A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding

Although the role of emergency esophagogastroduodenoscopy (EGD) and colonoscopy for upper and lower gastrointestinal bleeding (GIB) is well defined, there are no data on the concept of emergency double-balloon enteroscopy (DBE) for small-bowel bleeding. The aim of this study was to retrospectively evaluate the concept of emergency DBE in overt obscure GIB and assess its impact on patient management. A total of 17 emergency DBEs for overt obscure GIB were carried out in ten patients (six women, four men; mean age 68 years, range 35 - 83). The following diagnoses were made: actively bleeding Dieulafoy lesions of the small bowel, n = 2; bleeding tumors, n = 4 (carcinoids n = 2, adenocarcinoma n = 1, lipoma n = 1); bleeding angiodysplasias and/or large arteriovenous malformation (AVM), n = 2; multiple ulcers, n = 1; and no diagnosis, n = 1. Endoscopic therapies included argon plasma coagulation (n = 6), injection of epinephrine (n = 3), and use of fibrin glue (n = 1). It appears that emergency DBE is technically feasible, facilitates both diagnosis and therapy and enables management of patients with massive overt obscure GIB. This study is a first step in establishing the concept of emergency DBE for patients with suspected small-bowel bleeding.

Double-balloon enteroscopy-assisted virtual chromoendoscopy for small-bowel disorders: a case series

The Fujinon intelligent color enhancement (FICE) system is a new, virtual chromoendoscopy technique that enhances mucosal visibility. The aim of this study was to assess the utility of double-balloon enteroscopy (DBE) with FICE technology (EPX-4400 processor, Japan) for the characterization of various small-bowel diseases. Overall, a total of 574 endoscopic pictures were obtained and analyzed. FICE was found to be a helpful method for the evaluation of adenomatous small-bowel polyps and angiodysplasias. Its use for the characterization of celiac and Crohn's disease appears to be limited. Overall, FICE may become a useful method that aids in characterization and provides new insights to small-bowel pathologies.

[Catheter-free pH-metry using the Bravo capsule versus standard pH-metry in patients with non-erosive reflux disease (NERD)]

BACKGROUND

pH-monitoring is considered the gold standard for the detection of acid reflux in patients with non-erosive reflux disease (NERD). Preliminary pH studies performed over periods longer than 24 hours have shown that in up to one-third of subjects abnormal pH exposure is detected only on the second day of monitoring. Therefore, pH-monitoring during 48 hours may yield more information about pathological acid reflux in patients being investigated for NERD.

AIM

The aim of this study was to compare conventional 24-hour pH-monitoring with the new wireless 48-hour Bravo pH-monitoring in patients with NERD.

PATIENTS AND METHODS

Patients with typical reflux symptoms, a positive reflux disease questionnaire and negative endoscopy (NERD) and without any form of acid suppressive therapy were included in this prospective study. The patients were divided into two groups: group A for conventional 24-hour pH-monitoring and group B for wireless 48-h Bravo pH-monitoring.

RESULTS

76 patients with a diagnosis of NERD based on a positive RDQ questionnaire and negative endoscopy were included. (47 woman, 29 men, median age: 49 years). 54 underwent conventional pH-monitoring and 22 underwent 48-h pH-monitoring with the new wireless BRAVO system. The overall incidence of acid reflux was 55 % in patients with NERD. Acid reflux was detected less frequently when using Bravo as compared to conventional pH-monitoring. In addition, the Bravo pH-metry showed a large day-to-day variability.

CONCLUSIONS

Prolonged pH-monitoring over a period longer than 24 hours did not improve the detection of acid reflux in patients with NERD. Thus, it appears that the Bravo pH-metry does not offer an advantage over standard pH-metry in the daily clinical practice.

Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding

BACKGROUND

Double-balloon enteroscopy (DBE) is a useful method for evaluation of obscure gastrointestinal bleeding (OGIB).

AIM

To determine the incidence of lesions within reach of conventional upper and lower endoscopes as the cause of OGIB in patients referred for DBE.

METHODS

All patients undergoing DBE for OGIB during a 3.5-year period at a university hospital were studied. OGIB was defined according to American Gastroenterological Association (AGA) guidelines.

RESULTS

One hundred and forty-three DBEs were performed in 107 patients for obscure overt (n=85) and obscure occult (n=22) GIB. Lesions outside the SB as possible sources of GIB were found in 51 patients (47.6%) and a definite source of bleeding outside the small bowel (SB) was detected in 26 patients (24.3%). Lesions considered to explain a definite source of GIB were: gastric ulcer (n=3), duodenal ulcer (n=3), Cameron's lesions (n=2), gastric antral vascular ectasias (n=4), radiation proctitis (n=1), radiation ileitis (n=2), duodenal angiodysplasias (n=1), haemorrhoids with stigmata of recent bleed (n=1), colon angiodysplasias (n=3), colon diverticulosis (n=3), colonic Crohn's disease (n=1), anastomotic ulcers (n=1).

CONCLUSIONS

The frequency of non-SB lesions definitely explaining the source of GIB in patients referred for DBE was 24.3%. Therefore, repeat esophago-gastroduodenoscopy (EGD) and ileocolonoscopy should be taken into consideration before DBE.

Small bowel polyps and tumours: endoscopic detection and treatment by double-balloon enteroscopy

BACKGROUND

Double-balloon enteroscopy has allowed us not only to inspect deeply the small bowel but also to carry out interventions for diseases of the small bowel.

AIM

To evaluate the utility of double-balloon enteroscopy for the diagnosis and therapy of these lesions.

METHODS

All patients undergoing double-balloon enteroscopy for evaluation of small bowel polyps and tumours during a 3.75-year period at a university referral hospital were studied. The types of polyps and tumours as well as endoscopic technique of removal, surgery and complications were documented.

RESULTS

The incidence of small bowel polyps and tumours in-patients undergoing DBE was 9.6%. A total of 40 double-balloon enteroscopy procedures were performed in 29 patients [13 female (44.8%), mean age 51 years, range 22-74]. The following lesions were found most frequently: adenomas in familial adenomatous polyposis syndrome, n = 8; hamartomas, n = 4 (Peutz-Jeghers and Cronkhite Canada syndromes), jejunal adenocarcinoma n = 5, neuroendocrine tumour n = 4 and others n = 6.

CONCLUSIONS

The incidence of small bowel tumours in those in-patients who were undergoing double-balloon enteroscopy was 10%. Double-balloon enteroscopy is useful for the diagnosis and treatment of small bowel polyps and tumours.

Incidence, clinical management and outcomes of esophageal perforations after endoscopic dilatation

BACKGROUND

Esophageal dilatation is performed for the treatment of anatomic and sometimes functional narrowing of the esophageal lumen caused by a variety of benign and malignant conditions. Esophageal perforation is the major complication associated with endoscopic dilatation.

AIM

The object of this study was to assess the incidence of perforation, management and outcomes after endoscopic esophageal dilatation.

METHODS

All patients who underwent endoscopic esophageal dilatation at our institution from June 2001 to December 2006 were identified. Data were obtained by searching our prospectively collected electronic database (MEDOS AG, Langenselbold, Germany), which includes all endoscopic reports as well as discharge summaries of patients who have undergone endoscopy in our department.

RESULTS

248 patients (148 male, 100 female, mean age 58 years, range 14-87 years) underwent 365 esophageal dilatations: 74 pneumatic balloon dilatations for achalasia, 79 balloon dilatations for other reasons such as tumors, peptic stenosis, or post-radiotherapy stenosis and 212 dilatations with Savary bougies. The overall incidence of perforation based on the number of procedures was 2.2% (8 perforations/365 procedures) and 3.2% (8/248 patients) based on the number of patients. The perforation rate was 1.9% for bougie dilatation, 0% for balloon dilatation and 5-4% for pneumatic balloon dilatation for achalasia. Five patients were treated surgically and 3 patients were managed conservatively. The mean hospital stay was 14 days (7-33 days). One patient in whom the perforation was recognized 16 days after the dilatation died.

CONCLUSIONS

Endoscopic esophageal dilatation is a safe procedure for the palliation of malignant strictures, for the management of benign strictures as well as for the therapy of achalasia. The perforation rate after these procedures is low. Early recognition of the perforation is associated with a good outcome. Small perforations can be treated conservatively.

Characterization of yellow plaques found in the small bowel during double-balloon enteroscopy

BACKGROUND AND STUDY AIMS

The aim of this study was to characterize yellow (or whitish) plaques of the small bowel that were found during double-balloon enteroscopy (DBE) performed for small-bowel evaluation.

PATIENTS AND METHODS

Patients who were being evaluated for small-bowel pathology at our institution (for a variety of indications) were included in the study. In 16 patients, DBE revealed yellow or whitish submucosal plaques, defined as small, raised, submucosal lesions that were well circumscribed and covered by normal-appearing small-bowel mucosa. Biopsy tissue obtained during the procedures was stained with hematoxylin and eosin and with periodic acid-Schiff stain, and was subjected to immunochemical testing using endothelial markers (anti-CD31 and anti-CD34).

RESULTS

These 16 patients were identified out of a total of 150 DBE procedures performed in 120 patients (eight men, eight women; mean age 62, range 33 - 78). The lesions were mostly single (range 1 to > 5 lesions), ranging in size from 2 mm to 15 mm, and were slightly raised (from 1 mm to 2 mm). In four cases the plaques could not be biopsied because the patient had a coagulation disorder or because the DBE was being performed to investigate severe acute bleeding. In the other 12 patients, a characteristic white-yellow liquid exudated from the biopsy site in 80 % of lesions, and these 12 patients were shown to have lymphangiectasias. No association with an infiltrative disorder could be detected.

CONCLUSIONS

Yellow and white submucosal plaques are found in up to 13 % of patients undergoing DBE. They are most likely to be lymphangiectasias and are a normal anatomical variant. They do not require further work-up.

Severe Gastrointestinal Disease Due to HIV-1-Seronegative AIDS

An HIV-1 seronegative man presented with odynophagia, dysphagia, diarrhea, tenesmus and a 50-lb weight loss. A large esophageal ulcer and a rectal fissure were identified endoscopically. Stool samples and biopsy specimens from the esophageal ulcer, duodenum, colon and rectum were negative for pathogens. Seronegative AIDS was suspected, and high levels of HIV-1 mRNA (> 242,000 copies/mL) were detected. The esophageal ulcer responded to oral steroids and the HIV-1 infection to highly active anti-retroviral therapy (HAART). The virus isolated from the patient and an HIV-1 seropositive, asymptomatic, female sex worker with whom he had recently terminated a one-year heterosexual relationship showed sequence homology, indicating her as the source of his virus. The unusual presentation of severe gastrointestinal disease in an HIV-1 seronegative man with HIV-1 viremia underscores the importance of including AIDS in the differential diagnosis of wasting syndrome (i. e., B-type symptoms such as fever, night sweats, weight loss) in patients who are HIV-1 seronegative but at risk for AIDS.

Feasibility of double-balloon enteroscopy-assisted chromoendoscopy of the small bowel in patients with familial adenomatous polyposis

BACKGROUND AND STUDY AIMS

Patients with familial adenomatous polyposis (FAP) are at increased risk of developing duodenal and jejunal adenocarcinomas. The aim of this study was to assess the usefulness of double-balloon enteroscopy- (DBE-) assisted chromoendoscopy for the detection and characterization of small-bowel polyps in patients with FAP.

PATIENTS AND METHODS

We performed a prospective evaluation of patients with clinically and genetically proved FAP who were enrolled in an endoscopic surveillance program. DBE was performed using a Fujinon intestinoscope (FN 450P 5/20; Fujinon Corp., Omiya, Japan), and chromoendoscopy was performed using indigo carmine. The severity of small bowel polyposis was based on the Spigelman-Saurin classification.

RESULTS

Nine patients underwent DBE-assisted chromoendoscopy. Small-bowel polyps (including papillary adenomas) were detected in seven patients (88 %). The mean depth of small-bowel insertion was 180 cm (range 120-320 cm). The mean Spigelman-Saurin score was 4.6 (range 0-8). Jejunal polyps were detected in six patients (67 %). Chromoendoscopy aided in the detection of additional polyps in two patients. In one patient the polyps were flat and only visible with chromoendoscopy (biopsy confirmed these to be adenomas). Jejunal polyps and advanced neoplasms were more frequent in patients with APC gene mutations in exon 15. The following endoscopic therapies were performed: polypectomy (n = 1), duodenal mucosectomy (n = 1), and ablation therapy with argon plasma coagulation (n = 2).

CONCLUSIONS

DBE was found to be a helpful method for the evaluation of small-bowel polyps in patients with FAP. DBE-assisted chromoendoscopy was of further assistance for the detection of jejunal polyps.

The yield of capsule endoscopy in patients with abdominal pain or diarrhea

BACKGROUND AND STUDY AIMS

Capsule endoscopy, proven effective for evaluation of obscure gastrointestinal bleeding and suspected Crohn's disease, is increasingly used to investigate other small-intestine disorders, but its yield for other indications is not well known. We sought to evaluate its yield and findings for abdominal pain or diarrhea.

PATIENTS AND METHODS

Medical records of patients with abdominal pain or diarrhea (> 6 weeks' duration) who underwent capsule endoscopy between August 2001 and June 2004 were retrospectively reviewed for demographic data, indications, findings, diagnoses, complications, and radiologic studies. All patients had previous endoscopic or radiologic examinations (colonoscopy, enteroscopy, upper endoscopy, small-bowel series, computed tomography enterography, or computed tomography) demonstrating no abnormalities sufficient for diagnosis.

RESULTS

64 patients (26 men; 38 women; mean age, 43 years; age range, 19 - 83 years) who met study criteria had 68 capsule endoscopy studies. Indications were abdominal pain (35 patients), diarrhea (14), or both (15). Complete small-bowel visualization with identification of the cecum was achieved in 81 %; yield of positive findings was 9 % (6 patients). By indications, the yield was 6 % for abdominal pain, 14 % for diarrhea, and 13 % for both. Diagnoses included Crohn's disease (3), enteropathy induced by nonsteroidal anti-inflammatory drugs (2), and submucosal tumor (1). Capsule retention occurred in two patients, requiring surgical removal.

CONCLUSIONS

Capsule endoscopy had a low yield for evaluation of abdominal pain or diarrhea and cannot be recommended as a first-line test without further study. Nonetheless, it facilitated diagnosis in 9 % of patients with negative endoscopic and radiologic examinations.

Diagnostic and therapeutic impact of double-balloon enteroscopy

BACKGROUND AND STUDY AIMS

Double-balloon enteroscopy (DBE) is a new endoscopic method for examining the small intestine. Most reports of DBE have been from Japan, and very few data on this new technique have been reported by centers outside Japan. The aim of the present study was to determine the diagnostic yield of DBE, measure the frequency of management changes made on the basis of the results, and evaluate the clinical outcome for patients undergoing the procedure.

PATIENTS AND METHODS

All patients undergoing DBE using a Fujinon enteroscope (length 200 cm, diameter 8 mm) during a 11-month period were studied. All of the patients had previously undergone esophagogastroduodenoscopy and colonoscopy. They underwent small-bowel cleansing on the day before the procedure using a standard colon lavage solution.

RESULTS

Seventy DBE procedures were carried out in 53 patients (34 men, 19 women; mean age 60 years, range 24 - 80) by the oral route in 46 cases and the anal route in 24. The indications for the examination were gastrointestinal bleeding (n = 29), suspected Crohn's disease (n = 6), abdominal pain (n = 4), polyp removal or evaluation in polyposis syndromes (n = 6), chronic diarrhea (n = 4), and surveillance or tumor search (n = 4). The mean duration of the procedure was 72 min (range 25 min - 3 h). The mean radiation exposure was 441 dGy/cm (range 70 - 1462), and the mean depth of small-bowel insertion was 150 cm (range 1 - 470 cm). It was possible to evaluate the entire small bowel in four patients (8 %). A new diagnosis was obtained in 26 of the 53 patients (49 %). The findings in the 70 procedures were angiodysplasia (n = 13), ulcerations or erosions (n = 5), jejunitis or ileitis (n = 5), tumors (n = 5), stenosis (n = 4), polyps (n = 5), lymphangiectasias (n = 4), Crohn's disease (n = 4), and normal (n = 17). DBE resulted in a therapeutic intervention (endoscopic, medical or surgical, excluding blood transfusions) in 57 % of the patients (30 of 53). The only complication (1.4 %) observed was one case of intraprocedural postpolypectomy bleeding, which resolved with injection of epinephrine.

CONCLUSION

In almost two-thirds of the patients examined, DBE was clinically useful for obtaining a new diagnosis and starting new treatments, changing existing treatments, carrying out surgical intervention, or providing therapeutic endoscopy. DBE is a useful and safe method of obtaining tissue for diagnosis, providing hemostasis, and carrying out polypectomy.

Impaction and fracture of a video capsule in the small bowel requiring laparotomy for removal of the capsule fragments

Capsule endoscopy has become an important diagnostic tool because of its high sensitivity and specificity for evaluation of the small-bowel mucosa. It is usually a safe procedure. The main complication has been retention of the video capsule in patients with unsuspected obstructive small-bowel disease. We describe a case of a 76-year-old man who underwent capsule endoscopy for the investigation of chronic abdominal pain. The patient returned several months after the procedure with recurrence of his symptoms. Investigations at that time showed that the capsule had been retained in a section of the distal ileum which showed stricture formation and that it had broken up into fragments. This is the first reported case of a fractured video capsule.

Histological quality of polyps resected using the cold versus hot biopsy technique

BACKGROUND AND STUDY AIMS

The monopolar hot biopsy technique is a widespread method of removing and cauterizing small colonic polyps. Due to the insulated cups of the biopsy forceps, it also allows adequate histological interpretation of the resected specimen. In our experience, polyps removed using the monopolar hot biopsy technique have been less histologically interpretable in comparison with polyps removed using cold biopsy forceps. The aim of this study was to assess and compare the diagnostic quality of polyps obtained using the hot biopsy and cold biopsy techniques.

PATIENTS AND METHODS

This was a prospective study of consecutive patients undergoing colonoscopy with removal of polyps using either hot biopsy or cold biopsy techniques. One experienced endoscopist using the same techniques carried out the biopsies. An experienced gastrointestinal pathologist, blinded to the technique used, evaluated the specimens for diameter, artifacts, cautery damage, tissue fragmentation, and general histological and diagnostic quality. Statistical analysis was carried out using the chi-squared test, Fisher's exact test, and Student's t-test.

RESULTS

Forty-three consecutive patients (84 % men; mean age 63.8 +/- 15 years) underwent 88 biopsies (45 hot biopsies and 43 cold biopsies). There were no statistically significant differences between the two study groups with regard to demographic data, indications for colonoscopy, endoscopic findings, or polyp size. Cautery damage, architectural distortion, and tissue fragmentation occurred more frequently in polyps resected using the hot biopsy technique ( P < 0.001).

CONCLUSIONS

The quality of the specimens removed by cold biopsy was generally better than when using hot biopsy technique. Histological evaluation is more difficult in polyps resected with the hot biopsy technique in comparison with the cold biopsy technique. When the nature of polyps affects the patient's management, a biopsy may be obtained before polyp coagulation.