) is the first-line procedure after negative upper and lower gastrointestinal (GI) endoscopy for obscure gastrointestinal bleeding (OGIB). Approximately, two-thirds of patients undergoing CE for OGIB will have a small-bowel abnormality. However, several patients who underwent CE for OGIB had the source of their blood loss in the stomach or in the colon. The aim of the present study is to determine the incidence of bleeding lesions missed by the previous gastroscopy/colonoscopy with CE and to evaluate the indication to repeat a new complete endoscopic workup in subjects related to a tertiary center for obscure bleeding before CE.

METHODS AND METHODS

We prospectively reviewed data from 637/1008 patients underwent to CE for obscure bleeding in our tertiary center after performing negative gastroscopy and colonoscopy.

RESULTS

CE revealed a definite or likely cause of bleeding in stomach in 138/637 patients (yield 21.7%) and in the colon in 41 patients (yield 6.4%) with a previous negative gastroscopy and colonoscopy, respectively. The lesions found were outside the small bowel in only 54/637 (8.5%) patients. In 111/138 patients, CE found lesions both in stomach and small bowel (small-bowel erosions in 54, AVMs in 45, active small-bowel bleeding in 4, neoplastic lesions in 3 and distal ileum AVMs in 5 patients). In 24/41 (58.5%) patients, CE found lesions both in small bowel and colon (multiple small-bowel erosions in 15; AVMs in 8 and neoplastic lesion in 1 patients. All patients underwent endoscopic therapy or surgery for their nonsmall-bowel lesions.

CONCLUSIONS

Lesions in upper or lower GI tract have been missed in about 28% of patients submitted to CE for obscure bleeding. CE may play an important role in identifying lesions missed at conventional endoscopy.

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.

Antegrade double balloon enteroscopy for continued obscure gastrointestinal bleeding following push enteroscopy: is there a role?

BACKGROUND

The benefit of double balloon endoscopy (DBE) over push enteroscopy (PE) for the proximal small bowel in patients with obscure gastrointestinal bleeding remains unclear.

AIM

To quantify the benefit of DBE if PE fails to benefit patients with obscure gastrointestinal bleeding.

METHODS

This retrospective DBE database review between July 2004 and April 2008 was conducted at a tertiary university hospital in Australia. Thirty-three patients with obscure gastrointestinal bleeding who had undergone PE for proximal small bowel lesions were identified from a DBE database of 280 patients. Mean age was 68.6 (range 30-91) years, and 17 were men. In group A (n = 15) the target lesion was not reached by PE, and in group B (n = 18) an abnormality was found by PE (angioectasia in 17 and red spots in 1) but the patient had ongoing bleeding. Mean follow-up for the cohort was 19.2 (range 5-39) months. DBE interventions were performed as appropriate.

RESULTS

An abnormality was found at DBE in 28/33 (85%) patients. DBE found an abnormality in 12/15 (80%) in group A and 16/18 (89%) in group B. Endoscopic intervention was performed in 23/33 patients (70%). In 27/33 (82%) patients a clinical benefit was seen following DBE. Six patients (18%) had no clinical benefit from DBE.

CONCLUSIONS

In patients with obscure gastrointestinal bleeding and proximal small bowel lesions who fail to benefit from PE, DBE offers a very high benefit in finding and treating lesions with good long-term outcomes.

[Endoscopy of the small bowel: light into the dark]

Since the introduction of capsule endoscopy and later balloon enteroscopy in clinical practice, endoscopic examination of the small bowel has dramatically improved. For the first time, it is possible to diagnose the whole small bowel without the necessity of laparotomy and intraoperative enteroscopy. The methods revolutionized the field of small bowel diagnostic and therapy and become part of daily clinical practice. This article provides a review of small bowel enteroscopic methods.

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.

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.

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.

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.

Non-small-bowel lesions detected by capsule endoscopy in patients with obscure GI bleeding

BACKGROUND

Approximately two thirds of patients undergoing capsule endoscopy for obscure GI bleeding will have an abnormality found in the small intestine. This report describes 9 patients (4 men, 5 women) of 140 with obscure bleeding in whom a source of their blood loss was found in the stomach or the colon at capsule endoscopy.

METHODS

A review was made of a prospective database of 140 consecutive patients undergoing capsule endoscopy for obscure GI bleeding at a single center. Patients with a definite or likely cause of bleeding within reach of conventional upper or lower GI endoscopy were identified.

RESULTS

Three patients had gastric antral vascular ectasia and another an inflamed pyloric canal polyp. Two patients had actively bleeding cecal carcinoma, missed at previous colonoscopies. Two others had bleeding cecal angiodysplasia. The final patient had severe nonspecific cecal inflammation. The identification of these lesions was aided by the suspected blood indicator. All patients underwent endoscopic therapy or surgery for their non-small-bowel lesions.

CONCLUSIONS

Like push enteroscopy, capsule endoscopy also can identify lesions within reach of conventional endoscopy and colonoscopy. These subsequently can be treated successfully. The reasons why these lesions have been missed are unclear.

Small Bowel Adenocarcinoma: A Rare but Aggressive Disease

Unlike the colon and rectum, the small intestine is associated with a very low rate of tumor occurrence. Adenocarcinomas represent the most frequent of these rare digestive tumors and are often fatal as a result of tardy diagnosis. Regardless of the stage, surgery usually remains the cornerstone of small bowel adenocarcinoma therapy. Because of the rarity of the disease, very few significant clinical trials have identified any efficient nonsurgical treatment; however, recent data indicate these tumors might be sensitive to chemotherapy alone or in association with radiation therapy. Conversely, a great deal of progress has been achieved in diagnosis of the tumor, whether by adaptation of existing techniques or development of new ones. We reviewed the clinical aspects of this rare but aggressive disease, focusing on new diagnostic procedures as well as on recent advances in their therapeutic management.

Push enteroscopy in a UK district general hospital: experience of 51 cases over 2 years

OBJECTIVES

To determine the number of patients referred for enteroscopy in a district general hospital (DGH), the indication, enteroscopic +/- histological diagnosis, and to compare findings with other series from tertiary referral centres or outside the UK.

DESIGN

Retrospective case series over a 2-year period.

RESULTS

In the 2-year period, 52 patients were referred for enteroscopy. All except one underwent enteroscopy. The mean age of the patients was 60 years (range 31-84 years). The main indications for enteroscopy were obscure gastrointestinal haemorrhage in 31 (61%) patients (19 with acute and 12 with chronic bleeding) and 7 (14%) patients with arteriovenous malformations (AVMs) on initial oesophagogastroduodenoscopy (OGD). Other indications included clinical deterioration in known coeliac disease in four (8%) patients and abnormal small-bowel follow-through in five (10%) patients. More than half (51%) of the enteroscopies were reported as abnormal, but 10 (38%) had pathology in the stomach or first part of the duodenum (D1) not diagnosed on initial OGD. Diagnoses of two T-cell lymphomas and one of pre-lymphomatous monoclonal T-cell proliferation were made in the refractory coeliac disease group.

CONCLUSIONS

Indications (obscure gastrointestinal bleeding), most frequent findings (small-bowel AVMs), and 'missed' lesions within reach of a gastroscope (20%) were in keeping with other series. Enteroscopy is a useful tool in investigating patients with refractory coeliac disease. Its value in investigating patients with abnormal small-bowel radiology was not confirmed. The current need for push enteroscopy in a DGH is small (approximately 1 per 8000 population per year), but it would take only small changes in referral practice to escalate. Criteria for enteroscopy should be developed and refined with improving knowledge of the diagnostic yield for each indication and clinical outcome.

Enteroscopy

It is now more than 25 years since small bowel enteroscopy (SBE) was first described. For several reasons, this technique developed more slowly than other more usual forms of endoscopy. First, small bowel disease is relatively rare in comparison with other gastrointestinal diseases. Also, there was lack of initial design agreement, and three different types of enteroscopes were developed within a short time of each other, two of which (push-type and sonde) are now available commercially. Finally, commercial interests of the manufacturers of endoscopes were mainly focused on the more conventional, large volume markets. In the last few years, specifically designed modern small bowel enteroscopes have become available and, in centers that have access to them, they have superseded attempts at SBE using adult or pediatric colonoscopes. There are now clear indications for SBE, such as: the investigation of obscure causes of bleeding and anemia; malabsorption; clarification of x-ray abnormalities; and, increasingly, the application of therapeutic endoscopy to lesions within the small bowel. Problem areas remain, but with advancing technology and more professional interest in this area, these will be addressed during the next few years.

The small bowel as a source of gastrointestinal blood loss

The small bowel is a rare but important source of blood loss from the gastrointestinal (GI) tract. In approximately 5% of all patients with GI bleeding, no cause for the bleeding is evident even after an extensive workup. This bleeding is often termed "gastrointestinal bleeding of obscure origin" or "obscure gastrointestinal bleed" (OGIB). Recent advancements in enteroscopy have contributed to a better understanding of the small bowel as a source of bleeding. On average, 27% of patients with OGIB have been shown to have lesions in the small bowel, with common findings including arteriovenous malformations (AVMs) and small bowel tumors. The trend in primary diagnostic workup for obscure GI bleeding or suspected small bowel lesions is shifting toward enteroscopic examination. Availability of an accessory channel now offers the clinician management options such as endoscopic injection therapy, electrocautery, and polypectomy. The "gold standard" for examination of the entire small bowel is intraoperative enteroscopy. A newer technique involving laparascopic assistance may lower the morbidity associated with this examination. Combined hormonal therapy may be an alternative treatment for patients with AVMs or an unknown cause of bleeding after enteroscopic examination.