Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use

The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy

The introduction of capsule endoscopy in 2001 opened the last "black box" of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy are available in clinical practice. Recently, a novel motorized enteroscope has been described with the potential to shorten procedure time and allow for total enteroscopy in one session. In this review, we will present an overview of the currently available techniques, indications, diagnostic yield, and complications of device-assisted enteroscopy.

Video Capsule Endoscopy and Device-Assisted Enteroscopy

Mark Hanscom Courtney Stead Harris Feldman Neil B. Marya David Cave.

Factors Affecting Route Selection of Balloon-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study

Balloon-assisted enteroscopy (BAE) is an important diagnostic modality for ongoing obscure gastrointestinal bleeding (OGIB). However, it is difficult to determine the optimal insertion route. We retrospectively analyzed the records of patients with OGIB contained in a multicenter enteroscopy database of 1108 balloon-assisted enteroscopy (BAE) procedures (875 patients) to find out factors affecting BAE route selection in patients with OGIB. A total of 603 BAE procedures in 512 patients were investigated: there were 392 (65.0%) bidirectional and 211 (35.0%) unidirectional procedures. Overt OGIB was more frequent in the latter group (p = 0.024). Computed tomography (CT) was more frequently performed in the unidirectional group (p < 0.001). Capsule endoscopy and a small bowel barium study were performed more frequently in the bidirectional group (p < 0.001 and p = 0.039, respectively). Multivariate analysis showed that occult OGIB, capsule endoscopy and a small bowel barium study were independently associated with use of the bidirectional approach (p = 0.011, p = 0.013 and p = 0.046, respectively). Conversely, CT was associated with use of the unidirectional approach (p < 0.001). Conclusion: CT can aid the selection of an optimal insertion route in OGIB patients. However, capsule endoscopy and small bowel barium study are unhelpful.

Use, Yield, and Risk of Device-assisted Enteroscopy in the United States: Results From a Large Retrospective Multicenter Cohort

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.

The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021

The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.

Iron Deficiency and the Small bowel​

PURPOSE OF REVIEW

This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options.

RECENT FINDINGS

Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.

Total motorized spiral enteroscopy: first prospective clinical feasibility trial

BACKGROUND AND AIMS

Motorized spiral enteroscopy (MSE) was recently introduced into clinical practice and shown to be safe and effective for antegrade enteroscopy. The aim of the current trial was to prospectively study the efficacy and safety of MSE for visualization of the entire small bowel.

METHODS

All consecutive patients with indications for complete enteroscopy meeting the inclusion criteria were enrolled in a prospective observational bicentric trial, starting with antegrade MSE; a retrograde approach was performed if MSE remained incomplete from antegrade. The primary objective was to ascertain the total enteroscopy rate (TER); secondary objectives were diagnostic yield, procedural success, time, depth of maximum insertion (DMI), therapeutic yield, and adverse events (AEs).

RESULTS

Thirty patients (16 women, 14 men; median age 64 years [range, 37-100]) were enrolled. Technical success rate of antegrade MSE (advancement beyond the ligament of Treitz) and retrograde MSE (advancement beyond the ileocecal valve [ICV]) were 100% and 100%, respectively. Overall TER was 70%: 16.6% antegrade approach alone and 53.4% bidirectional approach. Median antegrade DMI distal from the ligament of Treitz was 490 cm (range, 160-600); median insertion time 26 minutes (range, 15-110). The median retrograde DMI beyond the ICV was 120 cm (range, 40-600), and median insertion time was 17 minutes (range, 1-68). Overall diagnostic and therapeutic yields were 80% and 86.7%, respectively. Overall AE rate was 16.7%. No serious AEs occurred.

CONCLUSIONS

This prospective study showed that complete enteroscopy is feasible with MSE, either from antegrade alone or bidirectionally, with high success rates and short procedural duration. These results justify further evaluation of MSE in a large prospective multicenter study, preferably with inclusion of a control group. (Clinical trial registration number: NCT03438695.).

Technical and Clinical Aspects of Diagnostic Single-Balloon Enteroscopy in the First Decade of Use: A Systematic Review and Meta-Analysis

Background/Aims

Single-balloon enteroscopy (SBE) has been widely used in diagnosing small bowel disease. We conducted this study to systematically appraise its technical and clinical performance.

Methods

Studies on SBE published by September 2018 were systematically searched. Technical and clinical performance data were collected and analyzed with descriptive or meta-analysis methods.

Results

In total, 54 articles incorporating 4,592 patients (6,036 procedures) were included. Regarding technical parameters, the pooled insertion depths (IDs) for anterograde and retrograde SBE were 209.2 cm and 98.1 cm, respectively. The pooled retrograde ID in Asian countries was significantly greater than that in Western countries (129.0 cm vs 81.1 cm, p<0.001). The pooled anterograde and retrograde procedure times were 57.6 minutes and 65.1 minutes, respectively. The total enteroscopy rate was 21.9%, with no significant difference between Asian and Western countries. Clinically, the pooled diagnostic yield of SBE was 62.3%. Obscure gastrointestinal bleeding (OGIB) was the most common indication (50.0%), with a diagnostic yield of 59.5%. Vascular lesions were the most common findings in Western OGIB patients (76.9%) but not in Asian ones (31.0%). The rates of severe and mild adverse events were 0.5% and 2.5%, respectively.

Conclusions

SBE is technically efficient and is clinically effective and safe, but total enteroscopy is relatively difficult to achieve with this technique. Etiologies of OGIB in Asian countries differ from those in Western countries.

Causes and Clinical Characteristics of Small Bowel Bleeding in Northern Vietnam

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.

First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus

Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.

Inspecting the total gastrointestinal tract by consecutive bidirectional double-balloon enteroscopy in patients with suspected small bowel bleeding

BACKGROUND/AIMS

This study aimed to investigate the feasibility, efficiency, and clinical significance of examining the total gastrointestinal (GI) tract by consecutive bidirectional double-balloon enteroscopy (DBE) within 1 day in patients with suspected small-bowel bleeding.

MATERIALS AND METHODS

From January 2016 to January 2018, the clinical and endoscopic data of 41 patients with suspected small-bowel bleeding undergoing DBE aimed at inspecting the total GI tract within 1 day.

RESULTS

A success rate of 87.8% (36/41) for examining the total GI tract with no adverse event was achieved by consecutive bidirectional DBE performed within 1 day. The total examination time was 140.61±36.41 (range, 82-270) minutes. Positive or negative findings of bleeding were detected in 51.2% (21/41) and 48.8% (20/41) patients, respectively. Single bleeding etiology with non-small-bowel lesions (NSBLs) or small-bowel lesions (SBLs) was detected in 12.2% (5/41) and 26.8% (11/41) of patients, respectively. Dual bleeding etiologies, including NSBLs and SBLs, were detected in 12.2% (5/41) of patients. A re-bleeding rate of positive or negative findings was different (4.8% vs. 40.0%; p<0.05).

CONCLUSION

Consecutive bidirectional DBE within 1 day can achieve complete vision of the total GI tract with a considerable success rate and high safety. This strategy may provide an option for detecting bleeding etiology throughout the GI tract. A negative finding with this method cannot absolutely exclude missed bleeding etiology and re-bleeding.

Roles of Capsule Endoscopy and Balloon-Assisted Enteroscopy in the Optimal Management of Small Bowel Bleeding

The small bowel had long been considered a dark unapproachable tunnel until the invention of capsule endoscopy and doubleballoon enteroscopy in the 21st century, which revolutionized the diagnosis and management of small bowel diseases, including bleeding. Various imaging modalities such as computed tomographic enterography, angiography, capsule endoscopy, and balloonassisted enteroscopy play vital roles in the diagnosis and management of small bowel bleeding. The choice of modality to use and timing of application differ according to the availability of the modalities, patient’s history, and physician’s experience. Small bowel bleeding is managed using different strategies as exemplified by medical treatment, interventional radiology, endoscopic therapy, or surgical intervention. Balloon-assisted enteroscopy enables endoscopic interventions to control small bowel bleeding, including electrocautery, argon plasma coagulation, clip application, and tattooing as a prelude to surgery. In this article, we clarify the recent approaches to the optimal diagnosis and management of patients with small bowel bleeding.

Small Bowel Enteroscopy - A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups

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.

New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review

Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.

Diagnosis and management of jejunoileal diverticular haemorrhage: An update on the experience in a single centre

INTRODUCTION

Jejunoileal diverticular haemorrhage is a rare disease that is difficult to diagnose and treat. Despite advances in endoscopic technology, recommendations on diagnosis and management for jejunoileal diverticular haemorrhage have remained unchanged and these new options have not been compared against traditional surgical management.

MATERIALS AND METHODS

We retrospectively reviewed the diagnosis, management, and outcome for jejunoileal diverticular haemorrhage cases at our institution over the past 20 years. Data were organized and analysed by chi-square test, student t-test and Kaplan-Meier survival analysis.

RESULTS

The most utilised diagnostic procedure was computed tomography, followed by enteroscopy, angiography, small bowel flow-through and surgery. Primary treatments included, in a decreasing order, medical therapy, surgery, endoscopy and radiology. Surgical treatment was not associated with rebleeding, but it did result in longer hospital stays and larger blood transfusions than non-surgical treatments. The bleeding-related mortality rate was very low. Notably, there was also little change in the diagnosis and treatment between decades.

CONCLUSION

We presented our experience with the diagnosis and management of jejunoileal diverticular haemorrhage, as well as long-term follow-up after treatments that have not been reported previously. Surgical treatment continues to dominate management for jejunoileal diverticular haemorrhage, but we support increasing the role of endoscopy for select patient groups.

Non-steroidal anti-inflammatory drug-induced enteropathy as a major risk factor for small bowel bleeding: a retrospective study

BACKGROUND

Small bowel (SB) bleeding accounts for 5% of all gastrointestinal (GI) bleeding cases and 80% of obscure GI bleeding cases. Although angioectasia is the common etiology of SB bleeding, nonsteroidal anti-inflammatory drug (NSAID)-induced SB lesions are also reported as a major cause in studies from Eastern countries. Herein, we assessed the frequency of occurrence of NSAID-induced SB lesions in Korean patients with obscure GI bleeding.

METHODS

We retrospectively analyzed medical records of all consecutive patients aged ≥18 years who underwent capsule endoscopy from March 2018 to February 2019 at Ulsan University Hospital and Kosin University Gospel Hospital.

RESULTS

Of the 83 subjects (all Korean; mean age ± standard deviation: 59 ± 18 years; age range: 18-84 years; men: n = 52; women: n = 31), 55 (66.2%) had stool with clear blood and 28 (33.8%) had normal stool with iron deficiency anemia. The detection rate of SB bleeding and lesions using capsule endoscopy was 72.3% (60 of 83 patients). A significantly higher frequency (40 of 51) of ulcerative/erosive lesions than other causes was observed in patients with inactive bleeding but visible SB lesions. As a result, NSAID-induced enteropathy accounted for 30.1% of 83 patients with obscure GI bleeding (25 of the all 60 SB bleeding cases).

CONCLUSIONS

Contrary to what is reported for patients in Western countries, this study in Korean patients showed an improved diagnostic yield of capsule endoscopy for obscure GI bleeding and that NSAID-induced enteropathy was the most common etiology of SB bleeding. Aggressive small intestine examination is required for patients with unexplained GI bleeding.

Diagnostic agreement between video capsule endoscopy and single and double balloon enteroscopy for small bowel bleeding at a tertiary care hospital in Bogota, Colombia

INTRODUCTION

Video capsule endoscopy and balloon-assisted enteroscopy are complementary diagnostic methods in the study of small bowel bleeding, and different factors can affect their diagnostic yield.

AIMS

To define the level of agreement between video capsule endoscopy and enteroscopy in small bowel bleeding, according to the type of lesion, in a cohort of patients at a tertiary care referral center.

MATERIALS AND METHODS

A retrospective study was conducted that included 428 capsule endoscopies performed within the time frame of 2011 and 2019 at our healthcare institution. Seventy-four video capsule endoscopies, followed by enteroscopy, in 71 patients suspected of presenting with small bowel bleeding, were analyzed.

RESULTS

Mean patient age was 63.9 ± 13.5 years and 42 patients were women. The two diagnostic procedures were performed. Overall diagnostic yield of positive findings between video capsule endoscopy and enteroscopy was 86.5% vs. 58.1%, respectively (p = 0.0527). Agreement between video capsule endoscopy and enteroscopy for positive pathologic findings was weak (Ik = 0.17, 95% CI: -0.0097-0.3543), but according to lesion type, it was good for inflammatory lesions (Ik = 0.71, 95% CI: 0.5182-0.9119) and moderate for angiectasias (Ik = 0.45, 95% CI: 0.2469-0.6538) and tumors (Ik = 0.40, 95% CI: 0.1217-0.6794). The results between the two methods differed in 38 patients (51.3%). There was complete intestinal capsule retention in one patient (1.4%) and active bleeding in 13 (17.6%).

CONCLUSIONS

The present study showed that the two techniques had a similar overall detection rate for small bowel lesions, but the type of lesion was the main factor that could modify diagnostic agreement.

The Diagnostic Yields and Safety of Double-Balloon Enteroscopy in Obscure Gastrointestinal Bleeding and Incomplete Small Bowel Obstruction: Comparison between the Adults and Elderly

Background

Double-balloon enteroscopy (DBE) is widely used worldwide. However, comparisons between the diagnostic yields in adults and the elderly remain scarce.

Aim

The aim of this study is to compare the diagnostic yields and safety of DBE between adults and elderly with obscure gastrointestinal bleeding and incomplete small bowel obstruction.

Method

We retrospectively reviewed patients who underwent DBE with indication of obscure gastrointestinal bleeding or incomplete small bowel obstruction in Ruijin Hospital and classified them into adults (18–64 years old) and elderly (≥65 years old). Clinical characteristics, diagnostic yields, and postoperative complications were collected and further analyzed.

Results

A total of 877 DBE procedures, 729 in adults and 148 in the elderly, were performed. In the patients with OGIB, the adults showed a higher frequency of Meckel's diverticulum compared with the elderly (4.6% vs. 0.9%, P = 0.032). Angioectasia was higher in frequency in the elderly than in the adults (25.9% vs. 17.9%, P = 0.048). In patients with incomplete small bowel obstruction, the elderly were more likely to have adenocarcinoma than the adults (19.4% vs. 7.1%, P = 0.038). The adults had higher tendency to have Crohn's disease than the elderly (23.4% vs. 8.3%, P = 0.045). Most of the postoperative complications were mild. The adults and elderly displayed comparable tolerance to DBE (P > 0.05)

Conclusion

DBE has a high diagnostic yield in small bowel disorders, and a slight difference in disease spectrum was observed between the adults and elderly. DBE can be well-tolerated in the elderly.

Small bowel enteroscopy - A joint clinical guideline by the Spanish and Portuguese small-bowel study groups

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.

Quality indicators in enteroscopy. Enteroscopy procedure

Within the project "Quality Indicators in Gastrointestinal Endoscopy," under the leadership of the Sociedad Española de Patología Digestiva (SEPD), our goal is to propose the procedures and the structure, process, and outcome indicators required for the application and assessment of quality in enteroscopy. To this end a search was performed for quality indicators in enteroscopy. Quality of evidence was measured by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, and classified as high, moderate, low, and very low. A total of 10 process indicators (one preprocedure, eight procedure, one postprocedure) were identified for enteroscopy, with appropriate indication and choice of most efficient route being most significant.

Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Usefulness of virtual enteroscopy for the detection of small polypoid lesion in the small bowel, a case report

INTRODUCTION

Virtual enteroscopy (VE) has been developed to explore the entire small bowel. We have previously reported that VE can reveal elevated lesions measuring >10 mm in diameter. However, data on the existence of smaller polypoid lesions is scarce. This study aimed to report a case of pyogenic granuloma in the ileum detected by VE.

PRESENTATION OF CASE

A 55-year-old woman presented to our hospital with iron deficiency anemia. Esophagogastroduodenoscopy, colonoscopy, and abdominal contrast-enhanced computed tomography did not indicate any bleeding sources. Video capsule endoscopy revealed a small polypoid lesion in the small bowel. VE was subsequently performed and a polypoid lesion was detected at 119 cm from the ileocecal valve. Its size was estimated to be 6 mm. Based on VE findings, laparoscopic-assisted surgery for the small bowel tumor was performed. During surgery, the polypoid lesion, at 120 cm from the end of the ileum, was barely palpable. The resected specimen showed a 5.5 × 5.0 mm polypoid lesion. Microscopically, the polypoid lesion was diagnosed as pyogenic granuloma.

DISCUSSION

We detected a 5.5 × 5.0 mm polypoid lesion in the small bowel, and this is the minimum size of the lesion visualized on VE. This imaging technique provides surgeons with data on the location, number, and size of polypoid lesions.

CONCLUSION

VE is a new useful tool for the preoperative collection of data on small polypoid lesions in the small bowel.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

Device assisted enteroscopy in the elderly - A systematic review and meta-analysis

BACKGROUND

Device assisted enteroscopy (DAE) is increasingly being carried out in elderly patients. This provides a challenge due to the underlying varied physiology and comorbidities these patients have.

METHODS

We performed a systematic literature search for studies on elderly patients undergoing DAE. We calculated the pooled diagnostic (DY) and therapeutic yields (TY), major adverse events, length of small bowel examined and sedation administered. These were also compared to younger patients.

RESULTS

Fourteen high quality articles on DAE in the elderly were included in this analysis (3289 total, 1712 elderly) patients. Nine of these studies were included in the final meta-analysis (681 elderly, 1577 young patients). The overall DY of DAE, double balloon enterosocpy (DBE) and single balloon enteroscopy (SBE) were 0.68 (p = 0.000001), 1.74 (p = 0.0001) and 1.90 (p = 0.009). The TY of DAE, DBE and SBE were 0.45 (p = 0.00001), 2.20 (p = 0.00001) and 2.36 (p = 0.00001). On comparison of elderly and young patients, DY (1.83; 95% CI: 1.49, 2.24; p = 0.00001) and TY (2.28; 95% CI: 1.79, 2.89) were better in elderly patients. There was no difference in adverse events in both groups (2.16; 95% CI: 0.82, 5.69, p = 0.12). Elderly patients were given less sedation than younger patients during DAE.

CONCLUSIONS

DAE has a higher DY and TY in the elderly than younger patients. DAE can be safely carried out in the elderly with less sedation.

Device-assisted enteroscopy: A review of available techniques and upcoming new technologies

The advent of video capsule endoscopy into clinical routine more than 15 years ago led to a substantial change in the diagnostic approach to patients with suspected small bowel diseases, often indicating a deep enteroscopy procedure for diagnostical confirmation or endoscopic treatment. Device assisted enteroscopy was developed in 2001 and for the first time established a practicable, safe and effective method for evaluation of the small bowel. Currently with double-balloon enteroscopy, single-balloon enteroscopy and spiral enteroscopy three different platforms are available in clinical routine. Summarizing, double-balloon enteroscopy seems to offer the deepest insertion depth to the small bowel going hand in hand with the disadvantage of a longer procedural duration. Manual spiral enteroscopy seems to be a faster procedure but without reaching the depth of the DBE in currently available data. Finally, single-balloon enteroscopy seems to be the least complicated procedure to perform. Despite substantial improvements in the field of direct enteroscopy, even nowadays deep endoscopic access to the small bowel with all available methods is still a complex procedure, cumbersome and time-consuming and requires high endoscopic skills. This review will give an overview of the currently available techniques and will further discuss the role of the upcoming new technology of the motorized spiral enteroscopy (PowerSpiral).

Capsule Endoscopy and Small Bowel Enteroscopy: Have They Rendered the Radiologist Obsolete?

Capsule endoscopy (CE) provides visualization of small bowel mucosa for evidence of inflammation. Given its ability to detect subtle mucosal changes, CE is recommended in the diagnostic work-up of small bowel Crohn disease (CD) and also in monitoring mucosal response to therapy in nonstricturing CD. Patency capsule and cross-sectional imaging can reduce risk of capsule retention in patients with suspected stenotic disease. CE is complementary to magnetic resonance enterography, which can provide extraintestinal information. Device-assisted enteroscopy has limited role in CD.

Device-assisted enteroscopy: An update on techniques, clinical indications and safety

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Enteroscopy in the Elderly: Review of Procedural Aspects, Indications, Yield, and Safety

Background

As human longevity continues to increase, age-related diseases are more common, which leads to a higher use of gastroenterology services. Endoscopic procedures are generally considered to be of higher risk in the elderly with multiple comorbidities. However, some endoscopic techniques have already been proved to be well tolerated in the elderly.

Summary

<underline></underline>Enteroscopy enables the nonsurgical diagnosis and therapeutic management of a wide variety of small bowel diseases. Although it has been shown to be safe and effective, with high diagnostic yield and therapeutic success rate in the general population, its safety and efficacy in the elderly is largely unknown, and there are still some concerns about its use in these patients.

Key Messages

This review will focus on enteroscopy in elderly people, taking into account patient and procedure characteristics, indications, findings, yield, and complication rate.

Experience with Balloon Dilatation in Crohn's and Non-Crohn's Benign Small-Bowel Strictures: Is There a Difference?

Background/Aim

Endoscopic balloon dilation (EBD) has been effective for small-bowel strictures in patients with Crohn's disease (CD). However, its efficacy and indication for small-bowel strictures in non-CD patients have not been established. This study evaluated the clinical efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients.

Methods

Ninety-eight consecutive patients (mean age, 53 years; average observation period, 45 months) with small-bowel strictures diagnosed by double-balloon endoscopy were retrospectively evaluated at Hiroshima University Hospital from August 2003 to April 2017. The average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups were examined.

Results

Surgery was selected as the initial treatment in 44 cases (45%) (non-CD group, 27 (61%); CD group, 17 (39%)) as EBD is not indicated. Fourteen non-CD patients had strictures due to malignant tumors, while 13 patients had benign strictures. Twenty-three patients (non-CD, 12; CD, 11) underwent EBD. Forty-three EBD procedures were performed for 17 stricture sites (average: 2.5 procedures/site) in non-CD patients and 41 EBD procedures for 18 stricture sites (average: 2.3 procedures/site) in CD patients. The short-term success rate was 100% (23/23), whereas the long-term success rate was 92% (11/12) in non-CD patients and 82% (9/11) in CD patients. No significant differences in the surgery-free rate occurred between both groups. Furthermore, one adverse event, bleeding after EBD, was encountered in the non-CD group (8%, 1/12).

Conclusion

EBD for small-bowel strictures demonstrated good clinical outcomes in non-CD patients.

Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review

Background: Small bowel bleeding accounts for 5-10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.

Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease

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.

Double-balloon enteroscopy for pediatric patients: Application and feasibility evaluation in a medical center in northern Taiwan

BACKGROUND/PURPOSE

The diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) in adults are established, but few data are available on pediatric patients. The aim of this study was to evaluate the clinical efficacy and safety of DBE in pediatric patients in Taiwan.

METHODS

From April 2005 to September 2015, DBE procedures performed for diagnosis or therapy of small-bowel disease in children less than 18 years of age at Linkou Chang Gung Memorial Hospital, Taiwan were evaluated. The clinical decision to perform DBE via the oral or anal approach was based on the patient's primary clinical presentation. Data on indications, endoscopic findings, treatment outcome, and complications associated with the procedure were collected and reviewed retrospectively.

RESULT

In total, 20 pediatric patients underwent a total of 29 DBEs due to suspicion of small-bowel disease. Among them, nine patients were evaluated for suspected small-bowel bleeding, six for Peutz-Jeghers syndrome, two for chronic abdominal pain, two for chronic diarrhea, and one for suspected protein-losing enteropathy. After excluding the six Peutz-Jeghers syndrome patients, 9 of the 14 patients (64%) got a positive endoscopic finding and diagnosis in 8 of the 14 patients (57%). DBE resulted in a further therapeutic intervention (endoscopic or surgical) in 50% of the patients (10/20) without serious complications.

CONCLUSION

DBE has a high diagnostic yield and leads to therapeutic interventions in pediatric patients and shows promise for assessment and treating small-intestinal diseases in children in Taiwan.

False-negative double-balloon enteroscopy in overt small bowel bleeding: long-term follow-up after negative results

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.

Etiology and long-term rebleeding of endoscopic ulcerative lesions in the small bowel in patients with obscure gastrointestinal bleeding: A multicenter cohort study

BACKGROUND

Among patients with obscure gastrointestinal bleeding (OGIB), endoscopic ulcerative lesions in the small bowel have diverse etiologies and often cause rebleeding. Certain characteristics of patients or ulcerations may be reasonable indications for diagnostic balloon-assisted endoscopy (BAE) to assess etiology and may be risks of rebleeding; however, these characteristics are unclear. We aimed to elucidate appropriate indications for diagnostic BAE and predictors of long-term rebleeding in patients with small bowel ulcerative lesions.

METHODS

We conducted a multicenter retrospective cohort study of 68 patients with OGIB, in whom small bowel ulcerative lesions were detected by capsule endoscopy (n = 60) and/or BAE (n = 43). Patients' characteristics, including medications and endoscopic findings, were evaluated. Predictors of the need for diagnostic BAE to determine ulceration etiology were identified by logistic regression analysis. Rebleeding risks were evaluated using Cox proportional hazards analysis.

RESULTS

Single ulcerations were diagnosed in 26 patients, and multiple ulcerations were diagnosed in 42 patients. Among 43 patients who underwent BAE, ulceration etiology was identified in 12 (28%) patients. In the etiology identification, BAE was more useful for a single ulceration than for multiple ulcerations (P < 0.001). Among the 68 patients, rebleeding occurred in 14 (21%) patients during a mean follow-up period of 17 months. Aspirin use and multiple ulcerations were significant predictors of rebleeding (P < 0.05).

CONCLUSIONS

When we manage small bowel ulcerative lesions in OGIB patients, a single ulceration is a reasonable indication for the diagnostic BAE. The rebleeding rate was lower for single ulcerations than for multiple ulcerations.

Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study

OBJECTIVE

Evaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.

DESIGN

Prospective cohort study.

SETTING

All patients undergoing DBE over a 30-month period were recruited at our tertiary centre.

PATIENTS

215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.

INTERVENTIONS

Patients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.

RESULTS

Cardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (p<0.05). Common indications for DBE were occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease (elderly vs young: 50.7% vs 42.3%, 17.8% vs 12% and 19.2% vs 26.1%, respectively). Diagnostic yield was higher in elderly compared with young patients (75.3% vs 58.5%, p=0.016). The most common findings in elderly and young patients were angioectasia (30.1% and. 18.3%, respectively) and ulcers (17.8% and 9.2%, respectively), while therapeutic intervention rates were comparable (42.5% vs 32.4%, p=0.18). ASA status did not affect propofol dose (p=0.55) or procedure duration (p=0.31). Tolerance scores were favourable in those receiving propofol compared with conventional sedation (p<0.05). There was no difference in complications between the four groups (p=0.17).

CONCLUSION

Compared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience

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.

Approach to the Diagnostic Workup and Management of Small Bowel Lesions at a Tertiary Care Center

BACKGROUND

Small bowel lesions (SBL) are rare, representing diagnostic and management challenges. The purpose of this cross-sectional study was to evaluate diagnostic modalities used and management practices of patients with SBL at an advanced endoscopic referral center.

METHODS

We analyzed patients undergoing surgical management for SBL from 2005 to 2015 at a single tertiary care center. Patients were stratified into gastrointestinal bleed/anemia (GIBA) or obstruction/pain (OP).

RESULTS

One hundred and twelve patients underwent surgery after presenting with either GIBA (n = 67) or OP (n = 45). The mean age of our study population was 61.8 years and 45% were women. Patients with GIBA were more likely to have chronic or acute-on-chronic symptoms (100% vs 67%) and more often referred from outside hospitals (82 vs. 44%) (p < 0.01). The most common preoperative imaging modalities were video capsule endoscopy (VCE) (96%) for GIBA and computer tomography CT (78%) for OP. Findings on VCE and CT were most frequently concordant with operative findings in GIBA (67%) and OP (54%) patients, respectively. Intraoperatively, visual inspection or palpation of the bowel successfully identified lesions in 71% of patients. When performed in GIBA (n = 26), intraoperative enteroscopy (IE) confirmed or identified lesions in 69% of patients. Almost all (90%) GIBA patients underwent small bowel resections; most were laparoscopic-assisted (93%). Among patients with OP, 58% had a small bowel resection and the majority (81%) were laparoscopic-assisted. Surgical exploration failed to identify lesions in 10% of GIBA patients and 24% of OP patients. Among patients who underwent resections, 20% of GIBA patients had recurrent symptoms compared with 13% of OP patients.

CONCLUSION

Management and identification of SBL is governed by presenting symptomatology. Optimal management includes VCE and IE for GIBA and CT scans for OP patients. Comprehensive evaluation may require referral to specialized centers.

The Role of Double-balloon Enteroscopy in the Diagnosis and Surgical Treatment of Metastatic Small Bowel Tumors

Objective The aim of the present study is to investigate the role of double-balloon enteroscopy in the diagnosis and surgical treatment of metastatic small bowel tumors. Patients We retrospectively reviewed the records of 13 patients with metastatic small bowel tumors among 376 patients who underwent double-balloon enteroscopy from June 2005 to March 2017 in our hospital. Results The primary lesion sites were the lung (n=9), kidney (n=2), stomach (n=1) and duodenum (n=1). The clinical presentations were anemia requiring blood transfusion (n=10), obstructive symptoms (n=2), and no symptoms (n=1). The locations of the metastatic small bowel tumors were the jejunum (n=7), ileum (n=1), and both sites (n=5). The histological diagnosis of the metastatic tumor was made from biopsy specimens taken with double-balloon enteroscopy from all 11 patients whose condition permitted a biopsy. In seven patients, the findings on double-balloon endoscopy were determinants of the kind and extent of surgical treatment performed. Four patients had multiple metastatic small bowel tumors, and all were able to be removed surgically with guidance from preoperative tattooing at double-balloon endoscopy. After operation, blood transfusions were no longer needed in four of six patients who had required preoperative transfusions for the treatment of anemia, and one patient with intestinal obstructive symptoms was able to resume oral intake. Conclusion Double-balloon endoscopy was useful for making a histological diagnosis and directing surgical treatment in patients with metastatic small bowel tumors. Surgical treatment afforded palliation of symptoms in five patients.

Small bowel bleeding: cause and the role of endoscopy and medical therapy

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.

The Use of Balloon-assisted Enteroscopy at a Large Volume Centre: A Retrospective Analysis

Objectives

Balloon-assisted enteroscopy (BAE) is increasingly used for the evaluation of small bowel disorders. We quantified local diagnostic and therapeutic yields of BAE in patients with suspected small bowel diseases.

Methods

Adult patients undergoing BAE between January 2010 and July 2015 at McGill University Health Centre were included. Procedures were identified using a prospectively maintained database. Patients were excluded if procedure report was unavailable. Electronic medical records were reviewed. Analyses were restricted to patients who did not have a previous BAE.

Results

BAE was performed in 453 patients, including 421 anterograde cases. Patients had a mean age of 61.0 ± 17.5 years. Most common indications for referral were obscure gastrointestinal bleeding (OGIB) (n=207, 45.7%), abnormal imaging (n=88, 19.4%), suspected small bowel neoplasia (SBN) (n=39, 8.6%) and Crohn’s disease (CD) (n=31, 6.8%). A diagnosis was established in 216 procedures (47.7%). A pre-endoscopic indication of CD (odds ratio [OR]: 3.78; 95% Confidence Interval [CI], 1.60–8.90), OGIB (OR: 3.69, 95% CI, 2.03–6.71), suspected SBN (OR: 2.45; 95% CI, 1.06–5.65) and previous VCE (OR: 9.33; 95% CI, 3.24–26.90) were associated with abnormal findings. A therapeutic procedure was performed in 126 cases (28.3%). OGIB (OR: 7.00; 95% CI, 3.83–12.81), previous video capsule endoscopy (VCE) (OR: 7.86; 95% CI, 2.93–21.04) and suspected SBN (OR: 6.30; 95% CI, 2.58–21.04) were associated with performance of a therapeutic intervention. Complication rate was 1.6%, with bleeding in seven cases and one perforation.

Conclusions

In carefully selected patients, such as those with OGIB, Crohn’s disease and previous VCE, BAE was a safe procedure that led to the identification of abnormal findings and therapeutic interventions.

Update in enteroscopy: New devices and new indications

The present review provides an update of the currently available (proto-) types of device-assisted enteroscopy (DAE). In recent years, newly designed double- and single-balloon enteroscopes have emerged. They aim to improve insertion depth into the small bowel, and they also allow more efficient endoscopic interventions. Nowadays, almost all conventional endoscopic procedures are feasible using DAE, opening the door to new indications. Recently, more data have become available on pediatric DAE, DAE-assisted colonoscopy, and DAE in patients with altered anatomy, including DAE-assisted endoscopic retrograde cholangiopancreatography and direct cholangioscopy. Although new enteroscopes are being developed, few comparative studies are available in order to define which DAE suits best for each indication. It is the duty of the international endoscopy community to set up clinical research projects to provide answers to these open questions.

Meta-analysis shows similar re-bleeding rates among Western and Eastern populations after index video capsule endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (VCE) is the first-line diagnostic procedure for investigating obscure gastrointestinal bleeding (OGIB). Different re-bleeding rates following index VCE have been reported among Western and Eastern studies.

METHODS

We conducted a comprehensive literature search to identify studies examining re-bleeding rates after VCE for OGIB. Meta-analysis assessed the pooled proportion of re-bleeding events after VCE for OGIB according to study's origin (Western vs. Eastern) and according to the length of follow-up (≥24 months vs. <24 months). We also calculated the re-bleeding odds ratios (OR; 95% CI) after positive vs. negative index VCE, overt vs. occult initial presentation of bleeding and after interventional treatment for positive index cases, according to the study's origin.

RESULTS

We included 46 (30 Western and 16 Eastern) studies with 5796 patients. Significant heterogeneity was detected among meta-analyzed studies. Overall, the pooled re-bleeding rate was similar between Western (29%; 95% CI: 23-34) and Eastern (21%; 95% CI: 15-27) populations, irrespective of the length of follow-up. The odds of re-bleeding was significantly higher after positive as compared to negative index VCE in Eastern studies (OR: 1.77; 95% CI: 1.07-2.94). Application of specific treatment after positive index VCE was associated with lower re-bleeding odds in both Western (OR: 0.37; 95% CI: 0.16-0.87) and Eastern (OR: 0.39; 95% CI: 0.21-0.72) populations.

CONCLUSIONS

Patients undergoing VCE for OGIB have similar re-bleeding rates in the East and the West, regardless of the length of follow-up. However, increased re-bleeding odds after positive index VCE is observed in Eastern studies.

Epidemiology of obscure gastrointestinal bleeding in China: A single-center series and comprehensive analysis of literature

OBJECTIVE

To determine the etiologies of obscure gastrointestinal bleeding (OGIB) in a Chinese population using a retrospective case series and a systematic analysis of the literatures on OGIB in Chinese patients.

METHODS

A large enteroscopy database in a tertiary endoscopic center was searched to identify patients with OGIB from 2010 to 2016. The patients' characteristics and diagnostic findings were collected and analyzed. A comprehensive search of the literature was carried out to harvest all relevant studies published from 2004 to 2016.

RESULTS

In total, 708 patients were included in the case series. The most common causes of OGIB were inflammatory diseases (36.3%), non-small bowel lesions (10.2%) and neoplasms (10.0%). A systematic analysis of the literatures included 39 studies providing relevant data for 3145 patients with a pooled detection rate of 84.2%. Inflammatory lesions (27.4%), neoplasms (18.5%), vascular lesions (16.1%) and diverticula or intestinal duplication (11.9%) were the most common causes of OGIB.

CONCLUSIONS

Inflammatory lesions, neoplasms, vascular lesions and diverticula or intestinal duplication are the most common in Chinese OGIB patients, while in pediatric patients diverticula or intestinal duplication, vascular lesions and Crohn's disease are prevalent. Furthermore, the etiologies of OGIB distribute differently across different areas in China.