Total intraoperative enteroscopy using a colonoscope for detecting the bleeding point

We report a case of bleeding in the small intestine of a 59-year-old man that was successfully diagnosed and treated by total intraoperative enteroscopy. The patient was admitted to our hospital because of gastrointestinal bleeding. Gastroscopy, colonoscopy and mesenteric arteriography could not identify the bleeding point. Technetium-99m-labeled red blood cell scintigraphy suggested bleeding from the small intestine but could not reveal the precise lesion. As the patient presented melena and went into a state of shock, we performed emergency laparotomy with total intraoperative enteroscopy using a colonoscope. A small ulceration was found at the jejunum, and subsequently partial resection of the jejunum was performed. The lesion was diagnosed histopathologically as angiodysplasia. The patient recovered uneventfully and was discharged on the 24th postoperative day. Bleeding in the small intestine is rare and difficult to diagnose but it sometimes induces a severe condition. Total intraoperative enteroscopy using a colonoscope is effective for detecting the bleeding point in the small intestine and can be performed at most centers without special fiberscopes and techniques.     

A prospective comparison of capsule endoscopy and push enteroscopy in patients with GI bleeding of obscure origin

BACKGROUND: Capsule endoscopy is used to investigate the small bowel in patients with GI bleeding of obscure etiology. Capsule endoscopy was compared prospectively with push enteroscopy in 20 patients with GI hemorrhage. METHODS: Twenty patients (8 men, 12 women; mean age 65.5 years, range 38-80 years) were enrolled in the study. All had undergone non-diagnostic EGD, colonoscopy, and barium contrast radiography of the small bowel. All patients underwent capsule endoscopy followed by push enteroscopy. The physician performing the enteroscopy (senior endoscopist) interpreted the capsule endoscopy in an unblinded manner, while a second blinded reviewer (endoscopy fellow) interpreted the capsule endoscopy to establish interinterpreter reliability. RESULTS: There was complete agreement between the blinded and the unblinded physicians in 18 of 20 cases; minor disparities were noted in the remaining two cases. In the small bowel, capsule endoscopy identified positive findings in 14 (70%) patients, whereas, push enteroscopy identified positive findings in 5 (25%) patients. Despite these results, the findings were definitive in only 6 of the 20 patients by using capsule endoscopy, and in two of 20 patients with push enteroscopy. CONCLUSIONS: When strict standards of interpretation were used, capsule endoscopy resulted in more positive findings than push enteroscopy, but the number of definitive findings for both imaging methods was low. There was a high degree of reliability between a novice and an experienced endoscopist with respect to the interpretation of capsule endoscopy.     

Push enteroscopy for gastrointestinal bleeding: diagnostic yield and long-term follow-up

AIM: Little is known about the long-term course of patients explored by push enteroscopy for gastrointestinal bleeding of obscure origin. This study aimed to determine the diagnostic yield and the therapeutic impact of enteroscopy, the rate of rebleeding and predictive factors of rebleeding in these patients. PATIENTS AND METHODS: One hundred nineteen patients underwent push enteroscopy for overt bleeding (N=66) or anemia (N=53). RESULTS: Enteroscopy was positive in 42% of patients (colon 17%, stomach 13%, small bowel 12%) and diagnosed arteriovenous malformations in two-thirds of patients. Twenty-five additional diagnoses were established during the 2-month follow-up. Treatment was definitive in 13% of patients, without recurrent bleeding. Rebleeding occurred in 45% of patients, and was more frequent when a lesion was visualized (73% vs 28% after 5 years, P=0.02). In multivariate analysis, a lesion visualized by enteroscopy was the only independent predictive factor. CONCLUSION: Enteroscopy is not a high-performance diagnostic tool for obscure gastrointestinal bleeding and enables definitive treatment in less than 15% of patients.     

Capsule enteroscopy vs. other diagnostic procedures in diagnosing obscure gastrointestinal bleeding: a cost-effectiveness study

BACKGROUND: Capsule enteroscopy is considered the gold standard for evaluating patients with obscure gastrointestinal bleeding. The costs of capsule enteroscopy examination, however, make it uncertain whether the clinically relevant diagnostic gain is also associated with cost savings. AIM: To evaluate the incremental cost-effectiveness ratio of capsule enteroscopy in patients with obscure gastrointestinal bleeding. METHODS: Retrospective study was carried out in nine Italian gastroenterology units from 2003 to 2005. Data on 369 consecutive patients with obscure gastrointestinal bleeding were collected. The diagnostic yield of capsule enteroscopy vs. other imaging procedures was evaluated as a measure of efficacy. The values of Diagnosis Related Group 175 (euro 1884.00 for obscure-occult bleeding and euro 2141.00 for obscure-overt bleeding) were calculated as measures of economic outcomes in the cost analysis. RESULTS: Obscure and occult gastrointestinal bleeding was recorded in 177 patients (48%) with a mean duration of anemia history of 17.6+/-20.7 months. Among patients, 60.9% had had at least one hospital admission, 21.2% at least two, and 1.2% of obscure bleeders up to nine admissions. Overall, 58.4% of patients had positive findings with capsule enteroscopy compared with 28.0% with other imaging procedures (P<0.001). The mean cost of a positive diagnosis with capsule enteroscopy was euro 2090.76 and that of other procedures was euro 3828.83 with a mean cost saving of euro 1738.07 (P<0.001) for one positive diagnosis. CONCLUSIONS: Capsule enteroscopy is a cost-saving approach in the evaluation of patients with obscure gastrointestinal bleeding.     

Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy

BACKGROUND: Obscure GI bleeding (OGIB) accounts for about 5% of all patients with GI bleeding. There are limited data on double-balloon enteroscopy (DBE) after a positive finding on capsule endoscopy (CE) in this setting. OBJECTIVE: To determine the clinical outcomes after DBE therapy. DESIGN: Prospective single-center cohort study. SETTING: Tertiary referral university hospital. MAIN OUTCOME MEASUREMENTS: Recurrent bleeding and blood transfusion requirements. PATIENTS AND METHODS: This prospective study of 60 consecutive patients with OGIB was conducted between July 2004 and March 2006. Patients underwent CE before DBE to target the lesion for either further diagnostic evaluation or therapeutic intervention. The mean (standard deviation [SD]) duration of follow-up was 10.0 +/- 5.2 months. RESULTS: The mean (SD) age was 62 +/- 18 years, with 31 men. A total of 74 DBE procedures were performed. An abnormality was seen by DBE in 45 patients (75%). In 12 patients (20%), a diagnosis was clarified or a new diagnosis was made. Therapy at DBE was performed in 34 patients (57%): 30 diathermies and 4 polypectomies. Endoscopic tattooing for targeted surgical removal was made in 3 additional patients. Multiple logistic regression analysis identified previous blood transfusion (odds ratio 10.5, 95% confidence interval 3.1-35; P < .001) to be the only independent predictor that required endoscopic therapy at DBE. Forty-eight patients (80%) had no further bleeding, and 46 patients (77%) had a normal Hb. Blood transfusion requirements fell from 34 patients to 10, P < .001. One patient had a perforation after therapeutic diathermy. LIMITATIONS: Nonrandomized study. CONCLUSIONS: In patients with OGIB and a positive finding on CE, DBE provided a safe and ambulatory method to achieve an excellent clinical outcome with significant reductions in recurrent bleeding and blood-transfusion requirements.     

Push-and-pull enteroscopy using the double-balloon technique (double-balloon enteroscopy) for the diagnosis of Meckel's diverticulum in adult patients with GI bleeding of obscure origin

BACKGROUND: Meckel's diverticulum (MD) occurs in 2-3% of the population. Although the clinical, histopathologic, and radiologic features of the complications of MD are well known, the diagnosis may be difficult before surgery. CASE REPORT: Three patients (age 22-34 yr, two women) presenting with gastrointestinal (GI) bleeding of obscure origin underwent multiple endoscopic and radiologic tests including capsule endoscopy and Tc-99m pertechnetate scintigraphy before push-and-pull enteroscopy using a double-balloon technique (double-balloon enteroscopy). Double-balloon enteroscopy was performed in all three patients using oral and anal approaches to evaluate the entire intestine. In one case, MD was detected using the oral route; the diagnosis was confirmed using the anal approach. In two patients, the lumen of MD was disclosed using the anal route. No procedure-related complications occurred. Push-and-pull enteroscopy was the only nonsurgical procedure that provided a precise diagnosis. All patients underwent surgical resection of the diverticulum. In one case, ectopic gastric tissue was found histologically. No further bleeding occurred during follow-up (6-9 months). CONCLUSIONS: Keeping the low sensitivity of Tc-99m scintigraphy in the adult population in mind, double-balloon enteroscopy might be the modality of choice in young adult patients with acute recurrent GI bleeding of obscure origin and a suspected diagnosis of MD.     

Double-balloon enteroscopy following capsule endoscopy in the management of obscure gastrointestinal bleeding: outcome of a combined approach.

BACKGROUND: There is no consensus on the relative accuracy of capsule endoscopy (CE) versus double-balloon enteroscopy (DBE) to investigate obscure gastrointestinal bleeding (GIB). CE is less invasive, but DBE more directly examines the small bowel, and allows tissue sampling plus therapeutic intervention. OBJECTIVES: To evaluate the yield and outcome of DBE following CE in patients with obscure GIB. METHODS: After DBE became readily available at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (St Michael's Hospital, Toronto, Ontario), all patients with obscure GIB seen from December 2002 to June 2007 were evaluated identically, first with CE, then with DBE (some with further interventions). Findings, adverse outcomes and interventions are reported. RESULTS: Fifty-one patients (25 women) with a mean (range) age of 64.1 years (34 to 83 years) are reported. Eight patients underwent DBE twice, for a total of 59 DBEs. Fourteen patients had overt GIB and the median (range) number of red blood cell unit transfusions was 10 (0 to 100). The positive findings for each type of lesion were compared in these 51 patients: angiodysplasia (CE 64.7% and DBE 61%, P=0.3), ulcers (CE 19.6% and DBE 18.6%, P=0.5), bleeding lesions (CE 43.1% and DBE 15.3%, P=0.0004) and mass (CE 10.2% and DBE 8.5%, P=0.5). DBE provided the advantage of therapeutic intervention: argon plasma coagulation (33 of 59 DBEs), clipping (two of 59), both argon plasma coagulation and clipping (three of 59), polypectomy (two of 59), tattooing (52 of 59) and biopsies (11 of 59). DBE detected lesions not seen by CE in 21 patients; lesions were treated in 18 patients. However, CE detected 31 lesions not seen by DBE. No major complications occurred with either examination. CONCLUSION: Overall detection rates for both techniques are similar. Each technique detected lesions not seen by the other. These data suggest that CE and DBE are complementary and that both evaluate obscure GIB more fully than either modality alone.     

Frequency and clinical outcome of capsule retention during capsule endoscopy for GI bleeding of obscure origin

BACKGROUND: Capsule endoscopy is now commonly performed for GI bleeding of obscure origin. Regional transit abnormality refers to slowed capsule movement during capsule endoscopy. The frequency and clinical outcome of capsule retention and regional transit abnormalities are unknown. METHODS: Initial capsule endoscopies performed at a single institution in 52 patients with GI bleeding of obscure origin were reviewed retrospectively. For patients with capsule retention or regional transit abnormality, preprocedural characteristics, and post-procedural outcomes were recorded. OBSERVATIONS: Capsule retention occurred in 7 patients, all of whom remained asymptomatic. Regional transit abnormality was noted in 3 patients. Sources of bleeding were localized in all cases. Seven patients underwent surgery. Stricture induced by non-steroidal anti-inflammatory drugs was the major cause of retention. In all patients, anemia resolved during follow-up. CONCLUSIONS: Capsule retention and regional transit abnormality occurred in almost 20% of patients who had capsule endoscopy for GI bleeding of obscure origin. These capsule movement abnormalities led to the diagnosis of bleeding sources and thereby influenced patient management. A history of non-steroidal anti-inflammatory drugs use may be associated with an increased risk of capsule retention.     

Diagnostic yield and therapeutic impact of double-balloon enteroscopy in a large cohort of patients with obscure gastrointestinal bleeding

OBJECTIVES: Double-balloon enteroscopy (DBE) is a novel endoscopic technique developed to investigate small bowel disease. There are limited available data on its impact in the diagnosis and management of obscure gastrointestinal bleeding (OGIB). The aim of this study was to evaluate the diagnostic yield and therapeutic impact of DBE in the management of patients with OGIB. METHODS: This study is a retrospective analysis of patients referred to our hospital from December 2003 to January 2005 for the investigation of overt or occult OGIB who underwent DBE after negative upper endoscopy and colonoscopy. Demographic, clinical, procedural, and outcome data were collected for analysis. RESULTS: One hundred fifty-two patients (73 women and 79 men) were studied, with a mean age of 48.2 yr. Seventeen patients presented with occult OGIB while 135 patients had overt OGIB. A total of 191 DBEs was performed. Antegrade and retrograde approaches were performed in 60 and 53 patients, respectively, and 39 patients had a combination of both routes. DBE demonstrated a potential bleeding site in 115 (75.7%) patients (102 overt, 13 occult). The more common abnormalities detected were small bowel tumors (39.1%) and angioectasia (30.4%). DBE altered management in 83.5% of patients with positive findings. Follow-up was obtained on 119 patients (mean 16 months, range 8-23 months). Of the 95 patients with follow-up and a positive DBE finding, 85 (89%) had no further rebleeding. The procedure was well tolerated with 23 patients (15.1%) experiencing mild self-limited bleeding during the procedure. CONCLUSIONS: DBE appears to have a high diagnostic yield and therapeutic impact in patients with OGIB with previously negative upper endoscopy and colonoscopy.     

Impact of capsule endoscopy in obscure small-bowel bleeding: defining strict diagnostic criteria for a favorable outcome

BACKGROUND: The most frequent indication for capsule endoscopy is to diagnose the cause of obscure GI bleeding. The objective of the study was to determine the impact of capsule endoscopy on the outcome of patients with GI bleeding of obscure origin. METHODS: Ninety-six patients (53 men, 43 women; mean [standard deviation] age, 60.84 years [16.55 years]) were enrolled in the study. All patients have been subjected to gastroscopy, colonoscopy, small-bowel barium follow-through or enteroclysis, and push enteroscopy; no bleeding site had been identified. Capsule endoscopy was performed with the Given M2A video capsule system. By using strict criteria, studies were classified as having positive findings, findings of uncertain significance, and no findings. Outcome was defined as continued or complete resolution of bleeding. RESULTS: Positive findings, findings of uncertain significance, and no findings were identified in 41.7%, 20.8%, and 37.5% of our study population, respectively. The most common lesions seen were angiodysplasias of the small intestine. Therapeutic intervention was possible in 82.5% of patients with positive findings and in 35.0% of patients with findings of uncertain significance. Complete resolution of bleeding, after a median (interquartile range) follow-up period of 14 months (9-17 months), occurred significantly more often in patients with positive findings (68.4%) compared with patients with findings of uncertain significance and no findings (40.8%, p = 0.009). CONCLUSIONS: Capsule endoscopy increases the diagnostic yield in the workup of patients with obscure small-bowel bleeding. Strictly defined positive findings are associated with a favorable outcome.     

Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis

Background and Aim: Uncertainty remains about the best test to evaluate patients with obscure gastrointestinal bleeding (OGIB). Previous meta‐analyses demonstrated similar diagnostic yields with capsule endoscopy (CE) and double balloon enteroscopy (DBE) but relied primarily on data from abstracts and were not limited to bleeding patients. Many studies have since been published. Therefore, we performed a new meta‐analysis comparing CE and DBE focused specifically on OGIB. Methods: A comprehensive literature search was performed of comparative studies using both CE and DBE in patients with OGIB. Data were extracted and analyzed to determine the weighted pooled diagnostic yields of each method and the odds ratio for the successful localization of a bleeding source. Results: Ten eligible studies were identified. The pooled diagnostic yield for CE was 62% (95% confidence interval [CI] 47.3–76.1) and for DBE was 56% (95% CI 48.9–62.1), with an odds ratio for CE compared with DBE of 1.39 (95% CI 0.88–2.20; P = 0.16). Subgroup analysis demonstrated the yield for DBE performed after a previously positive CE was 75.0% (95% CI 60.1–90.0), with the odds ratio for successful diagnosis with DBE after a positive CE compared with DBE in all patients of 1.79 (95% CI 1.09–2.96; P = 0.02). In contrast, the yield for DBE after a previously negative CE was only 27.5% (95% CI 16.7–37.8). Conclusions: Capsule endoscopy and double balloon enteroscopy provide similar diagnostic yields in patients with OGIB. However, the diagnostic yield of DBE is significantly higher when performed in patients with a positive CE.     

Preoperative "two-way" enteroscopy,followed by intraoperative enteroscopy in a patient with obscure-overt gastrointestinal bleeding and severe iron-deficiency anemia

We present the case of a 69-year-old woman admitted to hospital because of chronic gastrointestinal bleeding of an unknown source with a consequent severe iron deficiency anemia (IDA), undiagnosed for the past 25 years. In the last three years the episodes of severe bleeding became frequent, usually followed by melena. The patient was admitted 11 times in different departments without the identification of the bleeding source. During the evolution of the disease, the biological exams showed a severe IDA with low values of hemoglobin, low serum iron, mixed deficiency depicted by bone-marrow examination, and a reticulocyte crisis after parenterally administered iron. Repeated upper (6) and lower (2) gastrointestinal endoscopies failed to find a source of bleeding. Push enteroscopy allowed the visualization of approximately 40 cm of the proximal jejunum, after the Treitz angle, and demonstrated multiple punctiform jejunal angiodysplasias, which bled excessively after bipolar coagulation. We also performed a total colonoscopy with intubation of the ileo-cecal valve and visualization of the terminal ileum on approximately 30 cm, without any pathological findings. Because endoscopic treatment was ineffective, we decided to perform a segmentary enterectomy, with the length of small bowel resection tailored by intraoperative enteroscopy. A favourable evolution after limited resection of the small bowel indicated the importance of both preoperative "two-way" enteroscopy associated with intraoperative enteroscopy for diagnosing and treating the source of obscure gastrointestinal bleeding     

Diagnostic yield and clinical implications of push enteroscopy: results from a nonspecialized center

BACKGROUND Push enteroscopy is increasingly used as an investigative tool for the evaluation of gastrointestinal bleeding, and studies from specialized centers have shown an overall diagnostic yield of push enteroscopy in such patients ranging from 38% to 75%. The aim of our study was to characterize the yield and clinical effect of push enteroscopy to determine the applicability of prior observations to other academic centers.STUDY We retrospectively studied patients who underwent push enteroscopy between January 1995 and December 2000 at our institution. Detailed clinical history, endoscopic findings, endoscopic therapy, and subsequent medical treatment were obtained through review of medical records and our endoscopic database. Medications prescribed after enteroscopy and whether medical management was affected by the findings of push enteroscopy were also recorded.RESULTS Over the 6-year study period, 126 patients (48% men; mean age, 62 years; range, 15-91 years) underwent push enteroscopy. The most common indications for push enteroscopy were gastrointestinal bleeding in 57 patients (45%) and iron-deficiency anemia in 32 (25%). The results of push enteroscopy were normal in 44 patients (35%), and the most frequent endoscopic lesions were angiectasias in 24 patients (19%), gastric erosions in 10 (8%), gastric ulcer in four (3%), jejunal ulcer in three (2%), and esophagitis in three (2%). The identified lesions (n = 89) were within reach of a standard upper endoscope in 42 patients (47%). Endoscopic therapy was performed in 12 patients (13%), and the management of 50 patients (40%) was changed based on findings at push enteroscopy.CONCLUSIONS Push enteroscopy has a high diagnostic yield, similar to reports from specialized centers suggesting the potential clinical benefit of more widespread use.     

Accurate diagnosis and successful treatment for massive obscure small intestinal bleeding by means of intra-operative enteroscopy: a case report

Obscure gastrointestinal bleeding from the jejunum and ileum is always difficult to diagnose. Unstable patients with massive bleeding are not good candidates either for radiological studies or traditional endoscopic techniques. They usually need urgent operations to stop the bleeding. To identify the lesions, intraoperative enteroscopy is crucial for a better curing rate and for preventing massive unnecessary bowel resection. We report a 53-year-old unstable patient with massive obscure small intestinal bleeding. Urgent laparotomy with intraoperative enteroscopy was done. Two bleeding ulcers in the distal ileum were accurately identified and the diseased ileum was resected. Intraoperative enteroscopy may be a choice of diagnostic and therapeutic modality for unstable patients with obscure small intestinal bleeding.     

Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding

BACKGROUND: The development of wireless capsule endoscopy allows painless imaging of the small intestine. Its clinical use is not yet defined. The aim of this study was to compare the clinical efficacy and technical performance of capsule endoscopy and push enteroscopy in a series of 50 patients with colonoscopy and gastroscopy negative gastrointestinal bleeding. METHODS: A wireless capsule endoscope was used containing a CMOS colour video imager, transmitter, and batteries. Approximately 50,000 transmitted images are received by eight abdominal aerials and stored on a portable solid state recorder, which is carried on a belt. Push enteroscopy was performed using a 240 cm Olympus video enteroscope. RESULTS: Studies in 14 healthy volunteers gave information on normal anatomical appearances and preparation. In 50 patients with gastrointestinal bleeding and negative colonoscopy and gastroscopy, push enteroscopy was compared with capsule endoscopy. A bleeding source was discovered in the small intestine in 34 of 50 patients (68%). These included angiodysplasia (16), focal fresh bleeding (eight), apthous ulceration suggestive of Crohn's disease (three), tumour (two), Meckel's diverticulum (two), ileal ulcer (one), jejunitis (one), and ulcer due to intussusception (one). One additional intestinal diagnosis was made by enteroscopy. The yield of push enteroscopy in evaluating obscure bleeding was 32% (16/50). The capsule identified significantly more small intestinal bleeding sources than push enteroscopy (p<0.05). Patients preferred capsule endoscopy to push enteroscopy (p<0.001). CONCLUSIONS: In this study capsule endoscopy was superior to push enteroscopy in the diagnosis of recurrent bleeding in patients who had a negative gastroscopy and colonoscopy. It was safe and well tolerated.     

Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis

BACKGROUND & AIMS: The aim of this study was to compare the diagnostic yield of capsule endoscopy (CE) with double-balloon enteroscopy (DBE) in small-bowel (SB) disease using meta-analysis. METHODS: We performed a search of studies comparing CE with DBE in SB disease. Data on diagnostic yield of CE and DBE were extracted, pooled, and analyzed. The weighted incremental yield (IY(W)) (yield of CE--yield of DBE) of CE over DBE and 95% confidence intervals (95% CIs) for pooled data were calculated using a fixed-effect model (FEM) for analyses without, and a random-effect model (REM) for analyses with, significant heterogeneity. RESULTS: Eleven studies compared CE and DBE; the pooled overall yield for CE and DBE was 60% (n = 397) and 57% (n = 360), respectively (IY(W), 3%; 95% CI, -4% to 10%; P = .42; FEM). Ten studies reported vascular findings; the pooled yield for CE and DBE was 24% (n = 371) and 24% (n = 364), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .88; REM). Nine studies reported inflammatory findings; the pooled yield for CE and DBE was 18% (n = 343) and 16% (n = 336), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .89; FEM). Nine studies reported polyps/tumors; the pooled yield for CE and DBE was 11% (n = 343) and 11% (n = 336), respectively (IY(W), -1%; 95% CI, -5% to 4%; P = .76; FEM). CONCLUSIONS: CE and DBE have comparable diagnostic yield in SB disease, including obscure gastrointestinal bleeding. CE should be the initial diagnostic test because of its noninvasive quality, tolerance, ability to view the entire SB, and for determining the initial route of DBE. Because of its therapeutic capabilities, DBE may be indicated in patients with a positive finding on CE requiring a biopsy or therapeutic intervention, if suspicion for a SB lesion is high despite a negative CE, and in patients with active bleeding.