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.

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.

Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB.

We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE.

The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p < .01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43-12.6; p < .01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p < .01).

Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.

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.

This study aims to compare double- (DBE) and single-balloon enteroscopy (SBE) in small bowel disorders with respect to procedural performance and clinical impact.

This retrospective analysis at a tertial referral center included 1,052 DBEs and 515 SBEs performed in 904 patients over 7 years. Procedural and patients' characteristics were precisely analyzed.

Significantly more patients with anemia and gastrointestinal bleeding were investigated by DBE (P < 0.01). Oral insertion depth and length of investigated small bowel in the combined approach were significantly higher in the DBE compared to the SBE group (245 ± 65.3 vs. 218 ± 62.6 and 355 ± 101.9 vs. 319 ± 91.2, respectively; P < 0.001, each). By analyzing only recent years of enteroscopy (2008-2011), no difference in small bowel visualization could be observed. The anal insertion depths and complete enteroscopy rates (CER) were comparable. Procedure times were significantly shorter within the SBE procedure (oral: 50 vs. 40 min; anal: 55 vs. 46 min, P < 0.001) and the usage of sedation was significantly less (propofol: P < 0.001; pethidine: P < 0.05). Diagnostic yield was significantly higher in the SBE, compared to the DBE group (61.7 vs. 48.2 %; P < 0.001). The rate of severe adverse events was close to zero.

Both enteroscopy techniques are safe diagnostic tools and proved to be indispensable in the daily gastroenterological practice. The lower insertion depths, but higher diagnostic yield, of SBE may reflect the more focused selection of patients scheduled for small bowel diagnostics in recent years.

Double-balloon enteroscopy (DBE) is an established method in diagnostic and therapeutic small-bowel enteroscopy.

Spiral enteroscopy (SE) appears to be a promising new technique. A randomized, prospective study was conducted to compare both methods.

Randomized, prospective study.

Single tertiary referral center.

Between September 2009 and March 2011, 26 patients with suspected mid-GI disorders completed the study.

Patients were randomly assigned to DBE or SE. The oral examination was conducted first, with the deepest point reached being marked with India ink. An additional anal examination followed the day after, with the aim of reaching the ink mark.

The primary endpoint of the study was the rate of complete enteroscopies achieved.

The rate of complete enteroscopies with DBE was 12 times the rate achieved with SE (8% in the SE group and 92% in the DBE group; P = .002). With regard to the secondary study criteria, much longer examination times but greater depths of insertion were associated with DBE. There were no statistically significant differences in the diagnostic or therapeutic outcomes between the SE and DBE groups (diagnostic yield, P = .428; therapeutic yield, P = 1.0; Fisher exact test). One perforation occurred during an anal examination as a relevant adverse event in SE.

Single-center study, small sample size.

SE does not represent an alternative to DBE with regard to the depth of insertion or the rate of complete enteroscopies achieved. However, SE is advantageous in that it involves significantly shorter examination times. Further technical improvements will be necessary before SE can compete with DBE for complete enteroscopies.

Single-balloon enteroscopy (SBE) was introduced as an alternative to double-balloon enteroscopy (DBE) for the investigation and management of small-bowel conditions. To date, there is only 1 randomized, controlled trial comparing SBE and DBE in a Western population.

To compare the 2 instruments in a Western population to assess for differences in clinical outcomes and insertion depth (ID). A novel method to determine ID by counting folds on withdrawal was used.

Multicenter, randomized, controlled trial.

University hospitals in Melbourne and Sydney, Australia.

Patients with suspected or proven small-bowel disease.

SBE and DBE.

The primary endpoint was diagnostic yield (DY). Secondary endpoints were therapeutic yield (TY), procedure times, and ID. An intention-to-treat analysis was performed.

A total of 116 patients were screened, and 107 patients were enrolled between July 2008 and June 2010, in whom 119 procedures were undertaken (53 SBEs and 66 DBEs). DY was 57% for SBE and 53% for DBE (P = .697). TY was 32% for SBE and 26% for DBE (P = .490). The median enteroscopy times were identical for SBE and DBE at 60 minutes. The mean ID by the fold-counting method for antegrade procedures was 201.1 folds for SBE and 258.6 folds for DBE (P = .046). After multiple comparisons adjustment, this difference did not reach statistical significance. Mean IDs by using the visual estimation method for SBE and DBE were, respectively, 72.1 cm and 75.2 cm (P = .835) for retrograde procedures and 203.8 cm and 234.1 cm (P = .176) for antegrade procedures.

Unable to reach target sample size, mostly single-center recruitment, novel method to determine ID, which requires further validation.

SBE has DY, TY, and procedure times similar to those of DBE. There were no statistically significant differences in ID between SBE and DBE. By using the fold-counting method for antegrade procedures, the estimated IDs for SBE and DBE were 201.1 folds versus 258.6 folds (P = .046; P = not significant after adjustment for multiple comparisons). (

ACTRN12609000917235.).

Starting with the introduction of the double-balloon enteroscope in 2001, two more techniques have been successfully developed for small bowel investigation (single-balloon enteroscopy, spiral enteroscopy). To compare the different enteroscopy systems, within this review, 68 studies were analyzed and put into context. The procedural characteristics (mean insertion depth, diagnostic yields, adverse events) were comparable for DBE, SBE or SE. The higher panenteroscopy rate in DBE might not have any clinical relevance. Therapeutic procedures, such as argon-plasma coagulation, polypectomy, dilation therapy and foreign body extraction are described with the DBE and SBE procedure. With regard to the present literature, the balloon-assisted devices as well as spiral enteroscopy technique seem to be equally suitable in clinical routine for imaging of the small bowel. The choice of the method should be based on availability, physicians' experience and clinical implications. Future randomized, controlled trials with large numbers of patients are needed to work out the subtleties of every single method.

Obscure gastrointestinal haemorrhage is defined the presence of overt or occult bleeding in the setting of a normal endoscopic examination of the upper and lower gastrointestinal tracts. While obscure bleeding is not common, the evaluation and management of these patients often incurs considerable expense. Potential options for small bowel evaluation include traditional radiographic studies, push enteroscopy, video capsule endoscopy, deep enteroscopy, tagged red blood cell scans, angiography, and enterography examinations with either computed tomography and/or magnetic resonance imaging. The decision regarding which modality to employ depends on the cost of the procedure, its effectiveness in rendering a diagnosis, and the potential for administration of therapy. This article will discuss determination of costs associated with technology for small bowel imaging, quality of life data associated with chronic GI haemorrhage, and available cost-effectiveness studies comparing the options for small bowel exploration.

In patients with obscure gastrointestinal (GI) bleeding, capsule endoscopy is widely used to determine the source of bleeding. However, there is currently no consensus on how to further evaluate patients with obscure GI bleeding with a non-diagnostic capsule endoscopy examination. This study aims to determine the diagnostic yield of dual-phase computed tomographic enterography (CTE) in patients with obscure GI bleeding and a non-diagnostic capsule endoscopy.

Patients with obscure GI bleeding who were referred for capsule endoscopy were prospectively enrolled. Obscure GI bleeding was defined as overt if there was obvious GI bleeding; otherwise it was defined as occult. Patients with a non-diagnostic capsule endoscopy and no contraindications underwent a CTE.

Capsule endoscopy was performed in 52 patients; 26 patients (50%) had occult GI bleeding and 26 patients (50%) had overt GI bleeding. CTE was then performed in 25 of the 48 patients without a definitive source of bleeding seen on capsule endoscopy. The diagnostic yield of CTE was 0% (0/11) in patients with occult bleeding versus 50% (7/14) in patients with overt bleeding (P < 0.01). Using clinical follow up as the gold standard, for the 25 patients with a non-diagnostic capsule, CTE had a sensitivity of 33% (95% confidence interval 0.15, 0.56) and a specificity of 75% (95% confidence interval 0.22, 0.99).

In patients with a non-diagnostic capsule endoscopy examination, CTE is useful for detecting a source of GI bleeding in patients with overt, but not occult, obscure GI bleeding.

Obscure gastrointestinal bleeding (OGIB) is a commonly encountered clinical problem in gastroenterology and is associated with significant morbidity and mortality. The investigation and management of OGIB has changed dramatically over the past decade with the advent of newer gastroenterological and radiological technologies.

To review the current evidence on the diagnosis and investigation of OGIB.

We searched the PubMed database (1985-2010) for full original articles in English-language journals relevant to the investigation of OGIB. The search terms we used were 'gastrointestinal bleeding' or 'gastrointestinal hemorrhage' or 'small bowel bleeding' each in combination with 'obscure', or 'capsule endoscopy', or 'enteroscopy' or 'enterography' or 'enteroclysis'.

Capsule endoscopy (CE) or double balloon enteroscopy (DBE) should be first line investigations. They are complimentary procedures with comparable high diagnostic yields. DBE is also able to provide therapeutic intervention. Newer technologies such as single balloon and spiral enteroscopy are currently being evaluated. Radiological and nuclear medicine investigations, such as CT enterography and CT enteroclysis, are alternative diagnostic tools when CE or DBE are contraindicated. Repeating the gastroscopy and/or colonoscopy may be considered in selective situations. An algorithm for investigation of obscure bleeding is proposed.

The development of capsule endoscopy and double balloon enteroscopy has transformed the approach to the evaluation and management of obscure gastrointestinal bleeding over the past decade. Older diagnostic modalities still play a complementary, but increasingly selective role.

Balloon endoscopy has been accepted as an effective tool for examining the small intestine. Two types of balloon endoscopy, single and double, are commercially available. The difference in performance between these 2 types of balloon endoscopy has not yet been elucidated.

To compare the yield of single-balloon endoscopy (SBE) and double-balloon endoscopy (DBE).

Single-center, randomized, controlled trial.

University hospital in Tokyo, Japan.

Patients with suspected small-bowel disease.

SBE and DBE.

Outcomes were the total enteroscopy rate, diagnostic yield, complication rate, and clinical outcomes. Analysis was done by intent to treat.

The study started in April 2008 and was terminated in April 2010 because of an obvious disadvantage for the SBE group. Thirty-eight patients were enrolled in the study; 18 patients were assigned to the SBE group and 20 to the DBE group. The total enteroscopy rate was 0% in the SBE group and 57.1% in the DBE group (P = .002). In terms of complications, the DBE group had 1 patient with Mallory-Weiss syndrome, and the SBE group had 1 patient with hyperamylasemia. There was no difference in the overall diagnosis rate between the SBE and DBE groups (61.1% vs 50.0%, P = .49). There was no difference in therapeutic outcome between the SBE and DBE groups (27.8% vs 35.0%, P = .63).

Relatively small number of study patients.

Total enteroscopy is more easily performed with DBE than with SBE.

Single-balloon enteroscopy (SBE) is a novel, deep-enteroscopy modality for diagnosis and treatment of disorders of the small bowel.

The aim of the study was to examine the performance, yield, and safety of SBE in the initial experience at a tertiary-care center.

Retrospective analysis of all SBEs during a 10-month period in 2008. Data were extracted from electronic clinical and endoscopy records.

U.S. tertiary-care center.

All patients referred to our center for SBE during the study period were included in the current analysis.

SBE.

Anterograde SBE procedure time, diagnostic yield, and complications.

Thirty-eight anterograde SBEs were performed. The mean patient age was 62 years (42% female). Patients were referred for GI bleeding (97%), Crohn's disease, suspected polyps or neoplasia, and abnormal capsule endoscopy results. The mean (+/- SD) procedure time was 49 +/- 19 minutes. The estimated depth of insertion was proximal jejunum (34%), mid-jejunum (45%), and distal jejunum (21%). The SBE diagnostic yield was 47%, with significant findings in 18 patients. Findings included angiectasias, bleeding, abnormal mucosa, ulceration, polyps, and a foreign body. The therapeutic yield was 42%, with lesion ablation performed in 24% of cases. Diagnostic biopsies were performed in 24% of cases and tattooing in 52%. There were no significant complications.

Single-center, retrospective study.

Single-balloon enteroscopy appears to be a safe and efficient method for examination of the mid-small bowel. The significant therapeutic yield (42%) suggests that comparative studies with double-balloon and spiral enteroscopy are warranted.

The aim of this study is to evaluate the usefulness of double balloon enteroscopy (DBE) and video capsule endoscopy (VCE) in patients with primary follicular lymphoma (FL) of the gastrointestinal (GI) tract. Furthermore, we estimate the effectiveness of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) including rituximab for them.

Thirteen consecutive patients who were diagnosed of having FL in the duodenum between July 2005 and September 2008 were studied. All patients were given the conventional staging examinations, including total enteroscopy using DBE and/or VCE procedures. Chemotherapy was performed after written informed consent. Response assessment was performed every 6-12 months. The median follow-up period was 30.2 months.

FL was diagnosed in each patient as low grade (grade 1, n = 7; 2, n = 6) and, in all but 4 patients, localized lymphoma (stage I, n = 8; II(1), n = 1; II(2), n = 4). DBE revealed multifocal lesions in the jejunum in 10 of the patients, and in the ileum in 6. VCE showed similar findings in the jejunum in the recent 2 patients. Eleven of 13 patients finally received chemotherapy, and all of them achieved complete regression. They showed no evidence of recurrence after that.

Total examination of the small intestine using DBE should be performed before treatment to choose a suitable treatment procedure for primary FL of the GI tract. On the other hand, VCE is useful for screening and following the small intestine in the patients with it. Chemotherapy is effective to achieve complete regression of primary FL of the GI tract.

Double balloon enteroscopy (DBE) was introduced into the US in 2004. Potential complications include perforation, pancreatitis, and gastrointestinal bleeding. Prevalence and risk factors for complications have not been described in a US population.

We conducted a retrospective study of DBE complications in 9 US centers. We obtained detailed information for each complication including patient history, maneuvers performed during the DBE, and presence of altered surgical anatomy.

We collected data from 2478 DBE examinations performed from 2004 to 2008. The dataset included 1691 (68%) anterograde DBE, 722 (29%) retrograde DBE (including 5 per-stomal DBEs), and 65 (3%) DBE-facilitated endoscopic retrograde cholangiopancreatography ERCP cases. There were a total of 22 (0.9%) major complications including perforation in 11 (0.4%), pancreatitis in 6 (0.2%), and bleeding in 4 (0.2%) patients. One of 6 cases of pancreatitis occurred post retrograde DBE. Perforations occurred in 3/1691 (0.2%) anterograde examinations and 8/719 (1.1%) retrograde DBEs (P = .004). Eight (73%) perforations occurred during diagnostic DBE examinations. Four of 8 retrograde DBE perforations occurred in patients with prior ileoanal or ileocolonic anastomoses. In the subset of 219 examinations performed in patients with surgically altered anatomy, perforations occurred in 7 (3%), including 1/159 (0.6%) anterograde DBE examinations, 6/60 (10%) retrograde DBEs, and 1 of 5 (20%) peristomal DBE examinations (P < .005 compared with patients without surgically altered anatomy).

DBE is associated with a higher complication rate compared with standard endoscopic procedures. The perforation rate was significantly elevated in patients with altered surgical anatomy undergoing diagnostic retrograde DBE examinations.

Single-balloon enteroscopy (SBE) is a novel method of balloon assisted enteroscopy which allows deep intubation of intestine and has therapeutic potential. This prospective study was done in a tertiary care center to evaluate the feasibility, complications, diagnostic and therapeutic yield of SBE in patients with suspected small bowel disorders.

One hundred and six patients (mean age 40.1 years, range 12-76 years, 65 men) with suspected small bowel diseases underwent 131 SBE procedures between February 2007 and July 2008.

Indications for SBE included obscure gastrointestinal bleeding (OGIB) (40), chronic abdominal pain with abnormal imaging studies (34), chronic diarrhea (20), polyposis syndromes (11) and foreign body (1).The mean insertion depth was 255.8 +/- 84.5 cm beyond the duodenojejunal flexure by the oral route and 163 +/- 59.3 cm proximal to the ileocecal valve by the per anal approach. The mean duration of the procedure for antegrade and retrograde enteroscopy was 65.9 +/- 19.5 min and 72.3 +/- 18.3 min, respectively. Pan-enteroscopy was possible in 25% of cases (five of 20 cases in which total enteroscopy was attempted). Diagnostic yields in cases of OGIB, chronic abdominal pain and chronic diarrhea were 60%, 65% and 55%, respectively. Overall new diagnosis was established in 46% and the extent of known disease was assessed in 15% of cases. In 21% of patients, therapeutic interventions were carried out while surgical treatment was directed to 8.4% of the patients. No major complications were observed.

SBE is well tolerated and has good diagnostic yield, having a similar yield to previous double-balloon enteroscopy reports.

Double balloon endoscopy (DBE) is a new endoscopic method with the capability for complete observation of whole small bowel. This study evaluated the feasibility and usefulness of DBE for the diagnosis and therapy of small bowel diseases in patients with distorted intestinal anatomy by previous surgeries.

From January 2005 to August 2007, 15 patients with Roux-en-Y anastomosis underwent DBE in Asan Medical Center. Eight were men and the median age was 57 years (range, 40 to 68 y). Indications of DBE were suspected small bowel bleeding, chronic diarrhea, and recurrent acute pancreatitis. The main outcome measurements included completeness of the observation of afferent loop and DBE findings.

Because 1 patient underwent DBE twice separately owing to recurrent bleeding, a total of 16 cases were analyzed. The observation of afferent loop was complete in 13 (81%) of 16 cases. The overall diagnostic yield of DBE was 69% (11/16). Out of 11 cases in which DBE detected abnormalities, 6 (55%) showed definite lesions and 5 (45%) probable lesions. Of the 11 cases in which abnormalities were found, 7 (64%) showed lesions in afferent loop. Of the 6 cases in which definite lesions were found, 4 (67%) showed lesions in afferent loop. Therapeutic endoscopic procedures were performed in 4 cases, which include argon plasma coagulation, foreign body removal, and endoscopic nasobiliary drainage.

DBE in patients with distorted intestinal anatomy such as Roux-en-Y anastomosis is a useful tool for the management of small bowel lesions, especially those in the afferent loop.

The purpose of this article is to describe the available data regarding the short- and long-term outcomes associated with deep enteroscopy. Deep enteroscopy can be defined as the use of an enteroscope to examine small bowel distal to the ligament of Treitz or proximal to the distal ileum. The term deep enteroscopy includes double-balloon, single-balloon, and spiral enteroscopy. Comparisons are made with push enteroscopy and intraoperative enteroscopy, the major therapeutic endoscopic options available to the gastroenterologist before the introduction of deep enteroscopy. The article concludes with a discussion regarding complications associated with deep enteroscopy and cost-effectiveness of management strategies for obscure bleeding. Proposed changes to the current algorithm for management of obscure bleeding are suggested.

Poor weight gain and growth can be caused by many medical, nutritional, behavioral, and psychological factors. Crohn disease is one of the more common gastrointestinal etiologies associated with growth failure. The aim of this study is to determine the role of capsule endoscopy (CE) in the evaluation of older children and adolescents who were referred to a pediatric gastroenterology service for a chief complaint of unexplained growth failure.

We retrospectively reviewed the records of children with growth failure undergoing CE between August 2002 and November 2005. Height and weight (expressed as z scores) were recorded at least 6 months before study, at the time of the study, and at least 6 months post study. All of the patients had celiac disease and Crohn disease excluded using standard biochemical, radiologic, endoscopic, and histologic assessment.

Seven children (4 males and 3 females) were included in the study-mean age 11.7+/-3.6 years. Indications for CE were growth failure associated with abdominal pain (3 patients), diarrhea and apthous ulcers (2 patients), delayed puberty (1 patient), or a family history of Crohn disease (1 patient). The mean z score for weight at the time of the study was 2.10+/-1.0 and for height was 1.50+/-0.7 All 7 children had normal small bowel series performed before the CE. All had both endoscopically and histologically normal esophagogastroduodenoscopy and colonoscopy. In 4 of 7 patients, multiple small bowel apthous ulcerations consistent with Crohn disease were identified by CE. All 4 patients who had abnormal CE were treated and started gaining weight. The mean z score for weight after 6 months of treatment was 1.35+/-1.2 and for height was 0.50+/-1.7. The mean z score for weight after treatment was significantly improved compared with the mean z score at diagnosis (P<0.05).

In our study, 4 of the 7 older children and adolescents with unexplained growth failure and normal small bowel series were found to have Crohn disease involving the small intestine. In addition, we were able to show the improvement on the mean z score for weight after treatment of small bowel Crohn disease was instituted.

Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage.

We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period.

An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses.

The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions.

An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.

Although double balloon endoscopy (DBE) has demonstrated a high diagnostic yield in suspected small bowel bleeding, it is not known whether DBE is of equal value to all patients with suspected small bowel bleeding or of greater benefit in selected subgroups. We aimed to determine whether any clinical features predict an increased likelihood of finding a lesion in patients with suspected small bowel bleeding.

We retrospectively analyzed clinical features of 43 consecutive patients (M : F = 26:17, age 13-82 years) who underwent DBE because of suspected small bowel bleeding. Data associated with DBE procedure were collected prospectively. Predictive factors for the detection of a lesion were determined by comparison of clinical features between patients with positive DBE findings and those with negative findings.

Potential bleeding sources were discovered in 30 patients (69.8%) out of 43. Duration of bleeding was longer in patients with positive DBE findings than in those with negative findings (195 +/- 311 vs 18 +/- 17 days, P = 0.015). Number of bleeding episodes was higher in patients with positive DBE findings (2.2 +/- 1.2 vs 1.3 +/- 0.5, P = 0.011). The odds ratio for the detection of bleeding focus on DBE for patients with two or more bleeding episodes, relative to those with only one current bleeding episode was 5.67 (95% CI: 1.12-28.81, P = 0.036) in multivariate analysis.

DBE may be the most useful in patients with suspected small bowel bleeding if they have a history of frequent bleeding episodes over a long period.

Double-balloon enteroscopy (DBE) allows direct visualization and intervention in the entire small intestine. Concerns include long procedure times and a long learning curve after training.

To analyze the initial experience of a single endoscopist when using DBE; assess resource utilization, safety, clinical utility, and the learning curve.

Prospective study.

Tertiary-referral center.

A total of 137 consecutive patients with bleeding or other small-intestine disorders.

Clinical impact at the time of DBE and changes in the procedure time and extent with experience.

Two hundred DBE procedures were performed without major complications. For 115 oral DBEs, the mean (SD) procedure duration was 101 +/- 35 minutes and length of examined small intestine was 220 +/- 80 cm, with no significant change with experience. For 85 anal DBEs, the mean (SD) procedure duration was 96 +/- 33 minutes, and the length examined was 124 +/- 60 cm; the length examined increased with experience, but the duration did not decrease. The percentage of patients in which a DBE had a helpful clinical impact rose from 58% in the first 50 DBEs, to 86% in the last 50 of 200 DBEs. The total enteroscopy rose from 8% in the first 50 DBEs, to 63% in the last 50 of 200 DBEs.

No follow-up data on outcomes.

DBEs required significant time and did not always allow for a total enteroscopy. DBEs were safe and helpful in the management of most patients. An experienced endoscopist may perform a safe and useful DBE after limited training, but the development of expertise may require more than 100 to 150 DBE procedures.

Reliable closure of the translumenal incision is one of the main challenges facing natural orifice translumenal endoscopic surgery (NOTES). This study aimed to evaluate the use of an automated flexible stapling device (SurgASSIST) for closure of the gastrotomy incision in a porcine model.

A double-channel gastroscope was advanced into the stomach. A gastric wall incision was made, and the endoscope was advanced into the peritoneal cavity. After peritoneoscopy, the endoscope was withdrawn into the stomach. The SurgASSIST stapler was advanced orally into the stomach. The gastrotomy edges were positioned between the opened stapler arms using two endoscopic grasping forceps. Stapler loads with and without a cutting blade were used for gastric closure. After firing of the stapler to close the gastric wall incision, x-ray with contrast was performed to assess for gastric leakage. At the end of the procedure, the animals were killed for a study of closure adequacy.

Four acute animal experiments were performed. The delivery and positioning of the stapler were achieved, with technical difficulties mostly due to a short working length (60 cm) of the device. Firing of the staple delivered four rows of staples. Postmortem examination of pig 1 (when a cutting blade was used) demonstrated full-thickness closure of the gastric wall incision, but the cutting blade caused a transmural hole right at the end of the staple line. For this reason, we stopped using stapler loads with a cutting blade. In the three remaining animals (pigs 2-4), we were able to achieve a full-thickness closure of the gastric wall incision without any complications.

The flexible stapling device may provide a simple and reliable technique for lumenal closure after NOTES procedures. Further survival studies are currently under way to evaluate the long-term efficacy of gastric closure with the stapler after intraperitoneal interventions.

Double-balloon endoscopy (DBE) made the small bowel accessible to inspection and therapy in its entirety. However, DBE is a time-consuming procedure that requires a highly skilled endoscopist, several nurses and--more often than not--anesthesiological support. This makes the selection of patients for DBE a pivotal point. The mainstay of this screening examination of the small bowel is capsule endoscopy (CE). The aim of this study was to describe the results of this screening procedure and the subsequent DBE in patients with suspected mid-gastrointestinal bleeding (MGIB).

Patients referred for CE from March 2004 to September 2006 were evaluated retrospectively. If CE revealed pathology suitable for DBE, the procedure was then carried out. All referred patients were followed-up at the end of the period with regard to final diagnosis and symptom resolution.

A total of 83 patients were referred for suspected MGIB. Indications for DBE were found in 26 patients (31%). A total of 34 DBEs (27 oral, 7 anal) were performed. Insertion length for the oral and anal DBE was 200 cm (range 40-500 cm) beyond the ligament of Treitz and 137 cm (range 10-200 cm) beyond the ileocecal valve, respectively. In 2 out of 4 patients where insertion was attempted, a total inspection of the small bowel was possible (50%). The diagnostic yield was 77% (CI: 58-89%) with a therapeutic yield of 73% (CI: 54-86%). None of the 57 patients for whom there was no indication for DBE required DBE within the next 12 months.

CE can be applied as a screening procedure for DBE and allows for an approximately two-thirds reduction in the need for DBE as well as enabling a choice to be made between the oral and anal route.

This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007.

Data on the nature of small-bowel tumors found or missed by capsule endoscopy (CE) are limited. The aim of this study was to review the CE findings in patients with small-bowel tumors presenting as obscure gastrointestinal (GI) bleeding.

We retrospectively reviewed the medical records of the first 300 patients who underwent CE for obscure bleeding (non-diagnostic EGD and colonoscopy) at our institution.

Ten (3%) confirmed small-bowel masses were found in 9 patients. CE findings included distinct mass (n=4), focal irregular (ulcerated or nodular) mucosa (n=2), focal blood without clear lesion (n=1), proximal angiodysplasia with obscuring distal melena (n=1), incomplete distal examination with normal proximal images (n=1), and normal findings (n=1). Most (80%) of the lesions were potentially malignant: adenocarcinoma (n=4), neuroendocrine carcinoma (n=1), leiomyosarcoma (n=1), and GI stroma cell tumors (GISTs) (n=2). Benign lesions included inflammatory fibroid polyp (n=1) and lipoma (n=1). Three duodenal masses were missed on a previous EGD; one was missed by CE as well. CE findings led directly to tumor diagnosis in 7 of the 10 cases. Capsule retention occurred in 2 of the 10 cases, with one patient requiring urgent surgery for acute obstruction.

Small-bowel tumors are a rare but serious source of obscure GI bleeding. Our large single-center experience shows that most lesions are of malignant potential. Tumors can have an atypical appearance including focal ulceration, nodularity, or active bleeding without a clear lesion. Mass lesions in the duodenum are particularly elusive and can be missed by both EGD and CE.

Lower gastrointestinal bleeding represents one-fourth of all gastrointestinal hemorrhages. The bleeding usually originates in the colon while less than 10% of cases originate in the small bowel. Colonoscopy is considered the initial procedure of choice due to its diagnostic efficacy, safety, and therapeutic potential. Mesenteric arteriography can be an alternative in patients with massive hemorrhage. Helical computed tomography of the abdomen with endovenous contrast can be useful but has not been directly compared with arteriography. When the results of gastroscopy and colonoscopy are negative, small bowel bleeding is suspected. Capsule endoscopy allows non-invasive examination of the entire small bowel. The diagnostic efficacy of this procedure is clearly superior to that of other conventional examinations and, compared with intraoperative endoscopy, capsule endoscopy has a sensitivity of 95% and a specificity of 75%. Double balloon enteroscopy is a new modality that also allows complete examination of the small bowel with the additional advantage of its therapeutic potential. Definitive diagnosis of the hemorrhagic site is essential for appropriate treatment. Endoscopic and angiographic advances are therapeutic alternatives to surgical resection. Endoscopic treatment is indicated in lesions with active bleeding or signs of recent hemorrhage. Arterial embolization can be a therapeutic alternative when arteriography shows active hemorrhage. Surgical treatment is reserved for patients with persistent bleeding in whom other options have failed.

Diagnosing and treating patients with obscure gastrointestinal bleeding is clinically challenging. Most lesions responsible for the origin of obscure gastrointestinal bleeding are located in the small bowel. Double-balloon enteroscopy is a novel method for exploring the small intestine and has significant therapeutic potential. This study evaluated the value of double-balloon enteroscopy in diagnosing and managing obscure gastrointestinal bleeding. From October 2003 to January 2006, a total of 20 patients (6 men, 14 women; mean age, 55.2 years old) with obscure gastrointestinal bleeding (18 obscure overt bleeding, 2 obscure occult bleeding) were investigated by double-balloon enteroscopy. A total of 29 procedures (15 via oral approach and 14 via rectal approach) were performed. The diagnostic yield, endoscopic therapeutic procedures, complications, and outcome were then assessed. Small bowel lesions potentially responsible for the bleeding were identified in 15 (75%) of 20 patients, including 9 angiodysplasias, 2 gastrointestinal stromal tumors (GISTs), 2 ulcers, 1 jejunal granulation polyp, and 1 Peutz-Jeghers polyposis. Endoscopic treatments including heater probe coagulation, polypectomy, and endoscopic mucosal resection were performed in 11 patients. Two patients with GISTs received surgical intervention. Two patients with angiodysplasias that endoscopic treatment failed underwent laparoscopic resections following tattooing. There were no complications and the procedures were tolerated well. Among the 15 patients who had a lesion identified with subsequent treatment, rebleeding occurred in 3 (20%) patients with angiodysplasias. Of the five patients in whom no definite lesion was detected, rebleeding developed in four (80%). For patients with an identified lesion that was further treated, the rebleeding rate was lower than for those with "persistent" obscure gastrointestinal bleeding (P=0.031). We conclude that double-balloon enteroscopy offers a safe and effective method for diagnosing and managing patients with obscure gastrointestinal bleeding.

Capsule endoscopy (CE) is a new diagnostic tool for the study of patients with suspected small bowel pathology. The aim of the study was to clarify the usefulness of CE in the group of patients with obscure (overt / occult) gastrointestinal (GI) bleeding.

Thirty patients (14 men, 16 women, mean age 50 years, range 9 -79 years) were enrolled in the study. All of them undergone non-diagnostic esophagogastroduodenoscopy, colonoscopy and barium follow-through of the small bowel. All patients underwent capsule endoscopy. Fourteen patients had overt and sixteen occult bleeding. The single senior endoscopist interpreted CE findings in an unblinded manner.

CE identified a source of bleeding in 14/30 patients (46.6%). Lesions identified were: tumors in five pts, vascular lesions, Crohnzs disease and Meckelzs diverticulum in two pts and fresh bleeding, segmental celiac disease and colonic diverticulosis in one patient each. CE identified a source of bleeding in 9/14 (64.3%) of patients with ongoing overt bleeding and in only 5/16 (31.3%) of patients with occult bleeding. The positive suspicious findings were seen in 6/30 (20%) of patients (2/14 with overt bleeding and 4/16 with occult bleeding. In 3/14 (21.4%) with overt and 7/16 (43.7%) with occult bleeding findings on CE were negative. All patients with negative findings on follow-up remained asymptomatic for one year. Capsule retention because of unsuspected stenosis occurred in a single patient and required surgery, which resolved the problem.

CE is an effective diagnostic tool for patients with obscure GI bleeding. It is safe and painless technique which can diagnose the bleeding site beyond the reach of conventional endoscopy. The best candidates for the procedure are those with ongoing and overt bleeding.

To prospectively evaluate the indications, methodology, safety, and clinical impact of double-balloon endoscopy.

A total of 60 patients with suspected or documented small- or large-bowel diseases were investigated by double balloon endoscopy. A total of 103 procedures were performed (42 from the oral route, 60 from the anal route, and 1 from the stoma route). The main outcome measurements were the time of insertion and the entire examination, complications, diagnostic yields, and the ability to successfully perform treatment.

Observation of the entire small intestine was possible in 10 (40%) of 25 patients with total enteroscopy. The median insertion time was 122 min (range, 74-199 min). Observation of the entire colon was possible in 13 (93%) of 14 patients after failure of total colonoscopy using a conventional colonoscope. Small-intestine abnormalities were found in 20 (43%) of 46 patients with indications of suspected or documented small bowel diseases, obscure GI tract bleeding, or a history of ileus. Endoscopic procedures including tattooing (n = 33), bite biopsy (n = 17), radiographic examination (n = 7), EUS (n = 5), hemostasis (n = 1), polypectomy (n = 5), balloon dilatation (n = 1), endoscopic mucosal resection (n = 1) and lithotripsy (n = 1) were all successfully performed. No relevant technical problems or severe complications were encountered.

Double balloon endoscopy is a feasible technique that allows adequate small and large bowel examination and potentially various endoscopic procedures of small-intestinal lesions. It is safe, useful, and also provides a high clinical impact.

Surveillance and treatment of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS) can be challenging and may require intraoperative enteroscopy. While initial reports that used double-balloon enteroscopy (DBE) for the resection of small-bowel polyps in patients with PJS appear promising, complete enteroscopy when using this technique may require multiple procedures or may not be possible at all.

To develop a single-procedure approach to the surveillance and the treatment of small-bowel polyps in patients with PJS.

Retrospective review.

Single, North American tertiary-care center.

Individuals with PJS and small-bowel polyps identified by other modalities.

DBE was combined with laparoscopy as a single-procedure surveillance and therapeutic strategy for small-bowel PJS polyps.

Completion of enteroscopy, number of polyps resected, procedure duration, complications.

Three patients with a history of PJS and known small-bowel polyps underwent laparoscopic-assisted DBE (LADBE). Complete enteroscopy was performed, and all polyps larger than 0.5 cm were resected endoscopically. No cases of cancer or dysplasia were noted; procedure times lasted from 1 to 4 hours. Postoperative complications included ileus in 2 patients.

Small sample size, single-center experience.

LADBE holds promise as a new technique that can be used as both a surveillance and a therapeutic tool for small-bowel polyps in patients with PJS.

In spite of initial skepticism toward the practicability of double-balloon enteroscopy, this technology will become an integral part of endoscopy and is likely to find expanded applications in the future. One strong reason to support this technique is the capacity to deliver endoscopic therapies, and thereby minimize aggressive surgical options. With increasing acceptance of capsule endoscopy by the medical community, more small-bowel lesions will be found and more directed endoscopic interventions will be needed. Like many new procedures, reimbursement issues will possibly prevent it from gaining well-deserved popularity. Unlike other common endoscopies, double-balloon enteroscopy is an expensive procedure. It requires fluoroscopy, extended anesthesia support, long procedure time, significant capital investment, and a team of threeor four people (endoscopist, anesthesiologist, nurse). Gastroenterologists and their patients will have to work together to convince insurance carriers that this isa valuable and cost-effective technology worthy of appropriate reimbursement.