RARE CAUSE OF OBSCURE GASTROINTESTINAL BLEEDING DUE TO PYOGENIC GRANULOMA IN THE ILEUM DETECTED BY CAPSULE ENDOSCOPY AND TREATED WITH DOUBLE BALLOON ENDOSCOPY

Pyogenic granuloma is a lobular capillary hemangioma that occurs mostly on the skin, and occasionally on the mucosal surface of the oral cavity, but very rarely in the gastrointestinal tract. We report the case of a 63‐year‐old woman who suffered from palpitations, and iron deficiency anemia for 5 years. Esophagogastroduodenoscopy and colonoscopy could not reveal significant bleeding focus. She had not received medical treatment except for oral iron. Capsule endoscopy revealed a bleeding focus in the small intestine. Afterwards, we carried out double balloon endoscopy to treat the lesion. We found a subpedunculated polyp in the small intestine at 100 cm away from ileocecal valve by double balloon endoscopy and resected it endoscopically. The histological features of the polyp were consistent with pyogenic granuloma. Anemia had improved gradually without giving oral iron after polypectomy.     

USEFULNESS OF DOUBLE BALLOON ENTEROSCOPY AND VIDEO CAPSULE ENDOSCOPY FOR THE DIAGNOSIS AND MANAGEMENT OF PRIMARY FOLLICULAR LYMPHOMA OF THE GASTROINTESTINAL TRACT IN ITS EARLY STAGES

Aim: The aim of this study is to evaluate the usefulness of double balloon enteroscopy (DBE) and video capsule endoscopy (VCE) in patients with primary follicular lymphoma (FL) of the gastrointestinal (GI) tract. Furthermore, we estimate the effectiveness of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) including rituximab for them. Methods: Thirteen consecutive patients who were diagnosed of having FL in the duodenum between July 2005 and September 2008 were studied. All patients were given the conventional staging examinations, including total enteroscopy using DBE and/or VCE procedures. Chemotherapy was performed after written informed consent. Response assessment was performed every 6‐12 months. The median follow‐up period was 30.2 months. Results: FL was diagnosed in each patient as low grade (grade 1, n = 7; 2, n = 6) and, in all but 4 patients, localized lymphoma (stage I, n = 8; II₁, n = 1; II₂, n = 4). DBE revealed multifocal lesions in the jejunum in 10 of the patients, and in the ileum in 6. VCE showed similar findings in the jejunum in the recent 2 patients. Eleven of 13 patients finally received chemotherapy, and all of them achieved complete regression. They showed no evidence of recurrence after that. Conclusion: Total examination of the small intestine using DBE should be performed before treatment to choose a suitable treatment procedure for primary FL of the GI tract. On the other hand, VCE is useful for screening and following the small intestine in the patients with it. Chemotherapy is effective to achieve complete regression of primary FL of the GI tract.     

ENDOSCOPIC BALLOON DILATATION USING DOUBLE‐BALLOON ENDOSCOPY IS A USEFUL AND SAFE TREATMENT FOR SMALL INTESTINAL STRICTURES IN CROHN'S DISEASE

Background: Endoscopic balloon dilatation (EBD) is a therapeutic option for intestinal strictures of Crohn's disease (CD). Double‐balloon endoscopy (DBE) enables EBD to be performed even for deep‐situated strictures of the small intestine. The aim of this study was to clarify the efficacy and safety of EBD using DBE for small bowel strictures in patients with CD. Patients and Methods: The subjects comprised 25 patients with CD who underwent EBD using DBE for small intestinal strictures for which a colonoscope or gastrointestinal scope could not be inserted. All subjects had obstructive symptoms due to strictures that were confirmed using small intestinal enteroclysis. They were observed for at least 6 months after the initial EBD. The short‐term success rate of EBD using DBE, the complication rate and the long‐term outcome were investigated. Results: This procedure was successful with regard to short‐term dilatation in 18 of the 25 CD patients (72%). Long strictures measuring more than 3 cm were seen in six out of seven (85.7%) of the unsuccessful EBD cases, compared with two out of 18 (11.1%) of the successful EBD cases (P = 0.001). Complications were encountered in two of the 25 patients (8%). The cumulative surgery‐free rate for all the subjects was 83% and 72% at 6 and 12 months, respectively. Conclusion: EBD using DBE is a useful and safe procedure for small intestinal short strictures in CD patients. We conclude that this procedure is a therapeutic option that should be attempted before resorting to surgical therapy.     

DIAGNOSIS AND TREATMENT OF BLUE RUBBER BLEB NEVUS SYNDROME WITH DOUBLE BALLOON ENTEROSCOPY AND ENDOSCOPIC ULTRASOUND

Double balloon enteroscopy (DBE) is a new method that can identify and treat intestinal bowel diseases. Endoscopic ultrasound (EUS) can explore lesions of the different layers of the gastrointestinal tract. Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder with high morbidity and mortality. We describe a case of BRBNS that was diagnosed and treated with these two methods. A 13‐year‐old child presented to our department with a 9‐month history of chronic anemia. Eight months ago he was admitted to the emergency department with melena and upper endoscopy revealed two vascular lesions, one with active bleeding which was treated with sclerotherapy. The patient continued with anemia and intermittent melena. Other diagnostic tests were negative. Physical examination revealed one oral hemangioma. An initial DBE was performed and three small lesions in the antrum were found and treated. Two more jejunal lesions were observed and its vascular origin was confirmed with the aid of a 15 MHz miniprobe that was passed through the biopsy channel. Combined treatment was applied with polidocanol at 1.5% and argon plasma coagulation. Other lesions were found and treated. The control DBE did not show active hemangiomas. The patient was followed for 3 months and no more bleeding was seen and the anemia was corrected to a level of 11 g/dL. DBE with EUS can diagnose and effectively treat patients with vascular lesions, such as BRBNS. The combined treatment offered was safe and no complications were observed. The prognosis has been excellent.     

Current state of double balloon endoscopy: The latest approach to small intestinal diseases

Recent developments of capsule endoscopy and double balloon endoscopy (DBE) have made endoscopic examination of the entire small bowel practical, and changed the diagnostic algorithm for small bowel diseases. Double balloon endoscopy uses two balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops of intestine. Total inspection by DBE is usually achieved by combination of sequential oral and anal intubations; success rates are reported to be 40–80%. Indications for DBE include scrutiny for obscure gastrointestinal bleeding, small bowel tumor, small bowel stricture and following up evaluation of previously diagnosed small bowel diseases. Because DBE has an accessory channel and good maneuverability in the distal small intestine, it enables endoscopic treatment, including hemostasis, balloon dilation, polypectomy, mucosal resection, retrieval of foreign bodies and endoscopic retrograde cholangiopancreatography (in the case of post-operative anastomoses). Double balloon endoscopy is also useful for cases of difficult colonoscopy, providing success rates of total colonoscopy between 88–100%. Although it has been a few years since its development, the usefulness of DBE is now well recognized. This challenging procedure has become popular rapidly and is currently used in many countries.     

ENDOSCOPIC FINDINGS OF ENTEROPATHY‐TYPE T‐CELL LYMPHOMA BY DOUBLE‐BALLOON ENTEROSCOPY AND CAPSULE ENDOSCOPY

Enteropathy‐type T‐cell lymphoma (ETL) is a rare primary intestinal disorder, particularly in Japan, and there have been few reports on the endoscopic findings of the disease. Here we report detailed endoscopic findings of ETL based on double‐balloon enteroscopy and capsule endoscopy. Double‐balloon enteroscopy and capsule endoscopy may be useful tools for diagnosing and monitoring the effects of therapy in patients with ETL.     

HETEROTOPIC GASTRIC MUCOSA IN MECKEL'S DIVERTICULUM INCIDENTALLY FOUND BY DOUBLE BALLOON ENTEROSCOPY

A 45‐year‐old Japanese man who had been suffering from intestinal‐type Behcet's disease was referred to Yamagata University Hospital for enteroscopic examination. Double balloon enteroscopy was performed via the anal route. We identified ulceration of the terminal ileum that was detected previously. In addition, we incidentally recognized a Meckel's diverticulum coexisting with a heterotopic mucosal island nearly 100 cm on the oral side from the ileocecal valve. Meckel's diverticulum did not accompany ulcers and there was no history of bleeding. The heterotopic mucosal island was confirmed as gastric mucosa from biopsy specimens. High‐resolution endoscopic features of heterotopic gastric mucosa in Meckel's diverticulum using a double balloon enteroscopy are considered informative images.     

DOUBLE BALLOON ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN ROUX‐EN‐Y ANASTOMOSIS PATIENTS

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of patients with pancreaticobiliary disorders, but endoscopic therapy is very difficult to carry out in patients with a Roux‐en‐Y anastomosis. We herein present the results of ERCP for patients with a Roux‐en‐Y anastomosis using a double‐balloon endoscope. Six patients (six men with a mean age of 69 years) who had undergone prior gastric resection with Roux‐en‐Y reconstruction were enrolled in the present study and underwent ERCP and associated procedures. ERCP was carried out with a double balloon endoscope, which has one balloon attached to the tip of the endoscope and another attached to the distal end of the soft overtube. In all patients, entering the Y loop was successfully accomplished, and the papilla of Vater was also reached in all cases (100%). Cannulation was successful in four patients (66.7%). The final diagnosis was choledocholithiasis in two patients, biliary fistula in one patient and pancreatic cancer in one patient. A needle‐knife precut papillotomy was carried out after placement of a bile duct stent in two patients, and injection of N‐butyl‐2‐cyanoacrylate into a biliary fistula was carried out in one patient. None of the patients suffered from any complications. A double balloon endoscope is therefore considered to be useful for carrying out ERCP and associated procedures in patients with a Roux‐en‐Y anastomosis.     

USEFULNESS OF ENDOSCOPIC TREATMENT FOR DUODENAL ADENOMA

In recent years, due to the increasing prevalence of upper gastrointestinal endoscopy, there have been an increasing number of reports on duodenal adenoma and early stage cancer. However, endoscopic techniques for the resection of duodenal adenomas are difficult, due to the anatomical features of the duodenum, and the long distance to the lesion. There have only been a few reports on the use of endoscopic techniques for duodenal adenomas compared to those focused on the stomach and large intestine. For duodenal adenomas, we used a conventional endoscope for lesions proximal to the major duodenal papilla, and a short‐type double balloon endoscope for lesions distal to the papilla. The en‐bloc resection rate was 93.8%. There was only one case of microperforation. Endoscopic manipulation is considered difficult in the deep areas of the duodenum, but double balloon endoscopy enabled stable manipulation and successful resection of the tumor in the majority of cases.     

Single‐operator double‐balloon endoscopy (DBE) is as effective as dual‐operator DBE

Background and Study Aims: Double‐balloon endoscopy (DBE) is a new device that allows diagnosis and treatment throughout the entire small intestine. Although the originally described method requires two operators, we have recently developed a method to perform DBE by a single operator. We here assessed the clinical usefulness of this one‐person method in comparison to the conventional two‐person DBE. Patients and Methods: One hundred sixty‐two patients (102 men and 60 women, mean age 59 years) underwent 303 DBE procedures. Total observation time, completion rate of total intestinal and colonic observation, lesion‐discovery rate, and complication rate were retrospectively compared between the one‐person method and the conventional two‐person method of DBE. The one‐person method consists of the Grip and Pinch technique and Keep (or Hold) and Slide technique. Results: The total observation times were 95.5 ± 35.1 min and 96.7 ± 47.5 min by one‐person and two‐person antegrade DBE, respectively, and 103 ± 29.8 min and 111 ± 30.1 min by one‐person and two‐person retrograde DBE, respectively. The completion rate for examination of the entire small intestine was 74.2% in one‐person DBE and 76.5% in two‐person DBE, respectively. The lesion‐discovery rate was 69.0% in one‐person DBE and 65.5% in two‐person DBE, respectively. No significant differences between two methods were found in all measures. Also, no difference was observed in complication rate of the two methods. Conclusions: The single‐operator method for DBE was as efficient as the dual‐operator DBE without any higher risk of complications and, therefore, could replace the conventional dual‐operator method in the future.     

A REVIEW OF CURRENT CLINICAL APPLICATIONS OF UPPER GASTROINTESTINAL ZOOM ENDOSCOPY

Current clinical applications of upper gastrointestinal (GI) zoom endoscopy were reviewed. The objective of upper GI zoom endoscopy has been the diagnosis of neoplastic lesions as well as the diagnosis of minute inflammatory mucosal change. The target organ and pathology of the neoplastic lesions have been squamous cell carcinoma in the oro‐ and hypo‐pharynx and in the esophagus; intestinal metaplasia, dysplasia, and adenocarcinoma in Barrett's esophagus; and adenocarcinoma in the stomach. For analyzing the magnified endoscopic findings, there were two different basic principles (mucosal microstructural change and subepithelial microvascular changes). Overall diagnostic accuracy for diagnosing a neoplastic lesion was above 80% throughout the upper GI tract. Although the diagnostic accuracy of the zoom endoscopy technique seems to be superior to that of the ordinary endoscopy technique alone, the continuous efforts to establish standardized guidelines and procedures are mandatory in order to lead to the routine use of upper GI zoom endoscopy in clinical practice.     

SURVEILLANCE OF SMALL INTESTINAL ABNORMALITIES IN PATIENTS WITH HEPATOCELLULAR CARCINOMA: A PROSPECTIVE CAPSULE ENDOSCOPY STUDY

Background: Patients with hepatocellular carcinoma (HCC) sometimes suffer from obscure gastrointestinal bleeding. Portal hypertension (PH), common in cirrhosis, induces esophagogastric varices. Because of the location, PH also may influence mucosal abnormalities in the small intestine. The objective of this study is to estimate the prevalence of small intestinal mucosal abnormalities in HCC patients using capsule endoscopy (CE). Patients and Methods: We prospectively conducted CE in HCC patients, and analyzed the findings in relation to hepatic function, the number and size of HCC tumor and findings obtained by conventional endoscopy. Results: Thirty‐six patients (aged 66.7 ± 7.5 years, 29 men) underwent CE. Abnormal findings in the small bowel were found in 16 patients (44%), angioectasias in eight patients (22%), erosions in five (14%), varices in four (11%), polyps in four (11%), and submucosal tumor in one (3%). The patients with angioectasia had a larger spleen index than the no abnormal lesions group (85.4 ± 15.8 vs 59.0 ± 24.4, P = 0.02). The former group had been more frequently treated for esophageal varices endoscopically (62% vs 15%, P = 0.02). Large HCC nodules seemed more common in the patients with angioectasia than subjects without abnormal lesions (38% vs 5%, P = 0.06). Small intestinal varices also seemed to have a positive association with large HCC. During the follow up after CE, one patient with small intestinal polyps suffered from obscure gastrointestinal bleeding. Conclusions: CE revealed that HCC patients frequently have small intestinal mucosal lesions. In particular, small intestinal angioectasia, which may cause obscure gastrointestinal bleeding, seems to be associated with portal hypertension.     

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.     

MECKEL’S DIVERTICULUM WITH ULCERATION DIAGNOSED BY DOUBLE BALLOON ENTEROSCOPY

A 31‐year‐old man was referred to our hospital for an evaluation of recurrent episodes of melena. Esophagogastroduodenoscopy, total colonoscopy, computed tomography and Tc‐99 m scintigraphy were performed at a previous hospital, but the bleeding source remained unidentified. Double balloon enteroscopy (DBE) was performed with the use of an anal approach at our hospital. DBE was inserted into the ileum approximately 100 cm from the ileocecal valve, and then Meckel’s diverticulum was discovered. There was a circular ulceration in the middle part of the diverticulum without adherent blood clots, visible vessels nor heterotopic gastric mucosa. Meckel’s diverticulum was identified as the bleeding source, but an immediate risk of rebleeding was considered relatively low. The patient chose conservative therapy without surgery. Two years later, he is well, without further bleeding episodes. DBE made it possible not only to diagnose the existence of the Meckel’s diverticulum but also to assess the risk of rebleeding.     

DIAGNOSIS AND TREATMENT OF SMALL BOWEL DISEASES WITH A NEWLY DEVELOPED SINGLE BALLOON ENDOSCOPE

Background: Recent advances in capsule endoscopy (CE) and double balloon endoscopy (DBE) have enabled an endoscopic approach to small bowel diseases. However, CE is simply a diagnostic tool and DBE is fairly complicated to handle. Methods: We developed a single balloon endoscopy (SBE) in cooperation with Olympus Medical Systems. The single balloon enteroscope consists of an endoscope and a splinting tube. In this system, a balloon is attached to the splinting tube, but not to the scope itself. The single‐person insertion method was effective for SBE cases, but two persons were needed for DBE. The patients we examined had undergone upper and lower gastrointestinal endoscopy and were suspected of having small intestinal diseases. We examined a total of 30 cases (nine women, 21 men; range 19–78 years), and carried out a total of 48 examinations. Results: In fifteen cases, the cause of bleeding was diagnosed as either ulcer, angiodysplasia, Crohn's disease, inflammatory polyp, or metastatic cancer, but in eight cases, the cause was not identified. Four obstruction cases comprised ulcers, adhesion, and jejunal volvulus. For treatment, clippings were performed for bleeding in three patients, polypectomy for two, reversal of volvulus for one, and balloon dilation for ilial stenosis in one. The entire small intestine was observed in 71% of patients when the intention was to examine the whole bowel. No complications were encountered. Conclusions: The newly developed SBE is useful for diagnosis and treatment of small bowel diseases.     

CURRENT STATUS AND EVALUATION OF TRANSNASAL ESOPHAGOGASTRODUODENOSCOPY

We reviewed the current status of transnasal esophagogastroduodenoscopy (EGD) with regard to tolerance, safety, feasibility and accuracy. Comparison of standard and ultrathin scopes and recently reported endoscopic techniques with transnasal insertion are also described as well as the current status of transnasal EGD in European countries compared with Japan. As several studies concluded that transnasal EGD can facilitate comfortable endoscopy without the need for sedative drugs, it has been tried in countries in which a relatively high number of unsedated EGD are carried out in daily practice. Long‐tube intubation of the jejunum with the assistance of transnasal EGD will also be a part of the daily practice in the near future. However, its safety and accuracy should be further investigated. Even a standard scope whose charge‐coupled device (CCD) has the same resolution as an ultrathin scope is superior to an ultrathin scope in terms of luminosity and resolution. Given the small number of procedures reported to date, the absolute complication rate of unsedated transnasal EGD is unknown. Methods of nasal anesthesia, as well as informed consent, indications and contraindications for transnasal EGD are not standardized. A guideline of transnasal EGD is under discussion by the Japanese Gastroenterological Endoscopy Society.     

COMPARING BALLOON DIAMETER ON PERFORMING ENDOSCOPIC PAPILLARY BALLOON DILATATION WITH ISOSORBIDE DINITRATE DRIP INFUSION FOR REMOVAL OF BILE DUCT STONES

Background: Endoscopic papillary balloon dilatation (EPBD) is one of the methods to remove bile duct stones. EPBD might preserve the function of the sphincter of Oddi despite the potential risk of acute pancreatitis. There are only a few reports of EPBD reducing the risk of acute pancreatitis and, at same time, preserving the function of the sphincter of Oddi. Methods: We performed EPBD for bile duct stone removal in 60 patients using two balloons with different diameters. Patients were randomized to EPBD with a 6 mm balloon (n = 30) or an 8 mm balloon (n = 30). In both groups, isosorbide dinitrate (ISDN) was infused in a rate of 5 mg/h while low pressure EPBD were being performed. The pressure of the sphincter of Oddi was observed before and after the EPBD procedures. Also, serum amylase level after EPBD was observed for both groups. Results: Serum amylase level of the 6 mm group was signi?cantly higher than that of the 8 mm group (P < 0.05). Acute pancreatitis occurred in two patients ( 6.7%) in the 6 mm group whereas no case was observed for the 8 mm group. The rates of duct clearance were 93% in the 6 mm group and 100% in the 8 mm group. Stone removals were dif?cult in seven cases with 6 mm balloon dilatations due to the narrow ori?ces of the papilla. In the 6 mm group, there was no signi?cant difference between the basal sphincter of Oddi pressure (BSOP) and the phasic sphincter of Oddi pressure (PSOP) before and after EPBD. However in the 8 mm group, the BSOP observed after the EPBD procedure was signi?cantly higher than BSOP before the treatments. Within this group, BSOP values after EPBD were preserved by approximately 80% of the BSOP values before the treatments. In contrast, there was no signi?cant difference in PSOP before and after the treatments. Regarding the stone numbers, no signi?cant difference was observed in BSOP before and after the treatments for the 6 mm group with less than two stones. Also, as for stone size, no signi?cant difference was observed in BSOP before and after the treatments for the 6 mm group with stones of less than 6 mm in diameter. Conclusion: We are now conducting EPBD with ISDN infusion using a 6 mm balloon for a patient who has less than two stones with size not exceeding 6 mm in diameter. An 8 mm balloon is used for a patient with more than two stones or a stone greater than 6 mm in size.     

ULTRATHIN ENDOSCOPE‐ASSISTED ERCP FOR INACCESSIBLE PERIDIVERTICULAR PAPILLA BY A SINGLE‐BALLOON ENTEROSCOPE IN A PATIENT WITH ROUX‐EN‐Y ANASTOMOSIS

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux‐en Y (R‐Y). A 73‐year‐old man who had total gastrectomy with R‐Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre‐cutting, the ultraslim endoscope was replaced with a conventional forward‐viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure‐related complication.     

MANAGEMENT OF OBSCURE GASTROINTESTINAL BLEEDING BASED ON THE CLASSIFICATION OF CAPSULE ENDOSCOPIC BLEEDING FINDINGS

Background: Double‐balloon endoscopy (DBE) and capsule endoscopy (CE) have been useful in managing obscure gastrointestinal bleeding (OGIB). However, DBE is invasive, complex and time‐consuming, therefore indications should probably be selective. The aim of this study was to evaluate the usefulness of the classification of the CE bleeding findings for determining the indications and timing of DBE in patients with OGIB. Methods: From February 2003 to January 2009, 123 patients with OGIB who underwent CE were included in this study. These CE findings were classified based on the bleeding source. Type CE‐I, II, III, IV and 0 indicate active bleeding, previous bleeding, lesions without active bleeding, a lesion outside of the small bowel, and no findings, respectively. We compared diagnostic yield and outcome between the classification and the findings of DBE or enteroclysis. Results: Comparisons of the positive findings rate with DBE or enteroclysis, the treatment rate and the rebleeding rate with the classification showed: CE‐Ia, 100% (6/6), 50% (3/6), 33.3% (2/6); Ib, 66.7% (4/6), 0% (0/6), 16.7% (1/6); IIa, 33.3% (1/3), 33.3% (1/3), 33.3% (1/3); IIb, 53.8% (7/13),15.4% (2/13), 30.8% (4/13); III, 100% (84/84), 9.5% (8/84), 8.3% (7/84); IV, 100% (2/2), 50% (1/2), 0% (0/2); and 0, 0% (0/9), 0% (0/9), 0% (0/9), respectively. Conclusions: The proportion of patients requiring treatment, the positive findings rate with DBE or enteroclysis and the rebleeding rates tended to be higher in the higher ranked classification types (CE‐I > II > III > IV > 0). These findings suggest that the classification can provide useful information on determining the indications and timing of DBE.