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Dolu S, Arayici ME, Onem S, Buyuktorun I, Dongelli H, Bengi G, Akarsu M. Evaluation of double-balloon enteroscopy in the management of type 1 small bowel vascular lesions (angioectasia): a retrospective cohort study. BMC Gastroenterol 2025; 25:15. [PMID: 39806314 PMCID: PMC11727186 DOI: 10.1186/s12876-025-03591-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 01/03/2025] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND Small-bowel angioectasia is commonly diagnosed and managed using double-balloon enteroscopy; however, rebleeding rates can vary significantly. This study aimed to identify and evaluate the clinical predictors of rebleeding in patients with small-bowel angioectasia. METHODS This retrospective study focused on adult patients who underwent endoscopic management for small bowel vascular lesions (SBVLs). A total of 67 patients were included in the study, all of whom were retrospectively analyzed. The SBVLs were classified using the Yano et al. classification system. Among these, 62 patients with angioectasia who received endoscopic treatment were specifically analyzed. To further investigate the clinical outcomes, the angioectasia group that required endoscopic treatment was divided into two subgroups based on the number of double-balloon enteroscopy (DBE) procedures performed. Univariate and multivariate binary logistic regression analyses were used to establish which predictor variables were significantly related to the recurrence. RESULTS A total of 67 patients (mean age 68.1 ± 8.9 years; 44 males) with SBVL, angioectasia was diagnosed in 62 (92.5%) patients, dieulafoy lesion in 1 (1.5%) patient, and arteriovenous malformation in 4 (6%) patients. Similarly, the prevalence of chronic renal failure and diabetes mellitus were significantly higher in the multiple DBE endotherapy group compared to the single DBE endotherapy group (p < 0.001; p = 0.032, respectively). In multivariate logistic regression analysis, anticoagulant use (OR = 9.648, 95% CI: 1.729-53.817, p = 0.010), chronic renal failure (OR = 15.683, 95% CI: 2.727-90.203, p = 0.002), localization of duodenum (OR = 13.509, 95% CI: 1.598-114.168, p = 0.017), and localization of the ileum (OR = 17.100, 95% CI: 1.477-197.905, p = 0.023) were all independently associated with a higher risk of angioectasia recurrence. CONCLUSIONS The findings of this study demonstrates a high success rate of endoscopic treatment, with a rebleeding rate of 27%, highlighting the significance of this approach. Chronic renal failure, use of anticoagulant, and lesion localization in the duodenum or ileum were identified as independent risk factors for rebleeding, underscoring the need for careful patient monitoring and targeted intervention in these cases.
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Affiliation(s)
- Suleyman Dolu
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey.
| | - Mehmet Emin Arayici
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
- Department of Public Health, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Soner Onem
- Department of Gastroenterology, Gazi State Hospital, Samsun, Turkey
| | - Ilker Buyuktorun
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Huseyin Dongelli
- Department of Internal Medicine, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Goksel Bengi
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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Azancot S, Dray X, Moshiri P, Soualy A, Guilloux A, Michel PA, Boffa JJ, Becq A. Gastrointestinal Angiectasia in patients with chronic kidney disease: A matched case-control study. Clin Res Hepatol Gastroenterol 2024; 48:102454. [PMID: 39179202 DOI: 10.1016/j.clinre.2024.102454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/16/2024] [Accepted: 08/20/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND AND STUDY AIMS Chronic kidney disease (CKD) is a well-known risk factor of gastrointestinal angiectasia (GIA). The aim was to compare this population with CDK patients without GIA. METHODS Patients followed in the Nephrology Department of Tenon Hospital for which an endoscopy was performed between 2012 and 2022 were identified. Those with at least one GIA lesion were included ("GIA+" group). A matched control group for age, sex and GFR stage of patients with CKD and no GIA lesion ("GIA-" group) was constituted. A subgroup analysis compared patients with (SB+) and without (SB-) small-bowel involvement. RESULTS A total of 55 patients were included in the GIA+ group. 36.3 % (n = 20) were active smokers and 29.1 % (n = 16) had peripheral arterial disease versus 16.4 % (n = 9) (OR 2.89, p = 0.03), and 9.1 % (n = 5) (OR 4.05, p = 0.015) in the GIA- group. Thirteen patients (23.6 %) had a SB lesion. Duodenal involvement was present in 69.2 % of cases in the SB+ group versus 28.6 % in the SB- group (p = 0.02). Median number of endoscopies, hemostatic technics and hospitalizations was 7, 3 and 6, versus 2 (p = 0.0001), 1 (p = 0.001) and 1 (p = 0.0002) in the SB- group. CONCLUSIONS CKD patients with GIA had a greater cardiovascular risk with a higher incidence of vascular nephropathy. Small-bowel GIA were associated with a higher morbidity.
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Affiliation(s)
- Sarah Azancot
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France
| | - Xavier Dray
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Adil Soualy
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France
| | - Antoine Guilloux
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Jean Jacques Boffa
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France; Sorbonne University, INSERM U1155 CORAKID, Paris, France
| | - Aymeric Becq
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France.
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Zhang FB, Zhang JP, Bai YQ, Zhang DJ, Cao XG, Guo CQ. Effect of Abdominal Compression on Total Single-Balloon Enteroscopy Rate: A Randomized Controlled Trial. Mayo Clin Proc 2023; 98:1660-1669. [PMID: 37923523 DOI: 10.1016/j.mayocp.2023.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/02/2023] [Accepted: 02/24/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To evaluate whether abdominal compression significantly increased the total enteroscopy rate in single-balloon enteroscopy (SBE). METHODS Consecutive patients who underwent SBE at 2 hospitals were prospectively included between June 1, 2020, and September 30, 2021. They were randomly divided into an abdominal compression group and a non-abdominal compression group with use of sealed envelopes generated by a computer. Total enteroscopy rates were compared between the groups. RESULTS The study included 200 patients. The total enteroscopy rates were 73% and 16% in the abdominal compression and non-abdominal compression groups, respectively (relative risk, 13.55; 95% CI, 6.79 to 27.00; P<.001). The total enteroscopy rate was higher in the 70 patients who were identified to have undergone no previous abdominal surgery or small intestinal stenosis than in the 32 patients who had undergone such procedures in the abdominal compression group (84% vs 47%; relative risk, 6.08; 95% CI, 2.36 to 15.67; P<.001). Relevant positive findings were not significantly different between the groups (58% vs 45%; P=.07). Binary logistic regression analysis found abdominal compression to be associated with a better total enteroscopy rate (odds ratio, 16.68; 95% CI, 7.92 to 35.15; P<.001), and the presence of previous abdominal surgery or small intestinal stenosis was associated with difficulty in completing the total enteroscopy procedure (odds ratio, 0.26; 95% CI, 0.12 to 0.58; P<.01). CONCLUSION Abdominal compression significantly increased the total enteroscopy rate in SBE. Complete total enteroscopy may be challenging in patients with a history of abdominal surgery or small intestinal stenosis.
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Affiliation(s)
- Fang-Bin Zhang
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Jin-Ping Zhang
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang-Qiu Bai
- Department of Gastroenterology, Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Du-Juan Zhang
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin-Guang Cao
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chang-Qing Guo
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Lee HH, Kim JS, Goong HJ, Lee SH, Oh EH, Park J, Kim MC, Nam K, Yang YJ, Kim TJ, Nam SJ, Moon HS, Kim JH, Kim DH, Kim SE, Jeon SR, Myung SJ. [Use of Device-Assisted Enteroscopy in Small Bowel Disease: An Expert Consensus Statement by the Korean Association for the Study of Intestinal Diseases]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 81:1-16. [PMID: 36695062 DOI: 10.4166/kjg.2022.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/03/2022] [Accepted: 12/06/2022] [Indexed: 01/26/2023]
Abstract
The introduction of device-assisted enteroscopy (DAE) in the beginning of the 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of small bowel diseases, DAE has the unique advantages of allowing the observation of the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how it is to be performed and what technical factors should be taken into consideration. In response to these needs, the Korean Association for the Study of Intestinal Diseases has developed an expert consensus statement on the performance of DAE by reviewing current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.
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Affiliation(s)
- Han Hee Lee
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Su Kim
- Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon Jeong Goong
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Shin Hee Lee
- Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Eun Hye Oh
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jihye Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Cheol Kim
- Department of Internal Medicine, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Kwangwoo Nam
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Young Joo Yang
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Tae Jun Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Joo Nam
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lee HH, Kim JS, Goong HJ, Lee SH, Oh EH, Park J, Kim MC, Nam K, Yang YJ, Kim TJ, Nam SJ, Moon HS, Kim JH, Kim DH, Kim SE, Jeon SR, Myung SJ. Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases. Intest Res 2023; 21:3-19. [PMID: 36751042 PMCID: PMC9911273 DOI: 10.5217/ir.2022.00108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/12/2022] [Indexed: 02/09/2023] Open
Abstract
The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.
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Affiliation(s)
- Han Hee Lee
- Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Su Kim
- Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon Jeong Goong
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Shin Hee Lee
- Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Eun Hye Oh
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jihye Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Min Cheol Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kwangwoo Nam
- Department of Gastroenterology, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Young Joo Yang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Tae Jun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Joo Nam
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea,Co-Correspondence to: Seong Ran Jeon, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea. Tel: +82-2-709-9202, Fax: +82-2-709-9581, E-mail:
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea,Correspondence to Seung-Jae Myung, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3917, Fax: +82-2-476-0824, E-mail:
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Quality indicators for capsule endoscopy and deep enteroscopy. Gastrointest Endosc 2022; 96:693-711. [PMID: 36175176 DOI: 10.1016/j.gie.2022.08.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method. METHODS An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method. RESULTS The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE. CONCLUSIONS Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.
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Abstract
INTRODUCTION Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method. METHODS An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method. RESULTS The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE. DISCUSSION Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.
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Kim Y, Kim JH, Kang EA, Park SJ, Park JJ, Cheon JH, Kim TI, Park J, Jeon SR. Rebleeding Rate and Risk Factors for Rebleeding after Device-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study. Diagnostics (Basel) 2022; 12:diagnostics12040954. [PMID: 35454002 PMCID: PMC9027880 DOI: 10.3390/diagnostics12040954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/01/2022] [Accepted: 04/10/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: The impact of device-assisted enteroscopy (DAE) on long-term rebleeding in patients with obscure gastrointestinal bleeding (OGIB) exhibiting detectable small-bowel lesions remains unclear. We investigated the long-term rebleeding rate and predictive factors for DAE in patients with OGIB. Method: Patients with OGIB with small bowel lesions detected through DAE were enrolled at three Korean tertiary hospitals. Predictive risk factors associated with rebleeding were analyzed using the Cox regression analysis. Results: From April 2008 to April 2021, 141 patients were enrolled, including 38 patients (27.0%) with rebleeding. The rebleeding rates at 1, 2, and 3 years were 25.0%, 29.6%, and 31.1%, respectively. The Cox regression analysis revealed that multiple small-bowel lesions (hazard ratio [HR]: 2.551, 95% confidence interval [CI]: 1.157–5.627, p = 0.020), the need for more than five packed red blood cells (RBC) transfusions (HR: 2.704, 95% CI: 1.412–5.181, p = 0.003), and ulcerative lesions (HR: 1.992, 95% CI: 1.037–3.826, p = 0.039) were positively associated with rebleeding. Therapeutic interventions for patients with detectable lesions, overt bleeding (vs. occult bleeding), comorbidities, and medications were not associated with rebleeding. Conclusion: More than 25% of patients with OGIB having detectable small-bowel lesions had rebleeding. Patients with multiple lesions, a requirement of more than five packed RBC transfusions, and ulcerative lesions were associated with a higher risk of rebleeding.
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Affiliation(s)
- Yuna Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (Y.K.); (E.-A.K.); (S.-J.P.); (J.-J.P.); (J.-H.C.); (T.-I.K.)
| | - Jae-Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, Korea;
| | - Eun-Ae Kang
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (Y.K.); (E.-A.K.); (S.-J.P.); (J.-J.P.); (J.-H.C.); (T.-I.K.)
| | - Soo-Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (Y.K.); (E.-A.K.); (S.-J.P.); (J.-J.P.); (J.-H.C.); (T.-I.K.)
| | - Jae-Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (Y.K.); (E.-A.K.); (S.-J.P.); (J.-J.P.); (J.-H.C.); (T.-I.K.)
| | - Jae-Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (Y.K.); (E.-A.K.); (S.-J.P.); (J.-J.P.); (J.-H.C.); (T.-I.K.)
| | - Tae-Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (Y.K.); (E.-A.K.); (S.-J.P.); (J.-J.P.); (J.-H.C.); (T.-I.K.)
| | - Jihye Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea; (Y.K.); (E.-A.K.); (S.-J.P.); (J.-J.P.); (J.-H.C.); (T.-I.K.)
- Correspondence: (J.P.); (S.-R.J.)
| | - Seong-Ran Jeon
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University College of Medicine, Seoul 04401, Korea
- Correspondence: (J.P.); (S.-R.J.)
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Shao XD, Shao HT, Wang L, Zhang YG, Tian Y. Clinical Outcomes of Negative Balloon-Assisted Enteroscopy for Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:772954. [PMID: 35308514 PMCID: PMC8931682 DOI: 10.3389/fmed.2022.772954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Background For patients with obscure gastrointestinal bleeding (OGIB), finding the bleeding site is challenging. Balloon-assisted enteroscopy (BAE) has become the preferred diagnostic modality for OGIB. The long-term outcome of patients with negative BAE remains undefined. The present study aimed to evaluate the long-term outcomes of patients with negative BAE results for OGIB and to clarify the effect of further investigations at the time of rebleeding with a systematic review and meta-analysis of the available cohort studies. Methods Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following indexes were analyzed: rebleeding rate after negative BAE, rebleeding rate after different follow-up periods, the proportion of patients who underwent further evaluation after rebleeding, the percentage of patients with identified rebleeding sources, and the percentage of patients with rebleeding sources in the small intestine. Heterogeneity was assessed using the I2 test. Results Twelve studies that involved a total of 407 patients were included in the analysis. The pooled rebleeding rate after negative BAE for OGIB was 29.1% (95% CI: 17.2–42.6%). Heterogeneity was significant among the studies (I2 = 88%; p < 0.0001). The Chi-squared test did not show a difference in rebleeding rates between the short and long follow-up period groups (p = 0.142). The pooled proportion of patients who underwent further evaluation after rebleeding was 86.1%. Among the patients who underwent further evaluation, rebleeding sources were identified in 73.6% of patients, and 68.8% of the identified rebleeding lesions were in the small intestine. Conclusion A negative result of BAE in patients with OGIB indicates a subsequently low risk of rebleeding. Further evaluation should be considered after rebleeding.
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Affiliation(s)
- Xiao Dong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- *Correspondence: Xiao Dong Shao
| | - Hao Tian Shao
- School of Basic Medical Sciences, Guangxi Medical University, Nanning, China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yong Guo Zhang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Ye Tian
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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Liu S, Dong T, Shi Y, Luo H, Xue X, Zhu Y, Wang X, Wang B, Liang S, Pan Y, Guo X, Wu K. Water exchange-assisted versus carbon dioxide-insufflated single-balloon enteroscopy: a randomized controlled trial. Endoscopy 2022; 54:281-289. [PMID: 33754332 DOI: 10.1055/a-1459-4571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Single-balloon enteroscopy (SBE) is a valuable but difficult modality for the diagnosis and treatment of small-bowel disease. The water exchange method has the advantage of facilitating intubation during colonoscopy. Here, we evaluated the effects of water exchange on procedure-related variables related to SBE. METHODS This randomized controlled trial was conducted in a tertiary-care referral center in China. Patients due for attempted total enteroscopy were randomly allocated to undergo water exchange-assisted (water exchange group) or carbon dioxide-insufflated enteroscopy (CO2 group). All patients were planned to undergo both anterograde and retrograde procedures. The primary outcome was the total enteroscopy rate. Secondary outcomes included the maximal insertion depth, positive findings, procedural time, and adverse events. RESULTS In total, 110 patients were enrolled, with 55 in each group. Baseline characteristics between the two groups were comparable. Total enteroscopy was achieved in 58.2 % (32/55) of the water exchange group and 36.4 % (20/55) of the control group (P = 0.02). The mean (standard deviation) estimated intubation depth was 521.2 (101.4) cm in the water exchange group and 481.6 (95.2) cm in the CO2 group (P = 0.04). The insertion time was prolonged in the water exchange group compared with the CO2 group (178.9 [45.1] minutes vs. 154.2 [27.6] minutes; P < 0.001). Endoscopic findings and adverse events were comparable between the two groups. CONCLUSIONS The water exchange method improved the total enteroscopy rate and increased the intubation depth during SBE. The use of water exchange did not increase the complications of enteroscopy.
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Affiliation(s)
- Shaopeng Liu
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tao Dong
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yupeng Shi
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Luo
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xianmin Xue
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yijin Zhu
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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11
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Noujaim MG, Parish A, Raines D, Gross SA, Cave D, Vance I, Beyer D, Liu D, Hoffman B, Lawrence Z, Castillo G, Pavri T, Niedzwiecki D, Wild D. Use, Yield, and Risk of Device-assisted Enteroscopy in the United States: Results From a Large Retrospective Multicenter Cohort. J Clin Gastroenterol 2021; 55:792-797. [PMID: 32947375 DOI: 10.1097/mcg.0000000000001426] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Since 2001, device-assisted enteroscopy (DAE) has revolutionized the diagnostic and therapeutic capabilities for managing small bowel pathology. Though commonly performed, there have been no recent large studies to assess the use, yield, and risks of DAE and none that include all 3 DAE modalities. We hypothesized that DAE is safe with high diagnostic and therapeutic yields achieved within reasonable procedure duration and here we present a large retrospective multicenter US study evaluating the use, yield, and complications of DAE. METHODS After obtaining institutional review board approval, electronic records were used to identify all DAE's performed for luminal small bowel evaluation in adult patients at 4 US referral centers (Duke University Medical Center, New York University Langone Medical Center, Louisiana State University Health Sciences Center, and University of Massachusetts Medical Center) from January 1, 2014 to January 1, 2019. Electronic medical records were reviewed to collect and analyze a variety of procedure-related outcomes. Using the data pooled across centers, descriptive statistics were generated for the patient and procedure-related characteristics and outcomes; relationships between characteristics and outcomes were explored. RESULTS A total of 1787 DAE's were performed over this 5-year period (392 at Duke University Medical Center, 887 at Louisiana State University Health Sciences Center, 312 at New York University Langone Medical Center, and 195 at University of Massachusetts Medical Center). Of these, there were 1017 (57%) double-balloon, 391 (29%) single-balloon, and 378 (21%) spiral enteroscopies. The mean age of patients undergoing DAE was 66 years and 53% of examinations were performed on women; 18% of patients in the cohort underwent >1 DAE over this time span. A total of 53% of examinations were performed for suspected small bowel bleeding, 31% were directly guided by video capsule endoscopy findings and 8% were performed for abnormal imaging. A total of 85% of examinations used an antegrade approach and DAE took a mean of 45 minutes to complete; 76% of examinations revealed abnormal findings, with vascular, inflammatory, and neoplastic findings seen in 49%, 17%, and 15% of the cohort, respectively. Older age was significantly associated with any abnormal finding, including arteriovenous malformations (P<0.0001); 50% of examinations included a therapeutic maneuver, most commonly argon plasma coagulation/cautery (43%). There were complications in 16 examinations (0.9%) including 2 perforations (0.1%), 6 cases with bleeding (0.3%) and 1 episode of pancreatitis (0.1%). CONCLUSIONS DAE is most commonly performed to evaluate suspected small bowel bleeding and is commonly directed by video capsule findings. DAE is safe, has a high diagnostic yield, with 76% of examinations showing abnormal findings, and frequently features therapeutic maneuvers. Advancing age is associated with abnormal findings on DAE.
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Affiliation(s)
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Daniel Raines
- Division of Gastroenterology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Seth A Gross
- Division of Gastroenterology, New York University Medical Center, New York, NY
| | - David Cave
- Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | - Iris Vance
- Division of Gastroenterology, Duke University Medical Center
| | - David Beyer
- Division of Gastroenterology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Diana Liu
- Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | - Benjamin Hoffman
- Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | - Zoe Lawrence
- Division of Gastroenterology, New York University Medical Center, New York, NY
| | - Gabriel Castillo
- Division of Gastroenterology, New York University Medical Center, New York, NY
| | - Tanya Pavri
- Division of Gastroenterology, New York University Medical Center, New York, NY
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Daniel Wild
- Division of Gastroenterology, Duke University Medical Center
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12
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Zaver HB, Ghoz H, Stancampiano F, Alnahhal KI, Malviya B, Patel K, Rodriguez AC, Oberoi M, Koralewski A, Crawford MJ, Choudhry A, Mareth K, Werlang ME, Kroner PT, Simons-Linares CR, Lukens F, Bartel MJ, Stark M, Brahmbhatt B. Risk of bleeding following double balloon enteroscopy in patients on continued antiplatelet and/or anticoagulation therapy. Endosc Int Open 2021; 9:E1397-E1403. [PMID: 34466365 PMCID: PMC8382496 DOI: 10.1055/a-1499-6988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/25/2021] [Indexed: 11/03/2022] Open
Abstract
Background and study aims Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P = 0.12) or 1 year (19.9 % vs 15.7 %, P = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.
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Affiliation(s)
- Himesh B. Zaver
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | | | - Khaled I. Alnahhal
- Division of Vascular Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Balkishan Malviya
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | - Krupa Patel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | - Andrea C. Rodriguez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | - Mansi Oberoi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | - Andrea Koralewski
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Matthew J. Crawford
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Aruj Choudhry
- Division of Gastroenterology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, United States
| | - Karl Mareth
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Monia E. Werlang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | - Paul T. Kroner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | | | - Frank Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | - Michael J. Bartel
- Division of Gastroenterology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, United States
| | - Mark Stark
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, United States
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13
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Pérez-Cuadrado Robles E, Pinho R, González-Suárez B, Mão-de-Ferro S, Chagas C, Esteban Delgado P, Carretero C, Figueiredo P, Rosa B, García-Lledó J, Nogales Ó, Ponte A, Andrade P, Juanmartiñena-Fernández JF, San-Juan-Acosta M, Lopes S, Prieto-Frías C, Egea Valenzuela J, Caballero N, Valdivieso-Cortázar E, Cardoso H, Gálvez C, Almeida N, Borque Barrera P, Gómez Rodríguez BJ, Sánchez Ceballos FL, Bernardes C, Alonso-Aguirre PA, Argüelles Arias F, Mascarenhas Saraiva M, Pérez-Cuadrado Martínez E. Small bowel enteroscopy - A joint clinical guideline by the Spanish and Portuguese small-bowel study groups. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 112:309-318. [PMID: 32188259 DOI: 10.17235/reed.2020.7020/2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small-bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication, and its diagnostic and therapeutic yield. A set of recommendations was issued accordingly.
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Affiliation(s)
| | - Rolando Pinho
- Gastroenterología, Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | | | - Susana Mão-de-Ferro
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa. E.P.E., Portugal
| | | | | | | | - Pedro Figueiredo
- Gastroenterology , Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Bruno Rosa
- Gastroenterology, Hospital Senhora da Oliveira, Portugal
| | | | - Óscar Nogales
- Aparato Digestivo, Hospital General Universitario Gregorio Marañón, España
| | - Ana Ponte
- Centro Hospitalar Vila Nova de GaiaEspinho, Portugal
| | | | | | | | - Sandra Lopes
- Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Portugal
| | | | | | - Noemí Caballero
- Gastrointestinal Endoscopy, Hospital Universitario Germans Trias i Pujol, Spain
| | | | | | - Consuelo Gálvez
- Gastroenterología, Hospital Clínico Universitario de Valencia, Spain
| | - Nuno Almeida
- Gastroenterology , Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Pilar Borque Barrera
- Aparato Digestivo. Unidad de Endoscopia, Hospital Universitario Nuestra Sra. de Candelaria, España
| | | | | | - Carlos Bernardes
- Gastroenterology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Portugal
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14
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Rosa B, Margalit-Yehuda R, Gatt K, Sciberras M, Girelli C, Saurin JC, Cortegoso Valdivia P, Cotter J, Eliakim R, Caprioli F, Baatrup G, Keuchel M, Ellul P, Toth E, Koulaouzidis A. Scoring systems in clinical small-bowel capsule endoscopy: all you need to know! Endosc Int Open 2021; 9:E802-E823. [PMID: 34079861 PMCID: PMC8159625 DOI: 10.1055/a-1372-4051] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/26/2020] [Indexed: 02/08/2023] Open
Abstract
AbstractCapsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2
3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4
5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8
9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.
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Affiliation(s)
- Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Reuma Margalit-Yehuda
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Kelly Gatt
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Carlo Girelli
- Department of Internal Medicine, Gastroenterology & Digestive Endoscopy, Hospital of Busto Arsizio, Italy
| | - Jean-Christophe Saurin
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastro-Entérologie et d'Endoscopie Digestive, Lyon, France
| | - Pablo Cortegoso Valdivia
- Gastroenterology & Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Jose Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Flavio Caprioli
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Cà Granda, Ospedale Policlinico di Milano, Milan, Italy
| | - Gunnar Baatrup
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Pierre Ellul
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Ervin Toth
- Skåne University Hospital, Lund University, Malmö, Sweden
| | - Anastasios Koulaouzidis
- Endoscopy Unit, The Royal Infirmary of Edinburgh, Scotland, UK
- Department of Social Medicine & Public Health, Pomeranian Medical University, Szczecin, Poland
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15
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Abstract
Video capsule endoscopy and device-assisted enteroscopy are complementary technologies. Capsule endoscopy is a highly acceptable technology with high diagnostic yield that can guide a subsequent enteroscopy approach. This article aims to focus on the role of video capsule endoscopy as a prelude to deep enteroscopy with a focus on the strengths and limitations of either approach.
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16
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Arai Y, Ogawa M, Arimoto R, Ando Y, Endo D, Nakada T, Sugawara I, Yokoyama H, Shimoyama K, Inomata H, Kawahara Y, Kato M, Arihiro S, Hokari A, Saruta M. Contribution of Capsule Endoscopy Early in a Bleeding Episode to Treatment of Small Bowel Angioectasia: A Case Report. Medicina (B Aires) 2021; 57:medicina57040321. [PMID: 33807237 PMCID: PMC8067254 DOI: 10.3390/medicina57040321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Recent advances in endoscopic devices such as small bowel capsule endoscopy and balloon-assisted endoscopy have improved the level of medical care for small bowel bleeding. However, treating small bowel angioectasia remains challenging because repeated intermittent bleeding can occur from the multiple minute lesions (about 1 mm in size) that develop in a synchronous and metachronous manner. Here, we report a case of small bowel angioectasia in which capsule endoscopy performed early in a bleeding episode contributed to treatment. Case Summary: A 66-year-old man with suspected small bowel bleeding underwent small bowel capsule endoscopy and balloon-assisted endoscopy with argon plasma coagulation hemostasis for a small intestinal angioectasia. Because small bowel bleeding recurred intermittently after the treatment, small bowel capsule endoscopy and balloon-assisted endoscopy were repeated when there was no bleeding, but no abnormalities were found. Subsequent small bowel capsule endoscopy during a bleeding episode revealed bloody intestinal fluid in the proximal small intestine. Peroral balloon-assisted endoscopy was performed 2 days after SBCE for detailed observation of the small intestinal mucosa at the suspected bleeding site, and there a 1-mm Dieulafoy’s lesion with no active bleeding was identified. We performed argon plasma coagulation, and no bleeding was observed thereafter. Conclusions: Small bowel capsule endoscopy immediately after bleeding onset can identify the bleeding source of multiple minute lesions in small bowel angioectasia.
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Affiliation(s)
- Yoshinori Arai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
- Tekko Building Marunouchi Clinic, Tokyo 100-0005, Japan
| | - Maiko Ogawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Rikako Arimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Yoshitaka Ando
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Daisuke Endo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Tatsuya Nakada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Ichiro Sugawara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Hiroshi Yokoyama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Keiko Shimoyama
- Department of Endoscopy, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Hiroko Inomata
- Department of Endoscopy, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Yosuke Kawahara
- Department of Endoscopy, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Masayuki Kato
- Department of Endoscopy, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Seiji Arihiro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Atsushi Hokari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Katsushika Medical Center, Tokyo 105-8461, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
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17
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Kalra AS, Walker AJ, Benson ME, Guda NM, Soni A, Misha M, Gopal DV. Therapeutic Impact of Deep Balloon-assisted Small Bowel Enteroscopy on Red Blood Cell Transfusion. JOURNAL OF DIGESTIVE ENDOSCOPY 2020. [DOI: 10.1055/s-0040-1721552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Objective Evaluate impact of balloon-assisted deep small bowel enteroscopy on red blood cell transfusion requirement in patients with obscure gastrointestinal (GI) bleeding.
Methods Retrospective study of patients, who underwent balloon-assisted deep enteroscopy with double-balloon enteroscopy (DBE) at two tertiary care academic centers (University of Wisconsin and Aurora St. Luke’s Medical Center) over a 55-month consecutive period. Sixty-nine patients with reliable blood transfusion records were identified during this time period. DBE was preceded by small bowel capsule endoscopy (CE) within 1 year in 38 cases. Transfusion requirements 6 months prior and postintervention were measured to see if DBE had any impact on the need for blood transfusions.
Results Sixty-nine patients (25 females and 44 males) were included. Mean age ± standard deviation (SD) was 63 ± 17 years. Wilcoxon signed rank test statistics were used to find the difference in the rate of blood transfusion. There was a statistically significant decrease in rate of packed red blood cell (pRBC) transfusion post DBE and endoscopic therapy with coagulation (p < 0.001). Argon plasma coagulation was used to ablate all arteriovenous malformations (AVMs) except in one (subepithelial lesion). Those that required > 5 units pRBC transfusions pre-DBE had the most benefit.
Conclusions Our study demonstrates that transfusion requirements are significantly reduced in those undergoing therapy with DBE and coagulation for obscure GI bleed.
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Affiliation(s)
- Amandeep S. Kalra
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States
| | - Andrew J. Walker
- SSM Health System–Dean Medical Group, Madison, Wisconsin, United States
| | - Mark E. Benson
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States
| | - Nalini M. Guda
- Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin, GI Associates - Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Anurag Soni
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States
| | - Mehak Misha
- Gundersen Hospitals and Clinics, La Crosse, Wisconsin, United States
| | - Deepak V. Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States
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Causes and Clinical Characteristics of Small Bowel Bleeding in Northern Vietnam. Can J Gastroenterol Hepatol 2020; 2020:8884092. [PMID: 33313021 PMCID: PMC7721493 DOI: 10.1155/2020/8884092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/13/2020] [Accepted: 11/23/2020] [Indexed: 11/17/2022] Open
Abstract
AIM Causes, clinical features, and diagnostic approaches for small bowel (SB) bleeding were analyzed to derive recommendations in dealing with this clinical condition. METHODS We included 54 patients undergoing surgical treatment for SB bleeding, from January 2009 to December 2019. Detailed clinical data, diagnosis procedures, and causes of bleeding were collected. RESULTS Among 54 cases with SB bleeding, the most common causes were tumors (64.8%), followed by angiopathy (14.8%), ulcers (9.3%), diverticula (5.6%), tuberculosis (3.7%), and enteritis (1.9%). Most tumors (32/35 cases, 91.4%) and vascular lesions (8/8 cases, 100%) were located in the jejunum. The incidence of tumors was higher in the older (30/41 cases, 73.1%) than that in patients younger than 40 years of age (5/13 cases, 38.5%, P < 0.01). Common initial findings were melena (68.5%) and hematochezia (31.5%). The overall diagnostic yield of computed tomographic enterography (CTE) was 57.4% (31/54 cases), with the figures for tumors, vascular lesions, and inflammatory lesions being 71.4% (25/35 cases), 62.5% (5/8 cases), and 12.5% (1/8 cases), respectively. Double-balloon enteroscopy (DBE) definitively identified SB bleeding sources in 16/22 (72.7%) patients. CONCLUSION Tumors, angiopathy, ulcers, and diverticula were the most common causes of SB bleeding in Northern Vietnamese population. CTE has a high detection rate for tumors in patients with SB bleeding. CTE as a triage tool may identify patients before double-balloon enteroscopy because of the high prevalence of SB tumors.
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Aniwan S, Viriyautsahakul V, Luangsukrerk T, Angsuwatcharakon P, Piyachaturawat P, Kongkam P, Kongtab N, Treeprasertsuk S, Kullavanijaya P, Rerknimitr R. Low rate of recurrent bleeding after double-balloon endoscopy-guided therapy in patients with overt obscure gastrointestinal bleeding. Surg Endosc 2020; 35:2119-2125. [PMID: 32382887 DOI: 10.1007/s00464-020-07615-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 04/30/2020] [Indexed: 02/08/2023]
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20
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Pérez-Cuadrado-Robles E, Pinho R, Gonzalez B, Mão de Ferro S, Chagas C, Esteban Delgado P, Carretero C, Figueiredo P, Rosa B, García Lledó J, Nogales Ó, Ponte A, Andrade P, Juanmartiñena-Fernández JF, San-Juan-Acosta M, Lopes S, Prieto-Frías C, Egea-Valenzuela J, Caballero N, Valdivieso-Cortazar E, Cardoso H, Gálvez C, Almeida N, Borque Barrera P, Gómez-Rodríguez BJ, Sánchez Ceballos F, Bernardes C, Alonso P, Argüelles-Arias F, Mascarenhas Saraiva M, Pérez-Cuadrado-Martínez E. Small Bowel Enteroscopy - A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:324-335. [PMID: 32999905 DOI: 10.1159/000507375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
Abstract
The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication and on its diagnostic and therapeutic yields. A set of recommendations were issued accordingly.
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Affiliation(s)
| | - Rolando Pinho
- Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
| | - Begoña Gonzalez
- Department of Gastroenterology. Endoscopy Unit, ICMDiM, Hospital Clínic, Barcelona, Spain
| | - Susana Mão de Ferro
- Department of Gastroenterology, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | | | - Cristina Carretero
- Department of Gastroenterology, University of Navarra Clinic, Pamplona, Spain
| | - Pedro Figueiredo
- Gastroenterology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Bruno Rosa
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute, School of Medicine, University of Minho, ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Javier García Lledó
- Department of Gastroenterology, Endoscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Óscar Nogales
- Department of Gastroenterology, Endoscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Ponte
- Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
| | - Patrícia Andrade
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal
| | | | - Mileidis San-Juan-Acosta
- Department of Gastroenterology, Gastrointestinal Endoscopy Unit, Hospital Universitario Nuestra Señora de Candelaria, Candelaria, Tenerife, Spain
| | - Sandra Lopes
- Gastroenterology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - César Prieto-Frías
- Department of Gastroenterology, University of Navarra Clinic, Pamplona, Spain
| | - Juan Egea-Valenzuela
- Unit of Gastrointestinal Endoscopy, Department of Digestive Disease, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Noemí Caballero
- Department of Gastrointestinal Endoscopy, Hospital Universitario Germans Trias i Pujol, Badalona, Spain
| | | | - Hélder Cardoso
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal
| | - Consuelo Gálvez
- Department of Gastroenterology. Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Nuno Almeida
- Gastroenterology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Pilar Borque Barrera
- Department of Gastroenterology, Gastrointestinal Endoscopy Unit, Hospital Universitario Nuestra Señora de Candelaria, Candelaria, Tenerife, Spain
| | - Blas José Gómez-Rodríguez
- Department of Gastroenterology, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | | | - Carlos Bernardes
- Department of Gastroenterology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Pedro Alonso
- Department of Gastroenterology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Federico Argüelles-Arias
- Department of Gastroenterology, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
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21
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Lara LF, Silva R, Thakkar S, Stanich PP, Mai D, Samarasena JB. Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter. VideoGIE 2020; 5:162-167. [PMID: 32258850 PMCID: PMC7125393 DOI: 10.1016/j.vgie.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background and Aims GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported. Methods Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with melena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm2. The patients' demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions. Results Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation ± 11.1), and 14 men (average age 73 years, standard deviation ± 10.4). All had undergone at least 1 previous EGD and colonoscopy; 14 patients (70%) had SBA on video capsule endoscopy, and 14 patients had undergone previous endoscopic treatment of SBA with APC. A median of 23 treatments were applied (range, 2-99). The median follow-up time was 195 days (range, 30-240 days). Four patients, including 3 with a left ventricular assist device (LVAD), had recurrent bleeding between 45 and 210 days after treatment, and 2 patients received repeated blood transfusions. Three of those patients underwent repeated endoscopies, including a push enteroscopy and an upper endoscopy with no treatment, and a repeated enteroscopy with SBA treated with APC, respectively. One patient with LVAD underwent arterial embolization. Conclusions In this case series, bleeding recurred in 20% of patients in a follow-up time of ≤240 days. Notably, 3 of the 4 patients who had recurrent bleeding had an LVAD. These rates compare favorably with reported bleeding recurrence after APC of SBA. More studies on the benefits of SBRFA, which may include reduced risk of recurrent bleeding or prolonging the time to recurrent bleeding, resource utilization, and factors associated with bleeding recurrence are needed.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rogelio Silva
- Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Shyam Thakkar
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Mai
- University of California, Irvine, California USA
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22
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Gomes C, Rubio Mateos JM, Pinho RT, Ponte A, Rodrigues A, Fosado Gayosso M, Esteban Delgado P, Silva JC, Afecto E, Carvalho J. The rebleeding rate in patients evaluated for obscure gastrointestinal bleeding after negative small bowel findings by device assisted enteroscopy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:262-268. [PMID: 32202909 DOI: 10.17235/reed.2020.6833/2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND data on the long-term outcome of patients with obscure gastrointestinal bleeding (OGIB) with positive small bowel findings in capsule endoscopy but negative small bowel findings in device-assisted enteroscopy are scarce. OBJECTIVE this study aimed to evaluate the rebleeding rate and time to rebleed in patients with no small bowel findings in enteroscopy, after a positive capsule endoscopy in the setting of OGIB. Baseline predictors for rebleeding were assessed. METHODS a retrospective double-center study was performed, including patients with OGIB with positive findings by capsule endoscopy and negative small bowel findings by enteroscopy. RESULTS thirty-five patients were included. Rebleeding occurred in 40 % of patients during a median follow-up of 27 months. Further evaluation in patients with a rebleed was performed in 85.7 %, leading to a final diagnosis in 78.6 %. The rebleeding rate increased progressively over time, from 17.2 % at one month to 54.4 % at four years. Overt bleeding at the time of the first episode was a predictor of rebleeding (p = 0.03) according to the multivariate analysis. This was 50 % at one year compared with 21.8 % in patients with occult bleeding on admission. CONCLUSIONS in obscure gastrointestinal bleeding, long-term follow-up and further evaluation may be considered after a positive capsule endoscopy. Even if there are no small bowel findings by device-assisted enteroscopy. The rebleeding rate in our study was 40 %, mainly in the presence of an overt bleeding on admission.
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Affiliation(s)
- Catarina Gomes
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | | | | | - Ana Ponte
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Adélia Rodrigues
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | | | | | | | - Edgar Afecto
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - João Carvalho
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
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23
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Guo Y, Wang QJ, Shi LJ, Hu YY, Li WP. Evaluation of Low-Dose Multidetector Computed Tomography Whole Gastroenterography With Oral Administration of Contrast Agents. Can Assoc Radiol J 2020; 72:410-417. [PMID: 32066248 DOI: 10.1177/0846537119897143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To evaluate the degree of gastric, enteric, colonic, and rectal filling in multidetector computed tomography (MDCT) whole gastroenterography. METHODS In this prospective study involving 124 patients, 78 and 46 patients underwent MDCT whole gastroenterography using positive and neutral oral contrast agents, respectively. The degree of filling of the stomach, small and large bowel, was qualitatively analyzed by experienced radiologists using a 3-point scoring system. RESULTS The majority of patients received a score of ≥2 for small intestine filling using both positive and neutral contrast agents (90.5% and 78.2%, respectively), and <9% of the patients had a score of 0. The highest score for the degree of filling in the small intestine was observed in the ileum, followed by the duodenum and jejunum. There was a significant difference in the degree of filling achieved with positive and neutral contrast agents in the duodenum (P = .013) and jejunum (P = .047). More than 74% of cases had an optimal filling of the stomach, whereas >80% of the cases had an optimal filling of the colorectal segments. Only ≤5.1% had a score of 0 for the analyzed segments of the colorectum. Positive and neutral contrast agents were associated with similar degree of filling in the stomach and colon segments without a significant difference in the extent of contrast agent filling (P > .05). CONCLUSIONS Multidetector computed tomography whole gastroenterography was found to be a simple, safe, noninvasive, painless, and effective modality for the diagnosis of stomach and bowel complications in clinical settings.
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Affiliation(s)
- Yong Guo
- 74533Navy General Hospital, Beijing, The People's Republic of China
| | - Qing-Jun Wang
- 74533Navy General Hospital, Beijing, The People's Republic of China
| | - Li-Jing Shi
- 74533Navy General Hospital, Beijing, The People's Republic of China
| | - Ying-Ying Hu
- 74533Navy General Hospital, Beijing, The People's Republic of China
| | - Wen-Ping Li
- 74533Navy General Hospital, Beijing, The People's Republic of China
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24
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Sakai E, Ohata K, Nakajima A, Matsuhashi N. Diagnosis and therapeutic strategies for small bowel vascular lesions. World J Gastroenterol 2019; 25:2720-2733. [PMID: 31235995 PMCID: PMC6580356 DOI: 10.3748/wjg.v25.i22.2720] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.
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Affiliation(s)
- Eiji Sakai
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
| | - Atsushi Nakajima
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Nobuyuki Matsuhashi
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
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25
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Muftah M, Mulki R, Dhere T, Keilin S, Chawla S. Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease. Ann Gastroenterol 2018; 32:113-123. [PMID: 30837783 PMCID: PMC6394262 DOI: 10.20524/aog.2018.0341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/18/2018] [Indexed: 12/12/2022] Open
Abstract
Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.
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Affiliation(s)
- Mayssan Muftah
- Department of Medicine (Mayssan Muftah), Atlanta, United States
| | - Ramzi Mulki
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Tanvi Dhere
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Steven Keilin
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Saurabh Chawla
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States.,Grady Memorial Hospital (Saurabh Chawla), Atlanta, United States
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26
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Yang CW, Chen HW, Chen BC, Chen PJ, Shih YL, Chang WK, Hsieh TY, Huang TY. Is a bleeding scan prior to single-balloon enteroscopy necessary in patients with obscure gastrointestinal bleeding? J Formos Med Assoc 2018; 118:1031-1037. [PMID: 30473414 DOI: 10.1016/j.jfma.2018.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/20/2018] [Accepted: 11/07/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/PURPOSE To evaluate the efficacy and accuracy of bleeder localization in a pre-enteroscopic bleeding scan in patients with obscure gastrointestinal bleeding (OGIB). METHODS From January 2009 to December 2014, 98 patients with OGIB undergoing single-balloon enteroscopy (SBE) were enrolled. These patients were classified based on their history of a previous bleeding scan; 56 patients had undergone a previous bleeding scan, whereas 42 had not. The clinical characteristics, endoscopic findings, and rebleeding rate were compared between these two groups. The ability of the bleeding scan to localize the bleeding site was analyzed. RESULTS The mean age of patients was 56 ± 22 years; final diagnostic yield, 65.3%; and the most common etiology of OGIB, angiodysplasia (29.6%). There was no significant difference in demographic characteristics, OGIB etiologies, and final diagnostic yields (67.9% vs. 61.2%, bleeding scan vs. control group) between groups. In the bleeding scan group, the rate of positive detection was approximately 80.4%. However, only 26.7% patients with a positive bleeding scan showed correct localization of bleeding. Moreover, the bleeding scan delayed SBE (8.9 days vs. 3.0 days, p < 0.001). During the 24 months of follow-up, 15 patients (15.3%) exhibited rebleeding and needed to be hospitalized, but there was no significant difference between the groups. CONCLUSION In our study, bleeding scans in patients with OGIB revealed poor localization of the bleeder and delay in performing SBE. Thus, a bleeding scan prior to SBE showed a limited role for patients with OGIB.
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Affiliation(s)
- Chih-Wei Yang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Hsuan-Wei Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Bao-Chung Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Peng-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Yu-Lueng Shih
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Tsai-Yuan Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan.
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False-negative double-balloon enteroscopy in overt small bowel bleeding: long-term follow-up after negative results. Surg Endosc 2018; 33:2635-2641. [PMID: 30397745 DOI: 10.1007/s00464-018-6561-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 10/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Double-balloon enteroscopy (DBE) performed to investigate overt small bowel bleeding can miss the source of bleeding. We investigated the clinical outcomes of patients with negative DBE results for suspected overt small bowel bleeding, which is defined in the current guidelines as obscure gastrointestinal bleeding. METHODS We reviewed the prospectively collected medical records of patients who underwent DBE at our hospital between May 1, 2004 and April 30, 2016. During this period, 297 patients underwent DBE for suspected overt small bowel bleeding. The first DBE yielded negative results for 83 patients (27.9%). Written interviews, telephone interviews, and medical records of these patients were reviewed in April 2017. Follow-up data were collected for 63 patients (75.9%). RESULTS During a mean follow-up period of 83.5 months, re-bleeding occurred in 21 of 63 patients (33.3%) after a mean of 23.0 months after the first DBE yielded negative results. The bleeding source was identified in 19 of 21 patients (90.5%). In 15 of these 19 patients (78.9%), the source was the small intestine. Among these 15 patients, 14 (93.3%) had bleeding sites within reach of the first DBE and 3 (20%) experienced their first incidence of re-bleeding more than 3 years after the first DBE. The need for transfusion for the first bleeding episode was a predictor of re-bleeding (odds ratio 7.5; 95% confidence interval 1.7-33.0). CONCLUSIONS False-negative DBE results for overt small bowel bleeding are not rare, and the first re-bleeding episode can occur 3 years later. Repeat DBE when re-bleeding occurs should be considered, even if the first DBE results were negative.
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Ponte A, Pérez-Cuadrado Robles E, Pinho R, Rodrigues A, Esteban Delgado P, Silva J, Rodrigues J, Carvalho J, Pérez-Cuadrado Martínez E. High short-term rebleeding rate in patients undergoing a second endoscopic therapy for small-bowel angioectasias after recurrent bleeding. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:88-93. [PMID: 29152987 DOI: 10.17235/reed.2017.4872/2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Angioectasias represents the most frequently found lesion in the small bowel by device-assisted enteroscopy for obscure gastrointestinal bleeding in Western countries. Recurrence of gastrointestinal bleeding after angioectasias therapy remains unclear and data regarding the efficacy of additional endoscopic therapeutic sessions to reduce the rebleeding rate is limited. AIM To evaluate the rebleeding rate in small bowel angioectasias after a second endoscopic treatment with balloon-assisted enteroscopy after an initial bleed during the first endoscopic treatment. METHODS A retrospective double-center study of patients with small-bowel angioectasias undergoing a second enteroscopy treatment due to a first rebleeding episode. The endpoint was rebleeding, defined as the need for a blood transfusion, the presence of overt bleeding or a decrease in hemoglobin ≥ 2 g/dL. RESULTS Fifteen of 37 (40.5%) patients with small-bowel angioectasias that underwent a second endoscopic therapy after a first rebleeding episode (n = 15) experienced a second rebleeding episode. Kaplan-Meier curve analysis showed that most rebleeding episodes occurred within the first 12 months of follow-up, resulting in a rebleeding rate of 33.1% at 6 months, 39.1% at 12 months and 52.6% at 24 months. CONCLUSIONS Despite the high absolute short-term rebleeding rate, further endoscopic treatments may be beneficial due to the effective reduction of rebleeding in a subset of patients.
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Affiliation(s)
- Ana Ponte
- Gastrenterologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | | | - Rolando Pinho
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | | | | | - Joana Silva
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Jaime Rodrigues
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - João Carvalho
- Gastroenterology and Hepatology department, Centro Hospitalar de Gaia/Espinho, Portugal
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Shelnut DJ, Sims OT, Zaibaq JN, Oh H, Venkata KV, Peter S. Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience. Endosc Int Open 2018; 6:E751-E757. [PMID: 29876513 PMCID: PMC5988547 DOI: 10.1055/a-0602-3967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 03/07/2018] [Indexed: 12/19/2022] Open
Abstract
AIM The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting positive diagnostic yield, therapeutic yield, and readmission. METHODS We conducted a retrospective cohort study of patients (n = 420) who underwent DBE at a tertiary care center between 2012 and 2016 at a tertiary referral center. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and t-test analyses were used to compare patient characteristics. Logistic regression was used to predict outcomes of interest. RESULTS Of patients included in the study, 59 % were male with a mean age of 61.49 (SD = 15.15) Altered anatomy was noted in 14 %, while 5 % and 13 % of patients had end stage renal disease (ESRD) and current use of anticoagulation, respectively. The most common indication for DBE was obscure gastrointestinal bleed (OGIB) (33 %). Forty-nine patients had obscure and overt gastrointestinal bleeding (GIB) and 22 % had occult GIB with iron deficiency. The cohort's rate of positive diagnostic yield was 73 % and 35 % for therapeutic yield. The 30-day and 6-month readmission rates were both 11 %. A higher proportion of those readmitted were male (75 % vs 57 %, P = 0.027) and had longer procedural time (38.68 vs 46.57, P = 0.011). Likewise, occult GIB with iron deficiency anemia and iron deficiency alone (OR = 2.45, CI: 1.233 - 4.859, P = 0.011), inpatient status (OR 2.42, CI 1.344 - 4.346, P = 0.003), and longer procedural time (OR = 1.02, CI: 1.004 - 1.029, P = 0.008) were associated positively with readmission. CONCLUSION DBE procedures have relevant efficacy for both diagnostic and therapeutic yield while evaluating small bowel disease. Readmission rates are low and more in those with GI bleed and iron deficiency with longer index procedural times.
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Affiliation(s)
- Danielle Jarrard Shelnut
- University of Alabama at Birmingham, Tinsley Harrison Internal Medicine Residency, Birmingham, Alabama
| | - Omar T. Sims
- University of Alabama at Birmingham, Department of Social Work, College of Arts and Sciences/Department of Health Behavior, School of Public Health/Center for AIDS Research/Comprehensive Center for Healthy Aging, Birmingham, Alabama
| | - Jenine N. Zaibaq
- University of Alabama at Birmingham, Tinsley Harrison Internal Medicine Residency, Birmingham, Alabama
| | - Hyejung Oh
- Troy University, Dothan Campus Ringgold Standard Institution, Department of Human Services & Social Work, College of Health and Human Services, Dothan, Alabama
| | | | - Shajan Peter
- University of Alabama at Birmingham, Division of Gastroenterology and Hepatology, Birmingham, Alabama
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Al-Bawardy B, Piovezani Ramos G, Lennon RJ, Gorospe E, Wong Kee Song LM, Bruining DH, Alexander JA, Coelho-Prabhu N, Fidler JL, Rajan E. Outcomes of repeat balloon assisted enteroscopy in small-bowel bleeding. Endosc Int Open 2018; 6:E694-E699. [PMID: 29868634 PMCID: PMC5979197 DOI: 10.1055/a-0599-6085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/20/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS The rate of recurrent small-bowel bleeding (SBB) remains high despite the advent of balloon assisted enteroscopy (BAE). The study aims were to determine: (1) the diagnostic and therapeutic yields, and adverse event rate of repeat BAE in SBB, and (2) the predictors of a positive repeat BAE. METHODS A retrospective review of a BAE database was conducted. Patients who had > 1 BAE for SBB were included. Primary outcomes were diagnostic yield, therapeutic yield, and adverse events of repeat BAE. Secondary outcomes were predictors of a positive repeat BAE. RESULTS A total of 175 patients (55 % men; mean age 64.1 ± 16.3 years) were included. The diagnostic and therapeutic yields of repeat BAE were 55 % and 42 %, respectively. Repeat BAE adverse events occurred in 5 % with self-limited abdominal pain being most common. Patients with a positive repeat BAE were significantly older than the negative group (68.6 ± 13.9 vs. 60.9 ± 17.1; P = 0.001) and were more likely to have cardiac comorbidities (OR 2.4, 95 %CI: 1.3 - 4.6; P = 0.01), chronic kidney disease (OR 2.3, 95 %CI: 1.1 - 4.9; P = 0.04), chronic obstructive pulmonary disease (OR 3.3, 95 %CI: 1.3 - 8.1; P = 0.01), positive initial BAE (OR 3.6, 95 %CI: 1.9 - 6.8; P < 0.001), and antegrade procedure (OR 3.3, 95 %CI: 1.7 - 6.1; P < 0.001). On multivariate analysis, a positive initial BAE and antegrade route were the only significant predictive factors. CONCLUSIONS Performing a repeat BAE for SBB appears safe and provided modest yields. A positive initial BAE and antegrade route were predictive of a positive repeat BAE.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Ryan J. Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Emmanuel Gorospe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - David H. Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Jeff L. Fidler
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,Corresponding author Elizabeth Rajan, MD Division of Gastroenterology & HepatologyMayo Clinic200 First Street, S.W.RochesterMN 55905USA+1-507-284-0538
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Abstract
PURPOSE OF REVIEW The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias. SUMMARY SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.
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32
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Chetcuti Zammit S, Koulaouzidis A, Sanders DS, McAlindon ME, Rondonotti E, Yung DE, Sidhu R. Overview of small bowel angioectasias: clinical presentation and treatment options. Expert Rev Gastroenterol Hepatol 2018; 12:125-139. [PMID: 28994309 DOI: 10.1080/17474124.2018.1390429] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.
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Affiliation(s)
| | | | - David S Sanders
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | - Mark E McAlindon
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | | | - Diana E Yung
- b Endoscopy Unit , the Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Reena Sidhu
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
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33
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Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
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Abstract
BACKGROUND Gastrointestinal angioectasias (AEs) represent the most common vascular malformation within the gastrointestinal tract. This study sought to characterize epidemiologic/comorbid risk factors for AEs, rebleeding, and patterns of anatomic distribution within the small intestine. STUDY This retrospective observational cohort study included 158 patients with AEs on capsule endoscopy (CE) from 2007 to 2015. Epidemiologic/comorbid data were collected and incorporated into final analysis. Each AE was categorized by location using a small bowel transit time-based quartile system. Rebleeding was evaluated following CE. Multivariate logistic regression was applied to statistically significant factors on univariate analysis to determine independent risk factors for rebleeding. RESULTS Most lesions were found in the first quartile (67.1%). Rebleeding occurred in 46 (29.7%) of the 156 patients for whom data were available. Rates of rebleeding were significantly higher among older patients (74.4 vs. 67.7 y, P=0.001), those with active bleeding on CE (41.3% vs. 16.5%, P=0.001), those with a history of aortic stenosis (21.7% vs. 9.2%, P=0.033), and those with AEs presents in quartile 3 (26.1% vs. 8.3%, P=0.003). Age, active bleeding on CE, and AE presence in quartile 3 were independently associated with rebleeding in multivariate analysis (P=0.009, 0.023, and 0.008, respectively). CONCLUSIONS These data help improve our knowledge of AEs regarding risk factors for rebleeding, and utilizes a novel small bowel transit time-based quartile localization method that may simplify future research and comparisons of anatomic distribution and behavior of small bowel AEs.
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35
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Chen BC, Chen PJ, Shih YL, Huang HH, Lin XH, Lin JC, Tseng YC, Chen CT, Hsu CH, Chang WK, Hsieh TY, Huang TY. Single-balloon enteroscopy for managing obscure gastrointestinal bleeding: Results from a tertiary medical center in Taiwan. ADVANCES IN DIGESTIVE MEDICINE 2017. [DOI: 10.1002/aid2.12018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Bao-Chung Chen
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Peng-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Yu-Lueng Shih
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Hsin-Hung Huang
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Xuan-Huai Lin
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Jung-Chun Lin
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Yu-Chen Tseng
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Chun-Ting Chen
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Chin-Hui Hsu
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Tsai-Yuan Hsieh
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine; Tri-Service General Hospital, National Defense Medical Center; Taipei Taiwan
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36
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Jeon SR, Byeon JS, Jang HJ, Park SJ, Im JP, Kim ER, Koo JS, Ko BM, Chang DK, Kim JO, Park SY. Clinical outcome after enteroscopy for small bowel angioectasia bleeding: A Korean Associateion for the Study of Intestinal Disease (KASID) multiceter study. J Gastroenterol Hepatol 2017; 32:388-394. [PMID: 27356264 DOI: 10.1111/jgh.13479] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Angioectasias are the most common sources of bleeding in the small bowel. They can be treated using balloon-assisted enteroscopy (BAE). This study aimed to identify the rebleeding rate and associated factors after BAE in patients with small bowel angioectasia bleeding. METHODS We retrospectively analyzed the records of patients with bleeding due to small bowel vascular lesion in a multicenter enteroscopy database including 1108 BAEs. Finally, in rebleeding analysis, we analyzed 66 patients with angioectasia on the basis of the Yano-Yamamoto classification. Patients who had undergone endotherapy (ET) were divided into ET (n = 45) and non-ET (n = 21) groups. Rebleeding was defined as evidence of bleeding at least 30 days after BAE. RESULTS Fifty-three patients (80.4%) underwent only one-side enteroscopy. The most common ET was argon plasma coagulation (87.2%). During a mean follow-up duration of 24.5 months, ET and non-ET groups had rebleeding rates of 15.6% and 38.1% (P = 0.059), respectively. Median rebleeding time of ET and non-ET groups was 32.5 and 62 months, respectively. Liver cirrhosis (LC), low platelet count (< 105 /μL), and transfusions were the rebleeding-associated factors in the univariate analysis. In the multivariate analysis, the presence of LC (HR 4.064, 95% CI 1.098-15.045; P = 0.036) was the only independent rebleeding-associated risk factor. CONCLUSIONS ET using BAE did not significantly affect the rebleeding rate in patients with small bowel angioectasia bleeding. An independent rebleeding risk factor was the presence of LC. Regardless of ET, careful long-term follow-up may be needed, especially in LC patients with small bowel angioectasia bleeding.
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Affiliation(s)
- Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | | | - Hyun Joo Jang
- Hallym University College of Medicine, Hwasung, Korea
| | | | - Jong Pil Im
- Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Eun Ran Kim
- Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ja Seol Koo
- Korea University College of Medicine, Ansan, Korea
| | - Bong Min Ko
- Soonchunhyang University College of Medicine, Bucheon, Korea
| | | | - Jin-Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Su Yeon Park
- Biostatistical Consulting Unit, Soonchunhyang University Medical Center, Seoul, Korea
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37
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Hermans C, Stronkhorst A, Tjhie-Wensing A, Kamphuis J, Balkom BV, Dahlmans R, Gilissen L. Double-Balloon Endoscopy in Overt and Occult Small Bowel Bleeding: Results, Complications, and Correlation with Prior Videocapsule Endoscopy in a Tertiary Referral Center. Clin Endosc 2017; 50:69-75. [PMID: 28076941 PMCID: PMC5299980 DOI: 10.5946/ce.2016.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 08/23/2016] [Accepted: 10/06/2016] [Indexed: 12/22/2022] Open
Abstract
Background/Aims Videocapsule endoscopy (VCE) and double-balloon endoscopy (DBE) allow deep exploration in patients with suspected small bowel pathology. VCE is often performed as an initial small bowel examination to explore whether an intervention by DBE is indicated and to determine insertion route. The study aim was to evaluate the correlation between DBE and VCE in patients with obscure or overt bleeding or anemia, as well as intervention frequency, and complications. Methods Retrospective observational study. Results DBE procedures (n=205) showed small bowel lesions in 64% cases. Antegrade DBE showed positive results in 79% cases, mostly angiodysplasias (63%). Retrograde DBE showed positive results in 22% cases. An intervention was performed in 64% of DBE procedures. The major complication rate was 0.5%, which was one case of perforation. Pancreatitis did not occur. The overall diagnostic agreement was 66% among the 134 DBEs with preceded VCE. Conclusions In cases of overt or occult bleeding or anemia, DBE was positive in 64%, with only a few complications. Positive correlation was 66% among initially performed VCEs and DBEs. Owing to the time-consuming and invasive character of DBE, performing VCE before DBE might still be clinically relevant.
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Affiliation(s)
- Carlijn Hermans
- Department of Gastroenterology and Hepatology, Catharina Ziekenhuis, Eindhoven, Netherlands
| | - Arnold Stronkhorst
- Department of Gastroenterology and Hepatology, Catharina Ziekenhuis, Eindhoven, Netherlands
| | | | - Jan Kamphuis
- Department of Gastroenterology and Hepatology, Máxima Medisch Centrum, Veldhoven, Netherlands
| | - Bas van Balkom
- Department of Gastroenterology and Hepatology, Bernhoven Ziekenhuis, Uden, Netherlands
| | - Rob Dahlmans
- Department of Gastroenterology and Hepatology, Sint Jans Gasthuis, Weert, Netherlands
| | - Lennard Gilissen
- Department of Gastroenterology and Hepatology, Catharina Ziekenhuis, Eindhoven, Netherlands
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Gurudu SR, Bruining DH, Acosta RD, Eloubeidi MA, Faulx AL, Khashab MA, Kothari S, Lightdale JR, Muthusamy VR, Yang J, DeWitt JM. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc 2017; 85:22-31. [PMID: 27374798 DOI: 10.1016/j.gie.2016.06.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023]
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Abstract
Since the introduction of double-balloon enteroscopy 15 years ago, flexible enteroscopy has become an established method in the diagnostic and therapeutic work-up of small bowel disorders. With appropriate patient selection, diagnostic and therapeutic yields of 70% to 85% can be expected. The complication rates with diagnostic and therapeutic DBE are estimated at approximately 1% and 3% to 4%, respectively. Appropriate patient selection and device selection, as well as skill, are the key issues for successful enteroscopy. However, technical developments and improvements mean that carrying out enteroscopy is likely to become easier.
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Affiliation(s)
- Andrea May
- Department of Gastroenterology, Sana Klinikum Offenbach GmbH, Starkenburgring 66, Offenbach am Main 63069, Germany.
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40
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Pasha SF, Leighton JA. Detection of suspected small bowel bleeding: challenges and controversies. Expert Rev Gastroenterol Hepatol 2016; 10:1235-1244. [PMID: 27366927 DOI: 10.1080/17474124.2016.1207525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Detection of small bowel (SB) bleeding remains a challenge to gastroenterologists, with a dearth of standardized recommendations regarding evaluation and management. Areas covered: A recursive literature search was performed using PubMed, Cochrane and Medline databases for original and review articles on SB and obscure gastrointestinal bleeding (OGIB). Based upon the available literature, this review outlines the main challenges and controversies, and provides a practical and cost-effective approach towards SB bleeding. Expert commentary: SB bleeding is suspected in patients with persistent or recurrent bleeding after negative bidirectional endoscopy, and unexplained iron deficiency anemia. Selection of test(s) should be individualized based upon patient presentation and suspicion for type of underlying lesion. Endoscopic or radiologic evaluation and treatment is the mainstay in the majority of patients, while pharmacologic agents may have a role in patients with refractory bleeding, and those unable to undergo evaluation.
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Affiliation(s)
- Shabana F Pasha
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
| | - Jonathan A Leighton
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
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41
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Abstract
OPINION STATEMENT The small bowel is a challenging area for endoscopic evaluation and therapy due to its length and angulated configuration. A small lumen diameter and segmental peristalsis made it a perfect fit for examination by a novel ingestible wireless camera in a capsule. The development of capsule endoscopy changed the diagnosis and management of bleeding lesions, ulcers, and tumors deep in the small bowel, allowing earlier diagnosis with excellent patient acceptance. Device-assisted enteroscopy revolutionized small bowel therapy, particularly management of bleeding, Peutz-Jeghers polyposis, and tumor marking for minimally invasive surgery. Small bowel stricture dilation in select patients is safe and effective. Tools for a spectrum of small bowel therapies are available but remain suboptimal to tackle lesions on angulated folds deep in the small bowel. Universal terminology to describe the endoscopic appearance of vascular lesions will facilitate studies of endoscopic and medical therapy. The future holds improvements in imaging, easier advancement through the small bowel, and therapeutic capacity. This review focuses on methods of small bowel endoscopy, therapy, and outcomes.
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Affiliation(s)
- Dejan Micic
- Division of Gastroenterology, Hepatology and Nutrition, University of Chicago, 5841 South Maryland Avenue, S401 MC 4080, Chicago, IL, 60637, USA
| | - Carol E Semrad
- Division of Gastroenterology, Hepatology and Nutrition, University of Chicago, 5841 South Maryland Avenue, S401 MC 4080, Chicago, IL, 60637, USA.
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42
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Long-term rebleeding risk following endoscopic therapy of small-bowel vascular lesions with device-assisted enteroscopy. Eur J Gastroenterol Hepatol 2016; 28:479-85. [PMID: 26808473 DOI: 10.1097/meg.0000000000000552] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The effectiveness of endoscopic therapy of small-bowel vascular lesions (SBVL) remains unclear as recent studies report high recurrence rates after 2 years of follow-up. This study aimed to evaluate the long-term rebleeding risk after endoscopic therapy of SBVL and to identify predictive factors of rebleeding. METHODS This was a retrospective single-center series of patients with SBVL treated endoscopically between July 2007 and February 2015. Relevant data from patient files, capsule endoscopies, and enteroscopy reports were retrieved. The primary endpoint was long-term rebleeding and the secondary endpoints were risk factors for rebleeding and transfusion requirements. RESULTS Thirty-five patients were included. Capsule endoscopies indicated angioectasias in 74.3% and blood in the remaining; angioectasias were found in 97.1% of enteroscopies. Rebleeding occurred in 40% of patients during a median follow-up of 23 months (interquartile range 9-43). The rebleeding rate at 1, 2, 3, 4, and 5 years was 32.7, 38.3, 46.0, 53.7, and 63.0%, respectively. Only the presence of high-risk comorbidities (aortic valve stenosis, chronic renal or liver disease, or Osler-Weber-Rendu syndrome) was associated with higher rebleeding (P=0.006) in the univariate and multivariate analyses, being 51.3%/67.6% at 1/3 years, compared with 6.7%/22.2% in patients without any of these comorbidities. Transfusion requirements decreased to 6.3 (0.0-6.0) packed red blood cells units the year after endoscopic therapy compared with 11.5 (2.0-17.0) in the previous year (P=0.002). CONCLUSION More than half of the patients had rebleeding after 5 years of follow-up, although transfusion requirements decreased. Patients with high-risk comorbidities are more likely to rebleed.
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43
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Aoyama T, Fukumoto A, Mukai S, Ueda H, Kimura S, Nagata S. Successful Endoscopic Treatment of an Actively Bleeding Jejunal Dieulafoy's Lesion. Intern Med 2016; 55:1739-41. [PMID: 27374674 DOI: 10.2169/internalmedicine.55.6381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Although small bowel endoscopy is commonly performed, cases of ongoing bleeding from small bowel lesions have not been commonly encountered. In the present report, we describe a case of successful endoscopic treatment of an actively bleeding jejunal Dieulafoy's lesion in a 79-year-old man with persistent anemia and melena. Capsule endoscopy indicated active bleeding in the jejunum. Thereafter, double-balloon endoscopy-performed via the oral approach-showed active bleeding from a jejunal Dieulafoy's lesion, which was treated using argon plasma coagulation and hemoclips. The melena subsequently resolved, and the patient's condition improved after the endoscopic treatment.
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Affiliation(s)
- Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Japan
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44
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Irvine AJ, Sanders DS, Hopper A, Kurien M, Sidhu R. How does tolerability of double balloon enteroscopy compare to other forms of endoscopy? Frontline Gastroenterol 2016; 7:41-46. [PMID: 28839833 PMCID: PMC5369540 DOI: 10.1136/flgastro-2014-100550] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/17/2015] [Accepted: 02/19/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Gastrointestinal endoscopy can be difficult for patients to tolerate. Studies on endoscopic tolerability mainly focus on gastroscopy or colonoscopy with a paucity of data on double balloon enteroscopy (DBE). We aimed to prospectively evaluate tolerability in patients undergoing several forms of endoscopy including DBE. METHODS Consecutive patients undergoing colonoscopy, flexible sigmoidoscopy, gastroscopy, endoscopic retrograde pancreatography (ERCP), capsule endoscopy (CE) and DBE were prospectively recruited. A questionnaire recorded demographics, procedural data, patient tolerability (pain, discomfort and distress recorded on numerical rating scales) and the Hospital Anxiety and Depression Scale (HADS). RESULTS 956 patients were recruited (512 women; median age 57 years). The median pain score for DBE was poor with a score of 5 compared with 1 and 0 for oesophagogastroduodenoscopy and ERCP, respectively (p<0.001). Colonoscopy and retrograde DBE scores were not dissimilar. CE was well tolerated with a median pain score of 0. Patients with DBE required significantly higher doses of sedation and analgesia than other patients. The HADS Anxiety Score was also associated with poorer tolerability. CONCLUSIONS DBE is poorly tolerated when compared with other forms of endoscopy despite higher doses of sedation. Increasing demand to improve tolerability of DBE in the UK may be addressed with the use of propofol.
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Affiliation(s)
- Andrew J Irvine
- Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - David S Sanders
- Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Andrew Hopper
- Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Matthew Kurien
- Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Reena Sidhu
- Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
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Chauhan SS, Manfredi MA, Abu Dayyeh BK, Enestvedt BK, Fujii-Lau LL, Komanduri S, Konda V, Maple JT, Murad FM, Pannala R, Thosani NC, Banerjee S. Enteroscopy. Gastrointest Endosc 2015; 82:975-90. [PMID: 26388546 DOI: 10.1016/j.gie.2015.06.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/11/2015] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging with CT and magnetic resonance enterography or direct visualization with wireless capsule endoscopy can provide valuable diagnostic information and direct therapy. Enteroscopy technology and techniques have evolved significantly and allow diagnosis and therapy deep within the small bowel, previously attainable only with intraoperative enteroscopy. Push enteroscopy, readily available in most endoscopy units, plays an important role in the evaluation and management of lesions located up to the proximal jejunum. Currently available device-assisted enteroscopy systems, DBE, SBE, and spiral enteroscopy each have their technical nuances, clinical advantages, and limitations. Newer, on-demand enteroscopy systems appear promising, but further studies are needed. Despite slight differences in parameters such as procedural times, depths of insertion, and rates of complete enteroscopy, the overall clinical outcomes with all overtube-assisted systems appear to be similar. Endoscopists should therefore master the enteroscopy technology based on institutional availability and their level of technical expertise.
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Long-Term Outcomes in Patients with Overt Obscure Gastrointestinal Bleeding After Negative Double-Balloon Endoscopy. Dig Dis Sci 2015; 60:3691-6. [PMID: 26173504 DOI: 10.1007/s10620-015-3792-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 06/29/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The long-term outcomes of patients after negative double-balloon endoscopy (DBE) for obscure gastrointestinal (GI) bleeding remain unclear. AIM The aim of this study was to assess the long-term outcomes of patients with negative DBE and clarify the effect of repeat endoscopic work-up. METHODS A total of 42 patients with a negative DBE for overt obscure GI bleeding were enrolled, and their clinical data were retrospectively reviewed. The mean (± standard deviation) follow-up period is 5.4 (± 2.8) years. The outcome measurement was overt rebleeding witnessed by the patient after negative DBE. At the time of rebleeding, further endoscopic work-up and specific treatment were performed. RESULTS Rebleeding occurred in 16 of 42 patients (38%). At the time of rebleeding, further investigations were made in 14 of 16 patients (88%), and the bleeding source was identified in 10 of 14 patients (71%). These 10 patients received specific treatment (endoscopic in five, surgical in two, medical in two, and angiographic in one). The bleeding source was in the small intestine in seven of 10 patients (70%). Blood transfusion before DBE and multiple bleeding episodes before DBE were significant predictive factors for rebleeding (odds ratio 5.056, 95% confidence interval 1.158-22.059, p = 0.031 and odds ratio 8.167, 95% confidence interval 1.537-43.392, p = 0.014, respectively). CONCLUSIONS The rebleeding rate after a negative DBE is considerable. Careful long-term follow-up and repeat endoscopic work-up at the time of overt rebleeding are important.
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Holleran G, Hall B, Breslin N, McNamara D. Long-acting somatostatin analogues provide significant beneficial effect in patients with refractory small bowel angiodysplasia: Results from a proof of concept open label mono-centre trial. United European Gastroenterol J 2015; 4:70-6. [PMID: 26966525 DOI: 10.1177/2050640614559121] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/12/2014] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Small bowel angiodysplasias account for over 50% of causes of small bowel bleeding and carry a worse prognosis than lesions located elsewhere in the gastrointestinal tract. Re-bleeding rates are high even after first-line endoscopic therapy and are associated with high levels of morbidity for affected patients. Small trials of long-acting somatostatin analogues have shown promising results but have not yet been assessed in patients with refractory small bowel disease. AIM The purpose of this study was to assess the effect of long-acting somatostatin analogues in reducing re-bleeding rates and transfusion requirements, and improving haemoglobin levels in patients with refractory small bowel angiodysplasia. METHODS Patients with refractory small bowel angiodysplasia were treated with 20 mg of long-acting octreotide for a minimum of three months. Response was assessed according to: rates of re-bleeding, haemoglobin levels, transfusion requirements, and side effects. RESULTS A total of 24 patients were initially treated and 20 received at least three doses. Rates of complete, partial and non-response were 70%, 20% and 10% respectively. Average haemoglobin rates increased from 9.19 g/dl to 11.35 g/dl (p = 0.0027, 95% confidence interval (CI) -3.5 to -1.1) in the group overall and 70% remained transfusion-free after a mean treatment duration of 8.8 months. The rate of adverse events was higher than previously reported at 30%. CONCLUSION Long-acting somatostatin analogues offer a therapeutic advantage in a significant proportion of patients with small bowel angiodysplasia. With careful patient selection and close observation, a long-acting somatostatin analogue should be considered in all patients with persistent anaemia attributable to refractory disease in conjunction with other standard treatments.
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Affiliation(s)
- Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Barry Hall
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Niall Breslin
- Department of Gastroenterology, Tallaght Hospital, Dublin, Ireland
| | - Deirdre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
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Is Endoscopic Therapy Effective for Angioectasia in Obscure Gastrointestinal Bleeding?: A Systematic Review of the Literature. J Clin Gastroenterol 2015; 49:823-30. [PMID: 25518005 DOI: 10.1097/mcg.0000000000000266] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL We aimed to summarize pooled rebleeding rates of angioectasia after therapeutic endoscopy, and compare these to historical control (no intervention) rates. BACKGROUND Obscure gastrointestinal bleeding continues to be challenging to diagnose and treat; in America, small bowel angioectasias are the most common cause. Technology advances led to higher diagnostic yield for these lesions; however, therapeutic impact of endoscopy remains unclear. STUDY A PubMed search (June 1, 2006 to September 19, 2013) with 2 independent reviews sought articles reporting rebleeding rates of symptomatic angioectasia without therapy (natural history) and after endoscopic treatment. This study list was added to studies in the 2007 American Gastroenterological Association systematic review. Data on number of patients who underwent endoscopic therapy, type of therapy used, number of patients who experienced rebleeding, and follow-up time were extracted. Rebleeding data were pooled and weighted averages were reported with 95% confidence intervals (CI). RESULTS Twenty-four articles (n=490 patients) with data on endoscopic therapy for angioectasia and 6 natural history cohorts (n=130) receiving no therapy for angioectasia were eligible. Of the endoscopic therapy patients, 121 at push enteroscopy and 427 at balloon-assisted enteroscopy; 209/490 (42.7%; 95% CI, 38%-47%) rebled. Of the control (no therapy) patients, 64/130 (49.2%; 95% CI, 40%-58%) rebled. Number needed to treat is estimated at 15 to 16. CONCLUSIONS Rebleeding rate after endoscopic therapy for symptomatic small bowel angioectasia may be comparable to that expected without therapy. Endoscopic therapy may be ineffective; if effective, the needed to treat is estimated to be high. Controlled studies, with intervention-stratified and etiology-stratified outcomes are needed.
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Holleran G, Hall B, O'Regan M, Smith S, McNamara D. Expression of Angiogenic Factors in Patients With Sporadic Small Bowel Angiodysplasia. J Clin Gastroenterol 2015; 49:831-6. [PMID: 25319741 DOI: 10.1097/mcg.0000000000000260] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
GOALS To identify putative angiogenic factors associated with sporadic small bowel angiodysplasia (SBA). BACKGROUND SBAs account for 50% of obscure gastrointestinal bleeding and due to delays in diagnosis and ineffective treatments, are associated with high levels of morbidity and mortality. Treatment development is impeded by a limited knowledge of the pathophysiology behind SBA formation. STUDY We identified patients with definite sporadic SBA, and fecal immunochemical-negative controls were recruited from our institution's colorectal cancer screening program. Serum levels of VEGF, endoglin, Angiopoietin-2 (Ang-2), PDGF, Angiopoietin-1 (Ang-1), and TNF-α were measured using commercially available enzyme-linked immunosorbent assay kits. On the basis of serum results, we measured gene expression of target angiogenic factors in small bowel biopsy samples from angiodysplasias and unaffected tissue by quantitative PCR assessment. RESULTS Serum samples were analyzed from 40 SBA patients and 40 controls. Median serum levels of Ang-2 were significantly higher in patients than controls with levels of Ang-1 and TNF-α significantly lower. There were no differences in serum levels of VEGF, endoglin, or PDGF. Gene expression levels of Ang-1, Ang-2, and their receptor Tie2 were all significantly higher in biopsies from areas of angiodysplasia compared with normal small bowel. CONCLUSIONS This study, the first to explore the role of angiogenic factors in SBA, has identified a positive association between SBA and the Angiopoietin pathway, with increased serum and mucosal expression of Ang-2, which could potentially be used as a serum biomarker and future therapeutic target to improve outcome in affected patients.
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Affiliation(s)
- Grainne Holleran
- Departments of *Gastroenterology and Clinical Medicine, Tallaght Hospital †Biostatistics, Trinity College Dublin, Dublin, Ireland
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The role of deep enteroscopy in the management of small-bowel disorders. Gastrointest Endosc 2015; 82:600-7. [PMID: 26253015 DOI: 10.1016/j.gie.2015.06.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 06/23/2015] [Indexed: 12/11/2022]
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