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.     

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.     

胶囊内镜在小肠疾病中的应用进展

胶囊内镜（CE）技术发展迅速,已成为一线小肠无创检查技术之一,目前已广泛用于不明原因消化道出血（OGIB）、炎症性肠病、小肠肿瘤、乳糜泻和腹痛等的诊断,其与双气囊小肠镜（DBE）联合应用可提高小肠疾病的诊疗水平。本文就CE在小肠疾病中的应用进展作一综述。     

Clinical application of video capsule endoscopy

BACKGROUND: Non-invasive imaging of the complete small bowel has become possible with the recently available video capsule endoscopy technique. The aim of this study was to review and assess the possibilities and limitations of the clinical application of video capsule endoscopy. METHODS: Literature review. RESULTS: Video capsule endoscopy is a new promising technique with good to excellent visualization of the mucosa of the small bowel. It has a high diagnostic yield in patients with occult gastrointestinal blood loss (OGIB) and Crohn disease (CD). Several other indications need further study. Compared to small-bowel X-ray and push enteroscopy, diagnostic yield appears to be superior. Video capsule endoscopy is very well tolerated by patients. Its most important limitation is the impossibility of taking biopsies and therapeutic interventions. CONCLUSION: Video capsule endoscopy is a promising new diagnostic tool for small-bowel disease.     

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.     

Diagnostic yield of deep enteroscopy techniques for small-bowel bleeding and tumors

Endoscopic evaluation and management with deep enteroscopy techniques have largely replaced the role of intraoperative enteroscopy in the management of small-bowel (SB) disorders. While capsule endoscopy (CE) enables visualization of the entire SB, therapeutic deep enteroscopy techniques (balloon-assisted enteroscopy and spiral enteroscopy) facilitate diagnostic and therapeutic management deep within the SB. CE is currently recommended as the third test of choice in the evaluation of obscure gastrointestinal bleeding after a negative bidirectional endoscopy. The test also has a role in the diagnosis of SB tumors and surveillance of familial polyposis syndromes. Therapeutic deep enteroscopy techniques are mainly used for evaluation and management of CE findings, but they may also have a role in patients with a negative CE but high clinical suspicion for an SB disorder. Because preliminary data suggest a comparable diagnostic and therapeutic yield with double-balloon, single-balloon, and spiral enteroscopy, selection of the enteroscope should be based on availability and the endoscopist's experience with the technique.     

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.     

Capsule endoscopy in neoplastic diseases

Until recently, diagnosis and management of small-bowel tumors were delayed by the diffi culty of access to the small bowel and the poor diagnostic capabilities of the available diagnostic techniques. An array of new methods has recently been developed, increasing the possibility of detecting these tumors at an earlier stage. Capsule endoscopy （CE） appears to be an ideal tool to recognize the presence of neoplastic lesions along this organ, since it is non-invasive and enables the entire small bowel to be visualized. High- quality images of the small-bowel mucosa may be captured and small and ？ at lesions recognized, without exposure to radiation. Recent studies on a large population of patients undergoing CE have reported small-bowel tumor frequency only slightly above that reported in previous surgical series （range, 1.6%-2.4%） and have also confirmed that the main clinical indication to CE in patients with small-bowel tumors is obscure gastrointestinal （GI） bleeding. The majority of tumors identified by CE are malignant; many were unsuspected and not found by other methods. However, it remains difficult to identify pathology and tumor type based on the lesion’s endoscopic appearance. Despite its limitations, CE provides crucial information leading in most cases to changes in subsequent patient management. Whether the use of CE in combination with other new diagnostic （MRI or multidetector CT enterography） and therapeutic （Push- and-pull enteroscopy） techniques will lead to earlier diagnosis and treatment of these neoplasms, ultimately resulting in a survival advantage and in cost savings,remains to be determined through carefully-designed studies.     

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.     

Five years' experience with capsule endoscopy in a single Center

Capsule endoscopy (CE) is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding (OGIB) has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases.Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn's disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.     

Five years＇experience with capsule endoscopy in a single center

Capsule endoscopy （CE） is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding （OGIB） has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases. Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn＇s disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.     

胶囊内镜诊断不明原因消化道出血107例

目的:探讨胶囊内镜在不明原因消化道出血中的诊断价值及其与双气囊小肠镜在病因诊断中联合应用的意义。方法:采用M2A胶囊内镜对107例不明原因消化道出血患者进行检查,其中男61例,女46例,平均年龄(51.6±18.9)岁。其中36例患者依据胶囊内镜所观察到的结果,选择经口或经肛行双气囊小肠镜检查和(或)手术探查。结果:107例患者中106例(99.1%)完成胶囊内镜检查,75例(70.8%)胶囊内镜通过回盲瓣。107例中病变检出96例(89.7%)、确诊70例(65.4%)。36例中再经双气囊小肠镜检查和(或)手术后证实胶囊内镜诊断者为26例(72.2%)。2例(1.9%)发生胶囊滞留。结论:胶囊内镜对不明原因消化道出血具有较高的诊断价值,可作为病因诊断的首选筛查手段,与双气囊小肠镜联合应用可大大提高疾病的确诊率。     

Obscure gastrointestinal bleeding: single centre experience of capsule endoscopy

The advent of capsule endoscopy (CE) has resulted in a paradigm shift in the approach to the diagnosis and management of patients with obscure gastrointestinal bleeding (OGIB). With increasing global availability of this diagnostic tool, it has now become an integral part of the diagnostic algorithm for OGIB in most parts of the world. However, there is scant data on optimum timing of CE for maximizing diagnostic yield. OGIB continues to be a challenge because of delay in diagnosis and consequent morbidity and mortality. We evaluated the diagnostic yield of CE in identifying the source of bleeding in patients with OGIB. We identified patients who underwent CE at our institution from May 2006 to May 2011. The patients’ medical records were reviewed to determine the type of OGIB (occult, overt), CE results and complications, and timing of CE with respect to onset of bleeding. Out of 346 patients investigated for OGIB, 246 (71.1%) had some lesion detected by CE. In 206 patients (59.5%), definite lesions were detected that could unequivocally explain the OGIB. Small bowel angiodysplasia, ulcer/erosions secondary to Crohn’s disease, non-steroidal anti-inflammatory agent use, and neoplasms were the commonest lesions detected. Visualization of the entire small bowel was achieved in 311 (89.9%) of cases. Capsule retention was noted in five patients (1.4%). In this study, CE was proven to be a safe, comfortable, and effective, with a high rate of accuracy for diagnosing OGIB.     

胶囊内镜与单气囊小肠镜对可疑小肠疾病的诊断价值

目的比较胶囊内镜与单气囊小肠镜对小肠疾病的诊断价值。方法 2009年6月-2011年12月共有37例疑诊为小肠疾病的患者接受了胶囊内镜(CE)和单气囊小肠镜(SBE)检查。比较两种检查方法对小肠疾病的检出情况。结果在37例患者中,CE检查发现阳性病变28例,总体诊断率为75.68%(28/37),SBE检查发现阳性病变33例,总体诊断率为89.19%(33/37),两者之间差异无统计学意义(P=0.221)。CE和SBE检查结果不一致,CE检查阳性而SBE检查阴性3例,CE检查阴性而SBE检查阳性8例,CE和SBE检查均阴性1例。CE全小肠检查完成率为94.59%(35/37);SBE全小肠检查完成率为57.14%(4/7)。两种检查方法均未发生严重并发症。结论胶囊内镜和单气囊小肠镜对小肠疾病的诊断价值相当。     

Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding

BACKGROUND AND AIMS: Capsule endoscopy (CE) is superior to push enteroscopy and small bowel barium radiography in detecting the source of obscure GI bleeding. We now compared whether CE has a superior diagnostic yield than CT angiography (CTA) or standard mesenteric angiography (ANGIO) in patients with obscure GI bleeding. METHODS: From June 2004 to October 2005, consecutive patients admitted for OGIB underwent both CTA and ANGIO, followed by CE, performed blindly by independent examiners within the next 7 days. The primary end point of the study was the diagnostic yield for each technique, defined as the frequency of detection of lesions with a high probability of bleeding. RESULTS: Twenty-eight patients (16 men and 12 women, mean age 74 +/- 2 yr) with OGIB (overt bleeding in 20 cases and chronic occult in 8) were prospectively evaluated. CTA or standard angiography could be performed in 25 of 28 patients (applicability 86%), because of contrast allergy (1 patient) and chronic renal failure (2 patients). A source of bleeding was detected by CE in a greater proportion of patients, 72% (18 of 25, 95% CI 50.6-87.9%), than CTA, 24% (6 of 25, 95% CI 9.4-45.1%, P= 0.005 vs CE), or ANGIO, 56% (14 of 25, 95% CI 34.9-75.6%, P= NS). Similarly, CE was able to diagnose 100% of patients diagnosed by CTA and 86% of patients diagnosed by ANGIO. Moreover, CE was positive in 12 of 19 (63%) negative cases on CTA and in 6 of 11 (55%) negative cases on ANGIO. As a result of the CE findings, therapeutic intervention was undertaken in 9 of 19 (47%) patients with positive results. CONCLUSION: CE detects more lesions than CTA or standard mesenteric angiography in patients with obscure GI bleeding and has a therapeutic impact in almost half of the patients with positive findings.     

Capsule endoscopy:Present status and future expectation

Video capsule endoscopy(CE)since its introduction 13years back,has revolutionized our approach to small intestinal diseases.Obscure gastrointestinal bleed(OGIB)continues to be the most important indication for CE with a high sensitivity,specificity as well as positive and negative predictive values.It is best performed during ongoing bleed or immediately thereafter.Overt OGIB has a higher diagnostic yield than occult OGIB.However,even in iron deficiency anemia,CE is emerging as important investigation after initial negative work up.In suspected Crohn’s disease(CD),CE has been shown superior to traditional imaging and endoscopic technique and should be considered after a negative ileocolonoscopy.Although CE has also been used for evaluating established CD,a high capsule retention rate precludes its use ahead of cross-sectional imaging.Celiac disease,particularly where gastro-duodenoscopy cannot be performed or is normal,can also be investigated by CE.Small bowel tumor,hereditary polyposis syndrome,and non-steroidal anti-inflammatory drugs induced intestinal damage are other indications for CE.Capsule retention is the only significant adverse outcome of CE and occurs mostly in presence of intestinal obstruction.This can be prevented by use of Patency capsule prior to CE examination.Presence of cardiac pacemaker and intracardiac devices continue to be relative contraindications for CE,though data do not suggest interference of CE with these devices.Major limitations of CE today include failure to control its movement from outside,inability of CE to acquire tissue for diagnosis,and lack of therapeutic help.With ongoing interesting and exciting developments taking place in these areas,these issues would be solved in all probability in near future.CE has the potential to become one of the most important tools in diagnostic and possibly in the therapeutic field of gastrointestinal disorder.     

Capsule endoscopy: a comprehensive review

The development of wireless capsule endoscopy (CE) has been a significant technologic advancement for the non-invasive visual evaluation of the entire small bowel and esophagus. The capsule endoscope is disposable and measures 11 x 26 mm. There are two capsule endoscopes currently available: PillCam ESO and PillCam SB for the evaluation of the esophagus and the small bowel, respectively. The PillCam ESO has two cameras on each end and captures images 7 frames per second per each camera, while the PillCam SB has one camera and captures images at a rate of 2 frames per second. Both capsule endoscopes transmit the image data using a radiofrequency signal to a recording device worn on the patient's waist. Once image acquisition is completed, the data from the recording device is downloaded to a computer workstation and analyzed by a gastroenterologist. Common indications for the small bowel CE include obscure gastrointestinal bleeding (OGIB), suspected Crohn disease (CD), as well as other suspected small bowel pathologies, while indications for the esophageal CE include screening of Barrett esophagus and esophageal varices. Small bowel CE appears to be more sensitive in the evaluation of OGIB and small bowel CD compared with other conventional radiological and endoscopic modalities. Preliminary results for the esophageal CE reveal good accuracy for screening of both Barrett and esophageal varices. CE is well tolerated by most patients, requires no sedation, and carries few side effects. One of the complications of CE is capsule retention; however, a patency capsule system has been developed, which can indicate whether an obstructing lesion is present before CE is performed. Finally, there are preliminary data suggesting that a new capsule endoscope for the colon may be useful in the evaluation of patients for colon polyps and possibly, screening for colon cancer.     

The small bowel as a source of gastrointestinal blood loss

The small bowel is a rare but important source of blood loss from the gastrointestinal (GI) tract. In approximately 5% of all patients with GI bleeding, no cause for the bleeding is evident even after an extensive workup. This bleeding is often termed "gastrointestinal bleeding of obscure origin" or "obscure gastrointestinal bleed" (OGIB). Recent advancements in enteroscopy have contributed to a better understanding of the small bowel as a source of bleeding. On average, 27% of patients with OGIB have been shown to have lesions in the small bowel, with common findings including arteriovenous malformations (AVMs) and small bowel tumors. The trend in primary diagnostic workup for obscure GI bleeding or suspected small bowel lesions is shifting toward enteroscopic examination. Availability of an accessory channel now offers the clinician management options such as endoscopic injection therapy, electrocautery, and polypectomy. The "gold standard" for examination of the entire small bowel is intraoperative enteroscopy. A newer technique involving laparascopic assistance may lower the morbidity associated with this examination. Combined hormonal therapy may be an alternative treatment for patients with AVMs or an unknown cause of bleeding after enteroscopic examination.     

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.