Preoperative detection and localization of small bowel hemangioma: Two case reports

Among the various diagnostic modalities for small bowel hemangioma,video capsule endoscopy(VCE)and double-balloon enteroscopy( BE)can be recommended as part of the work-up in patients with obscure gastrointestinal bleeding(OGIB). BE is superior to VCE in the accuracy of diagnosis and therapeutic potential,while in most cases total enteroscopy cannot be achieved through only the antegrade or retrograde BE procedures.As treatment for small bowel bleeding,especially spout bleeding,localization of the lesion for the decision of BE insertion facilitates early treatment,such as endoscopic hemostatic clipping,allowing patients to avoid useless transfusion and the worsening of their disease into life-threatening status.Applying endoscopic India ink marking prior to laparoscopic surgical resection is a particularly useful technique for more minimally invasive treatment.We report two cases of small bowel hemangioma found in examinations for OGIB that were treated with combination of laparoscopic and endoscopic modalities.     

Double Balloon Enteroscopy Detects Small Bowel Mass Lesions Missed by Capsule Endoscopy

BACKGROUND: Small bowel mass lesions (SBML) are a relatively common cause of obscure gastrointestinal bleeding (OGIB). Their detection has been limited by the inability to endoscopically examine the entire small intestine. This has changed with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE) into clinical practice. STUDY AIM: To evaluate the detection of SBML by DBE and CE in patients with OGIB who were found to have SBML by DBE and underwent both procedures. METHODS: A retrospective review of a prospectively collected database of all patients undergoing DBE for OGIB at seven North American tertiary centers was performed. Those patients who were found to have SBML as a cause of their OGIB were further analyzed. RESULTS: During an 18 month period, 183 patients underwent DBE for OGIB. A small bowel mass lesion was identified in 18 patients. Of these, 15 patients had prior CE. Capsule endoscopy identified the mass lesion in five patients; fresh luminal blood with no underlying lesion in seven patients, and non-specific erythema in three patients. Capsule endoscopy failed to identify all four cases of primary small bowel adenocarcinoma. CONCLUSIONS: Double balloon enteroscopy detects small bowel mass lesions responsible for OGIB that are missed by CE. Additional endoscopic evaluation of the small bowel by DBE or intraoperative enteroscopy should be performed in patients with ongoing OGIB and negative or non-specific findings on CE.     

Darier's disease with esophageal involvement

Abstract

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.     

Randomized controlled trial comparing outcomes of video capsule endoscopy with push enteroscopy in obscure gastrointestinal bleeding

BACKGROUND:

Optimal management of obscure gastrointestinal bleeding (OGIB) remains unclear.

OBJECTIVE:

To evaluate diagnostic yields and downstream clinical outcomes comparing video capsule endoscopy (VCE) with push enteroscopy (PE).

METHODS:

Patients with OGIB and negative esophagogastroduodenoscopies and colonoscopies were randomly assigned to VCE or PE and followed for 12 months. End points included diagnostic yield, acute or chronic bleeding, health resource utilization and crossovers.

RESULTS:

Data from 79 patients were analyzed (VCE n=40; PE n=39; 82.3% overt OGIB). VCE had greater diagnostic yield (72.5% versus 48.7%; P<0.05), especially in the distal small bowel (58% versus 13%; P<0.01). More VCE-identified lesions were rated possible or certain causes of bleeding (79.3% versus 35.0%; P<0.05). During follow-up, there were no differences in the rates of ongoing bleeding (acute [40.0% versus 38.5%; P not significant], chronic [32.5% versus 45.6%; P not significant]), nor in health resource utilization. Fewer VCE-first patients crossed over due to ongoing bleeding (22.5% versus 48.7%; P<0.05).

CONCLUSIONS:

A VCE-first approach had a significant diagnostic advantage over PE-first in patients with OGIB, especially with regard to detecting small bowel lesions, affecting clinical certainty and subsequent further small bowel investigations, with no subsequent differences in bleeding or resource utilization outcomes in follow-up. These findings question the clinical relevance of many of the discovered endoscopic lesions or the ability to treat most of these effectively over time. Improved prognostication of both patient characteristics and endoscopic lesion appearance with regard to bleeding behaviour, coupled with the impact of therapeutic deep enteroscopy, is now required using adapted, high-quality study methodologies.     

Bleeding Dieulafoy’s-like lesions of the gut identified by capsule endoscopy

Dieulafoy’s-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.     

推进式双气囊电子小肠镜对不明原因小肠出血的病因诊断

目的通过对不明原因消化道出血患者行双气囊电子小肠镜检查，评价双气囊电子小肠镜对小肠出血的诊断价值。方法2003年4月至11月，对34例疑为小肠出血患者行推进式双气囊电子小肠镜检查，结合手术和病理做出病因诊断。结果在34例患者中30例发现病灶，检查总体阳性率为88．2％。4例阴性患者中，1例内镜抵达空肠中段，3例抵达回肠中下段。30例阳性患者中，血管病变7例(占20．6％，位于空肠1例，空回肠3例，回肠3例)；小肠肿瘤11例(占32．4％，均经手术及病理证实，位于十二指肠2例，空肠5例，回肠4例。肿瘤性质分别为：间质肿瘤3例，脂肪瘤1例，平滑肌瘤2例，血管瘤2例，嗜铬细胞瘤1例，Kaposi型血管内皮瘤1例，腺癌1例)；克罗恩病4例(占11．8％，位于空回肠部)；其他8例。结论小肠血管病变、小肠肿瘤及小肠克罗恩病为不明原因小肠出血最常见病因；推进式双气囊电子小肠镜是一项安全、直观、可靠、有效的检查手段，对不明原因小肠出血具有较高临床诊断价值。     

Ileo-ileal invagination – a cause of recurrent mid-gastrointestinal bleeding: Diagnostic and endoscopic therapy by means of push-and-pull enteroscopy

The types of lesions that cause bleeding in the small bowel are similar to those found in other areas in the gastrointestinal tract, such as vascular malformations, ulcers and inflammatory lesions, neoplasms and other less common lesions like Meckel's diverticulum.

This report describes three patients with suspected mid-gastrointestinal bleeding with no significant past medical history. Before presenting to our unit the diagnostic work-up such as oesophagogastroduodenoscopy, colonoscopy and radiological small bowel imaging such as conventional enteroclysis or magnet resonance imaging enteroclysis had been performed without detecting any bleeding source. Capsule endoscopy suspected an angiodysplasia in the terminal ileum in one patient, in the other two patients a polyp in the region of the ileum as the potential bleeding source was diagnosed. In all three patients, a polyp with an ulcerated tip was found with the anal push-and-pull enteroscopy. An endosocpic resection was performed in all three cases without complication with the exception of one. In this patient a perforation occured 3 days after resection and was treated surgically without further complications. Histology revealed in all three cases, a polypoid diaphragmatic invagination of the small bowel with a vast area of chronic ulceration on the tip of this pseudopolyp with infiltration of the muscularis propria.

In summary, the present paper describes the rare cases of erosive pseudopolyps after ileo-ileal invagination treated with endoscopic resection by means of push-and-pull enteroscopy.     

A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding

OBJECTIVES: Due to its superior ability to examine the entire small bowel mucosa, capsule endoscopy (CE) has broadened the diagnostic evaluation of patients with obscure gastrointestinal bleeding (OGIB). Published studies have revealed a numerically superior performance of CE in determining a source of OGIB compared with other modalities, but due to small sample sizes, the overall magnitude of benefit is unknown. Additionally, the types of lesions more likely to be found by CE versus alternate modalities are also unknown. The aim of this study was to evaluate the yield of small bowel findings with CE in patients with OGIB compared to other modalities using meta-analysis. METHODS: We performed a recursive literature search of prospective studies comparing the yield of CE to other modalities in patients with OGIB. Data on yield and types of lesions identified among various modalities were extracted, pooled, and analyzed. Incremental yield (IY) (yield of CE-yield of comparative modality) and 95% confidence intervals (95% CI) of CE over comparative modalities were calculated. RESULTS: A total of 14 studies (n = 396) compared the yield of CE with push enteroscopy for OGIB. The yield for CE and push enteroscopy was 63% and 28%, respectively (IY = 35%, p < 0.00001, 95% CI = 26-43%) and for clinically significant findings (n = 376) was 56% and 26%, respectively (IY = 30%, p < 0.00001, 95% CI = 21-38%). Three studies (n = 88) compared the yield of CE to small bowel barium radiography. The yield for CE and small bowel barium radiography for any finding was 67% and 8%, respectively (IY = 59%, p < 0.00001, 95% CI = 48-70%) and for clinically significant findings was 42% and 6%, respectively (IY = 36%, p < 0.00001, 95% CI = 25-48%). Number needed to test (NNT) to yield one additional clinically significant finding with CE over either modality was 3 (95% CI = 2-4). One study each compared the yield of significant findings on CE to intraoperative enteroscopy (n = 42, IY = 0%, p= 1.0, 95% CI =-16% to 16%), computed tomography enteroclysis (n = 8, IY = 38%, p= 0.08, 95% CI =-4% to 79%), mesenteric angiogram (n = 17, IY =-6%, p= 0.73, 95% CI =-39% to 28%), and small bowel magnetic resonance imaging (n = 14, IY = 36%, p= 0.007, 95% CI = 10-62%). Ten of the 14 trials comparing CE with push enteroscopy classified the types of lesions found on examination. CE had a 36% yield for vascular lesions versus 20% for push enteroscopy, with an IY of 16% (p < 0.00001, 95% CI = 9-23%). Inflammatory lesions were also found more often in CE (11%) than in push enteroscopy (2%), with an IY of 9% (p= 0.0001, 95% CI = 5-13%). There was no significant difference in the yield of tumors or "other" findings between CE and push enteroscopy. CONCLUSIONS: CE is superior to push enteroscopy and small bowel barium radiography for diagnosing clinically significant small bowel pathology in patients with OGIB. In study populations, the IY of CE over push enteroscopy and small bowel barium radiography for clinically significant findings is >or=30% with an NNT of 3, primarily due to visualization of additional vascular and inflammatory lesions by CE.     

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

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

Obscure gastrointestinal bleeding: role of videocapsule and double-balloon enteroscopy

Capsule endoscopy (CE), which allows the non-invasive visualisation of mucosa throughout the entire small bowel, has revolutionised the exploration of small-bowel diseases, and particularly the evaluation of obscure gastrointestinal bleeding (OGIB) after a negative initial evaluation, including gastroscopy and colonoscopy. CE has a high negative predictive value and a higher diagnostic yield than all other modalities, such as radiology (small-bowel X-rays or computed tomography scan) or push enteroscopy. CE may be the preferred initial diagnostic choice in OGIB because of its non-invasive quality and better tolerance. Double-balloon enteroscopy, also known as push-and-pull enteroscopy, has recently been developed. It has made it possible not only to explore the small bowel but also to carry out therapeutic interventions deep in the small bowel without the need for surgical laparotomy. This exploration should be considered as a second-line exploration for OGIB in patients with a positive finding on CE requiring endoscopic follow-up for histology or intervention, and in patients in whom suspicion of a small-bowel lesion is high despite a negative CE.     

Capsule endoscopy and single-balloon enteroscopy in small bowel diseases: Competing or complementary?

AIM To evaluate diagnostic yields of capsule endoscopy(CE) and/or single-balloon enteroscopy(SBE) in patients with suspected small bowel diseases.METHODS Were trospectively analyzed 700 patients with suspected small bowel diseases from September 2010 to March 2016. CE, SBE, or SBE with prior CE was performed in 401, 353, and 47 patients, respectively. Data from clinical and endoscopy records were collected for analysis. Indications, procedure times, diagnostic yields, and complications were summarized and evaluated.RESULTS The overall diagnostic yield for the CE group was 57.6%. The diagnostic yield of CE in patients with obscure gastroin testinal bleeding(OGIB) was significantly greater than that in patients with no bleeding(70.5% vs 43.8%, P 0.01). The overall diagnostic yield of SBE was 69.7%. There was no difference in the diagnostic yield of SBE between patients with OGIB and those with no bleeding(72.5% vs 68.9%, P = 0.534). Forty-seven patients underwent CE prior to SBE. Among them, the diagnostic yield of SBE with positive findings on prior CE was 93.3%. In addition, SBE detected two cases with superficial ulcer and erosive lesions in the small bowel, which were missed by CE. However, one case with lymphoma and two with Crohn's disease were not confirmed by SBE. The rate of capsule retention was 2.0%. There were no significant complications during or after SBE examinations.CONCLUSION SBE is a safe and effective technique for diagnosing small bowel diseases. SBE with prior CE seemed to improve the diagnostic yield of small bowel diseases.     

Prevalence of mid-gastrointestinal bleeding in patients with acute overt gastrointestinal bleeding: multi-center experience with 1,044 consecutive patients

Background  Video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) enable the detection of small intestinal lesions. Aim  To examine causes of acute overt gastrointestinal (GI) bleeding and the prevalence of mid-GI bleeding, defined as small intestinal bleeding from the ampulla of Vater to the terminal ileum, in a multi-center experience in Japan in the VCE/DBE era. Methods  Data were collected retrospectively from consecutive patients with acute overt GI bleeding in ten participating hospitals. All patients were examined by esophagogastroduodenoscopy and/or colonoscopy. When the source of bleeding was not identified after these procedures, patients suspected to have mid-GI bleeding were referred to our hospital and VCE/DBE was performed to determine the source of bleeding. Results  Of the 1044 patients with acute overt GI bleeding, 524 (50.2%) patients were diagnosed with upper GI bleeding, 442 (42.3%) with lower GI bleeding, and 13 (1.2%) with mid-GI bleeding. Gastric ulcer was the most common cause of bleeding (20.4%). Among cases of mid-GI bleeding, ulcers were found in 4 (30.8%) patients, erosions in 3 (23.1%), angiodysplasia in 3 (23.1%), submucosal tumor in 2 (15.4%), and hemangioma in one (7.7%). Seven lesions were located in the jejunum, 5 in the ileum, and one in both the jejunum and ileum. Analysis of age-related cause showed that the prevalence of mid-GI bleeding among younger patients under 40 years of age was higher (5%) than in other age groups (1–2%). Conclusion  mid-GI bleeding is rare among Japanese patients with acute overt GI bleeding.     

Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding

The diagnosis and management of obscure gastrointestinal bleeding(OGIB) have changed dramatically since the introduction of video capsule endoscopy(VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.     

Video capsule endoscopy compared with standard endoscopy for the evaluation of small-bowel polyps in persons with familial adenomatous polyposis (with video)

BACKGROUND: Video capsule endoscopy (VCE) may be useful for surveillance of small-bowel polyps in patients with familial adenomatous polyposis (FAP). OBJECTIVE: To compare VCE to standard endoscopy for diagnosing small-bowel polyps in a defined segment of small bowel (proximal to a tattoo) and the entire examined small bowel. DESIGN: Prospective. SETTING: Single tertiary referral center. PATIENTS: Participants with FAP (n = 32). The majority were selected for their high number of proximal small-bowel polyps and prior endoscopic tattoo placement in the proximal small bowel. INTERVENTIONS: VCE (interpreted by 2 readers), push enteroscopy (PE), and lower endoscopy (LE) to count and measure small-bowel polyps. RESULTS: In the defined segment, VCE detected a median of 10.0 (interquartile range [IQR], 5.0-19.0) and 9.0 (IQR, 6.0-16.0) polyps for each reader compared with a median of 41.0 (IQR, 19.0-64.0) polyps on PE (P = .002). Agreement between the 2 methods was fair (kappa = 0.34, 0.36). Agreement between VCE and PE was poor to fair (kappa = 0.10, 0.22) for estimating the size of the largest polyp and poor (kappa = -0.20, -0.27) for detecting large polyps (> or =1 cm). In the entire examined small bowel, VCE diagnosed a median of 38.0 (IQR, 10.5-71.5) and 54.0 (IQR, 13.0-100.0) polyps for each reader compared with a median of 123.0 (IQR, 38.5-183.0) for combination endoscopy (PE and LE) (P < .001). Agreement between the 2 methods was fair to moderate (kappa = 0.21, 0.56). LIMITATIONS: Participants selected for high polyp burden, and results may not be applicable to all patients with FAP. CONCLUSIONS: VCE underestimates the number of small-bowel polyps in persons with FAP and does not reliably detect large polyps.     

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.     

术中内镜在胃肠手术中的应用价值

目的：探讨术中内镜在胃肠手术中的应用价值。方法：对32例胃肠手术的患者进行了术中内镜检查，其中25例为剖腹探查，7例为术前明确诊断但术中找不到病灶或难以确定病灶的边缘者。结果：25例剖腹探查术患者24例通过术中内镜明确了诊断，分别为：胃底Dieulafoy病1例，胃溃疡1例，十二指肠平滑肌瘤3例，小肠平滑肉瘤2例，十二指肠水平部Dieulafoy病1例，十二指肠水平部平滑肌瘤2例，回肠淋巴瘤2例，小肠腺瘤性息肉2例，加肠末段溃疡2例，小肠海绵状血管瘤3例，小肠动静脉畸形4例，胰空肠吻合口出血1例。所有32例患者除1例小肠息肉和1例结肠息肉予内镜下高频电切除术、1例未找到病灶而未予特别处理外，其余28例患者均进行了病变切除。结论：应用术中内镜不仅极大地提高了病变的检出率，而且能对病变准确定位。术中内镜诊疗术是安全且有效的。     

Push enteroscopy in the era of capsule endoscopy

GOALS: To evaluate the diagnostic yield of push enteroscopy in relation to indication and compare the yield in patients who had capsule endoscopy followed by push enteroscopy against capsule endoscopy naive patients. BACKGROUND: With the advent of capsule endoscopy the role of push enteroscopy needs to be reevaluated. STUDY: Patients who underwent push enteroscopy from January 2002 to May 2006 were included. RESULTS: One hundred fifty-five patients underwent push enteroscopy: 93 females, average age 55 years. There were 74 cases where both push enteroscopy (PE) and capsule endoscopy (CE) were performed. Indications for PE were iron deficiency anemia (n=51), overt bleeding (n=31), suspected celiac disease (n=32), refractory celiac disease (n=19), assessment for Crohn's disease (n=10), and miscellaneous (n=12). In 148 patients, an average length of 70 cm of small bowel was examined (range 30 to 130 cm). PE was unsuccessful in 7 patients due to anatomic strictures or patient distress. The overall diagnostic yield was 30% with the highest yield in overt bleeding when compared with other subgroups (P<0.001). Nine percent of lesions were within the reach of a standard endoscope. Comparison of the diagnostic yield in patients who had CE followed by PE against CE naive patients was 41% versus 47%, respectively (P<1). There were no cases where push enteroscopy recognized a lesion that had not been already detected by capsule endoscopy. CONCLUSIONS: Push enteroscopy has the greatest diagnostic yield in patients with overt bleeding when compared with other referral indications. PE should be used as an adjuvant to CE for therapeutic intervention.     

Multiple angiodysplasia of the small intestine. A diagnostic and therapeutic challenge

Small bowel bleeding is infrequent and presents a challenge to the clinician. Approximately 30-40% of gastrointestinal bleeding localized in the small bowel is due to angiodysplasia, a vascular malformation. We present the case of a patient with multiple angiodysplasia of the small bowel who required push enteroscopy and capsule endoscopy to establish the diagnosis. Treatment with subcutaneous octreotide was successful. In conclusion, in doubtful cases or in patients with persistent hemorrhage, capsule endoscopy can improve the diagnostic yield of enteroscopy in bleeding gastrointestinal vascular lesions such as angiodysplasia. Endoscopic treatment (laser coagulation) and drug therapy (somatostatin or analogs) are valid alternatives in inoperable or non-resectable cases.     

Video capsule endoscopy: procedure, indications and diagnostic yield

Video capsule endoscopy (VCE) is a new noninvasive imaging technique for the complete small bowel. It provides good to excellent visualisation of the mucosa of the small bowel and has a high diagnostic yield in selected patients with gastrointestinal blood loss of suspected small bowel origin and in patients with Crohn's disease. In comparison with small bowel X-ray and push enteroscopy, diagnostic yield appears to be superior. Although VCE is becoming increasingly popular, good studies on its clinical implications and application are only just emerging. In this paper we review the possibilities and limitations of clinical application of VCE.     

Diagnostic yield, safety, and efficacy of push enteroscopy in pediatrics

BACKGROUND: Push enteroscopy has not been compared to standard endoscopy in children. OBJECTIVE: The aim of this study was to determine the feasibility of push enteroscopy in children with suspected proximal small bowel disease, and to compare its diagnostic yield and safety with standard endoscopy. DESIGN/SETTING: Database review. PATIENTS: A database analysis was performed on all children who underwent push enteroscopy at The Johns Hopkins Children's Center from 2001 to 2005. Patient demographics, clinical history, and indication for push enteroscopy were all recorded. Clinical utility was qualified based on the influence of PE on therapy. MAIN OUTCOME MEASUREMENTS: Diagnostic yield and safety of push enteroscopy in children. RESULTS: Push enteroscopy was performed on 44 children (27 M; 17 F) with a median age (range) of 10 (2-18) years. The most common indications for push enteroscopy were suspected proximal small bowel disease based on radiological criteria (21), and bleeding (9). Push enteroscopy confirmed the diagnosis of proximal small bowel Crohn's disease (CD) in 23, polyps in 5, eosinophilic gastroenteritis in 4, celiac disease in 1, microvillous inclusion disease in 1, and lymphoproliferative disease in 1 patient. An isolated non-Crohn's related gastric (1) and jejunal ulcer (1) was also identified. Just 9 of these identifiable lesions were within reach by esophagogastroduodenoscopy (EGD). Seven patients had a normal push enteroscopy. The clinical management was modified in 34 patients. Push enteroscopy was not shown to significantly alter the time of procedure when compared to EGD. CONCLUSIONS: Push enteroscopy is a safe diagnostic tool with proven clinical utility in children with suspected proximal small bowel disease. Larger studies are needed to establish the widespread application of push enteroscopy in pediatrics.