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.     

Clinical Practice Guideline for Enteroscopy

Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon‐assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed ‘Clinical Practice Guidelines for Enteroscopy’ in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease‐based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.     

小肠肿瘤诊断:双气囊小肠镜与其他检查手段的对比研究

目的比较双气囊小肠镜与小肠稀钡灌注和胶囊内镜检查在小肠肿瘤诊断中的诊断率和准确率。方法对59例临床怀疑小肠肿瘤患者行双气囊小肠镜检查。其中有34例和17例患者分别同期行插管法小肠稀钡灌注或胶囊内镜检查。检查分别由专职医师独立操作并诊断，最后进行汇总比较。结果34例小肠稀钡灌注检查者中，19例诊断为小肠肿瘤或怀疑小肠肿瘤，诊断率为55．9％，最终经双气囊小肠镜确诊为12例，诊断准确率为63．2％（12／19例）；在15例小肠稀钡灌注阴性者中，双气囊小肠镜发现肿瘤3例。17例胶囊内镜检查者中，8例检查结果为小肠肿瘤或怀疑小肠肿瘤，诊断率为47．1％，最终经双气囊小肠镜确诊为4例，诊断准确率为4／8例；在9例胶囊内镜阴性者中，双气囊小肠镜发现小肠肿瘤2例。59例患者中，经一侧进镜检查后（经口或经肛）发现小肠肿瘤36例，完成双侧检查后发现肿瘤16例。7例患者在双侧检查后未发现任何病变。双气囊小肠镜对小肠肿瘤的检出率为88．1％，并经病理和临床随访确诊。上述三项检查中未见明显的与操作相关的并发症。结论双气囊小肠镜在小肠肿瘤诊断率及准确率方面明显优于小肠稀钡灌注和胶囊内镜检查。     

Evaluation and outcomes of patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding(OGIB) is defined as recurrent or persistent bleeding or presence of iron deficiency anaemia after evaluation with a negative bidirectional endoscopy. OGIB accounts for 5% of gastrointestinal bleeding and presents a diagnostic challenge. Current modalities available for the investigation of OGIB include capsule endoscopy, balloon assisted enteroscopy, spiral enteroscopy and computed tomography enterography. These modalities overcome the limitations of previous techniques. Following a negative bidirectional endoscopy, capsule endoscopy and double balloon enteroscopy remain the cornerstone of investigation in OGIB given their high diagnostic yield. Longterm outcome data in patients with OGIB is limited, but is most promising for capsule endoscopy. This article reviews the current literature and provides an overview of the clinical evaluation of patients with OGIB, available diagnostic and therapeutic modalities and longterm clinical outcomes.     

双气囊小肠镜与胶囊内镜诊断小肠出血病因比较

目的比较双气囊小肠镜和胶囊内镜在小肠出血中的诊断准确率和实用价值。方法24例原因不明的可疑小肠出血患者分别接受双气囊小肠镜和胶囊内镜检查。双气囊小肠镜首选进镜方式分为经口或经肛2种，首选方式检查后未发现病灶者，日后改换进镜方式再行检查。胶囊内镜采用以色列GIVEN公司产品。2种检查方法分别由专门医师独立操作并诊断，最后进行汇总比较。结果24例患者中21例通过小肠镜检查发现病灶，总检出率为87．5％。24例患者行胶囊内镜检查后，有阳性发现者11例(45．8％)，另13例无异常发现。双气囊小肠镜检查发现的阳性病灶均经活检病理和手术探查证实，其病因诊断准确率为87．5％，胶囊内镜诊断准确率为25％。在耐受性评估方面，胶囊内镜和全麻下经口进镜的耐受性最佳，以后依次为非麻醉经肛方式和非麻醉经口方式。所有小肠镜和胶囊内镜检查者中未见操作相关的严重不良反应。结论①经口和经肛方式结合能使双气囊小肠镜完成对全小肠的检查。②双气囊小肠镜在不明原因小肠出血的病因诊断方面明显优于胶囊内镜检查。③胶囊内镜在小肠多节段病变和长段病变的诊断上仍有一定价值。④胶囊内镜和全麻下经口双气囊小肠镜检查是一项易为患者接受的、安全的检查方法。     

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: diagnostic and therapeutic approach

Obscure gastrointestinal bleeding (OGIB) is defined as an intermittent or continuous loss of blood in which the source has not been identified after upper endoscopy and colonoscopy. It constitutes a diagnostic and therapeutic challenge for the general internist and the gastroenterologist. This article provides an overview of the etiology, clinical presentation, and diagnostic modalities of OGIB including push enteroscopy, double balloon enteroscopy, wireless capsule endoscopy, enteroclysis, angiography, bleeding scanning with labeled red blood cells, and surgery with intraoperative enteroscopy. Therapeutic modalities including iron replacement, combined hormones, octreotide acetate, therapeutic endoscopy, and surgery are also discussed. In addition, a rational approach to patients with OGIB according to the clinical presentation is presented herein.     

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.     

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.     

Capsule endoscopy： Current status in obscure gastrointestinal bleeding

Capsule endoscopy (CE) is a safe, non invasive diagnostic modality for the evaluation of small bowel lesions. Obscure gastrointestinal bleeding (OGIB) is one of the most important indications of capsule endoscopy. Capsule endoscopy has a very high diagnostic yield especially if the bleeding is ongoing. This technique appears to be superior to other techniques for the detection of suspected lesions and the source of bleeding. Capsule endoscopy has been shown to change the outcome in patients with obscure gastrointestinal (GI) bleed.     

Fields of applications,diagnostic yields and findings of OMOM capsule endoscopy in 2400 Chinese patients

AIM:To retrospectively analyze the fields of application,diagnostic yields and findings of OMOM capsule endoscopy in Chinese patients.METHODS:A database including 2400 Chinese patients who received OMOM capsule endoscopy in 27 endoscopy centers in China was retrieved from the Jianshan Science and Technology Ltd.OMOM capsule endoscopy database.The patient's age,gender,fields of application,the potentially relevant findings,pyloric transit time(PTT),small bowel transit time(SBTT),and complete small-bowel exam...     

CAPSULE ENDOSCOPY FOR OBSCURE GASTROINTESTINAL BLEEDING IN THE TROPICS: REPORT FROM INDIA

Background: Capsule endoscopy (CE) is useful in patients with obscure gastrointestinal bleeding (OGIB). Experience in CE in OGIB in the tropics is limited. Methods: Eighty‐six patients with OGIB were evaluated clinically and using CE (Given Imaging, Yoqneam, Israel) 89 times (twice in three patients) during a 64‐month period. Images were downloaded and examined by a single investigator using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Patients received specific treatment and were followed up. Intraoperative findings, response to specific treatment and outcome on follow up (10.3 ± 14.1 months) were considered to confirm CE findings. Results: Of 86 patients (aged 54.5 ± 16.3 years, 63 males), 64 and 22 had OGIB‐overt and OGIB‐occult, respectively. Lesions were equally detected in OGIB‐overt and OGIB‐occult patients (48/64, 75% vs 18/22, 81.8%, P = ns). Lesions were detected in 64 of 86 (74.4%) patients [vascular malformations with or without fresh bleeding in 24 (37.5%), tumors in 12 (18.8%), strictures in 15 (23.4%), ulcers in five (7.8%), hookworm in five (7.8%), and more than one lesion in three patients (4.7%)]. Endoscopic insertion of the capsule was required in four patients, and in six it was retained, although none developed intestinal obstruction (surgical removal in two). The sensitivity, specificity, positive and negative predictive values of CE to detect the lesion(s) were 92.9%, 68.2%, 84.8%, and 83.3%, respectively. Conclusion: CE is safe and is equally effective in detecting lesion(s) in occult and overt OGIB. Worm infestation and small bowel tuberculosis are unique and important causes of OGIB in the tropics.     

Capsule and balloon endoscopy: When are they really needed in patients with inflammatory bowel diseases?

The evaluation of the small bowel in patients with suspected or established IBD is generally performed by radiologic techniques. Capsule endoscopy and balloon enteroscopy may offer additional advantages in the evaluation of small bowel inflammation in patients with suspected small bowel involvement but negative prior radiologic evaluation. This review summarizes the current clinical status of capsule and balloon enteroscopy in patients with suspected or established IBD.     

双气囊小肠镜与胶囊内镜在小肠出血应用中的对比研究

目的比较双气囊小肠镜与胶囊内镜在小肠出血中的病变检出率、病因诊断率、耐受性和安全性,初步探讨双气囊小肠镜对小肠出血的内镜下治疗。方法2006年4月至2009年10月烟台毓璜顶医院消化内科收治的可疑小肠出血患者159例,其中81例患者行双气囊小肠镜检查,首选进镜方式分为经口或经肛2种,首选方式检查后未发现病灶者,日后改换进镜方式再行检查。对活动性出血病灶行内镜下止血治疗。另78例患者行胶囊内镜检查。两组患者分别由专门医师独立操作并诊断,最后进行汇总分析,对比双气囊小肠镜与胶囊内镜的临床应用价值。结果双气囊小肠镜组的病变检出率为95.06%,病因诊断率为82.72%,23例检查时见病变活动性出血,行内镜下止血治疗,21例止血成功,内镜止血成功率为91.30%;胶囊内镜组的病变检出率82.05%,病因诊断率为66.67%。双气囊小肠镜组的病因检出率及病因诊断率均显著高于胶囊内镜组,差异有统计学意义(P0.05)。在耐受性方面,胶囊内镜的耐受性最好,双气囊小肠镜的耐受性依次为:全麻下经肛进镜、全麻下经口进镜、非麻醉经肛进镜、非麻醉经口进镜。所有患者均未发生严重并发症。结论双气囊小肠镜对小肠出血的病因诊断明显优于胶囊内镜,并且可行内镜下止血治疗,是一项安全、有效的临床诊疗方法。     

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.     

The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use

Background We report our preliminary experience with the use of video capsule endoscopy (VCE) in 64 patients with obscure gastrointestinal bleeding (OGIB) and suspected small intestine disease.Methods To be eligible for VCE, patients had to have undergone upper endoscopy, small bowel series, and colonscopy without discovering any source of bleeding. To find the best timing to perform VCE, the patients were retrospectively divided in two groups of 32 cases each: group 1 with patients who had been submitted to VCE within 15 days from OGIB diagnosis, and group 2 with patients who had been submitted to VCE at least 15 days after OGIB diagnosis.Results Lesions were found by VCE in 29 (91%) in group 1: angioectasia-like lesions of the small bowel in 12, some erosions of the ileum without signs of bleeding in 14, a polyp with erosions in 1, and a bleeding site where the surgery showed a tumor of the ileum in 2 patients. In 2 cases, VCE missed showing two small tumors that were revealed by laparoscopy in 1 case and by push enteroscopy in the other. In group 2, lesions were found by VCE in 11 (34%): angioectasia-like lesions of the small bowel in 6, some erosions in 3, a short segmental stenosis in 1, and two polyps in 1. In 1 case, VCE missed showing a small polyp in the jejunum that was revealed by push enteroscopy. In none of these cases was a bleeding site identified. VCE was well tolerated and able to acquire good images in patients with OGIB. It showed lesions in 91% of the patients in group 1 and 34% of cases in group 2.Conclusions Our data suggest that the optimal timing to perform VCE is within a few days after the occurrence of bleeding, possibly within 2 weeks.     

Enteroscopy in children and adults with inflammatory bowel disease

Inflammatory bowel disease(IBD) includes Crohn's disease(CD), ulcerative colitis and unclassified entities. CD commonly involves the terminal ileum and colon but at the time of diagnosis it can be confined to the small bowel(SB) in about 30% of the patients, especially in the young ones. Management of isolated SB-CD can be challenging and objective evaluation of the SB mucosa is essential in differentiating CD from other enteropathies to achieve therapeutic decisions and to plan the follow-up. The introduction of cross-sectional imaging techniques and capsule endoscopy(CE) have significantly expanded the ability to diagnose SB diseases providing a non-invasive test for the visualization of the entire SB mucosa. The main CE limitations are the low specificity, the lack of therapeutic capabilities and the impossibility to take biopsies. Device assisted enteroscopy(DAE) enables histological confirmation when traditional endoscopy, capsule endoscopy and cross-sectional imaging are inconclusive and also allows therapeutic interventions such as balloon stricture dilation, intralesional steroid injection, capsule retrieval and more recently stent insertion. In the current review we will discuss technical aspect, indications and safety profile of DAE in children and adults with IBD.     

Capsule enteroscopy in small bowel transplantation

BACKGROUND: Enteroscopy plays a key role in the post-operative monitoring of patients with small bowel transplantation for the early detection of post-transplant complications and for the assessment of the graft's integrity. Routine surveillance enteroscopies (trans-stomal terminal ileoscopy or jejunoscopy) are invasive, may be unsafe in frail patients, and only allow incomplete exploration of the transplanted graft, which may be unsatisfactory. since the distribution of the lesions is often patchy or segmental. AIMS. To evaluate the potential of capsule enteroscopy, a new, minimally invasive technique which allows complete exploration of the small bowel. in small bowel transplant recipients. METHODS: Five small bowel transplanted patients underwent capsule enteroscopy with the GIVEN endoscopy system. The results of capsule enteroscopy were compared with those of trans-stomal ileoscopy. RESULTS: Capsule enteroscopy was better tolerated than ileoscopy and good quality images of the small bowel were obtained in four patients. The terminal ileum was normal both on ileoscopy and capsule enteroscopy. Mucosal changes in segments not reached by ileoscopy were detected by capsule enteroscopy in three of four patients. CONCLUSIONS: Capsule enteroscopy is better tolerated than ileoscopy, allows complete exploration of the transplanted graft and can detect mucosal changes in segments not reached by ileoscopy.     

Capsule endoscopy: current indications and future prospects

Capsule endoscopy represents a significant advance in the investigation of small bowel diseases and the beginning of wireless endoscopic imaging. Capsule endoscopy involves swallowing a video capsule endoscope, which is painless and relatively safe. Its use has been established for suspected small bowel bleeding, and the role of capsule endoscopy in the investigation of inflammatory bowel disease, iatrogenic disease, polyposis syndromes and coeliac disease is evolving. It is likely that in many instances it will become the next test after standard endoscopic evaluation. Early data suggest that capsule endoscopy improves outcome in patients with suspected small bowel bleeding, but more data are required on outcomes for the other indications.     

小肠原发性肿瘤的临床表现与诊断

原发性小肠肿瘤在临床上较少见,其临床表现缺乏特异性,可表现为消化道出血、腹痛、腹块、肠梗阻等,因此诊断较为困难.目前常用的诊断方法包括小肠钡灌、多层螺旋CT小肠造影、磁共振小肠造影、胶囊内镜、双气囊小肠镜、经小肠镜超声检查、小肠血管造影等.对于临床怀疑小肠肿瘤的患者,应根据患者的具体情况选用各种检查方法以提高术前诊断率并缩短诊断时间.