Advances in modern enteroscopy therapeutics

Clinical impact of videocapsule endoscopy and device-assisted enteroscopy in non-bleeding small bowel lesions

Background

Videocapsule endoscopy (VCE) and double-balloon enteroscopy (DBE) are part of the diagnostic and therapeutic work-up of indications other than suspected small bowel bleeding (OSBB). The literature is currently lacking studies describing these procedures in this particular setting.

Objectives

We assessed the clinical impact of VCE and DBE in a large monocentric cohort of OSBB patients, as compared to a control group of suspected small bowel bleeding (SSBB) patients who underwent enteroscopy over the same period.

Design

Monocentric, retrospective, cohort study.

Methods

We collected the data of consecutive patients with OSBB undergoing VCE and/or DBE from March 2001 to July 2020. The demographic and clinical parameters of the patients, technical characteristics, and adverse events for each procedure were collected. The impact of VCE and DBE was defined in terms of diagnostic yield (DY). The patients were subdivided according to the main indication into four groups: celiac disease, Crohn's disease (CD), neoplasia, and persistent gastrointestinal symptoms.

Results

A total of 611 VCEs and 387 DBEs were performed for OSBB. The main indications were complicated celiac disease and CD. The DYs of VCE and DBE overall were 53 and 61.7%, respectively, with some variance among the four groups. We report no statistical differences in the DY of VCE and DBE in SSBB vs OSBB (57.7% vs 53%, p = 0.0859 and 68.8% vs 61.7%, p = 0.0582, respectively). OSBB patients were significantly younger than those with SSBB. However, similarly to SSBB (k = 0.059), poor agreement between the enteroscopic techniques was found in the OSBB population (k = 0.109). The safety of both procedures in OSBB was comparable to that in SSBB patients.

Conclusion

VCE and DBE are effective and safe in suspected OSBB, where their role is similar to that in SSBB, their main indication.

Clinical impact of videocapsule and double balloon enteroscopy on small bowel bleeding: Results from a large monocentric cohort in the last 19 years

BACKGROUND

Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center.

METHODS

We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE-DBE concordance, hemoglobin (Hb) values before and after DBE, and complications.

RESULTS

807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1-5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients.

CONCLUSION

VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.

Enteroscopy and radiology for the management of celiac disease complications: Time for a pragmatic roadmap

Celiac disease is the most common autoimmune enteropathy in Western countries, and is usually associated with a good response to the gluten free diet and an excellent prognosis. However, a minority of patients develop complications of the disease, such as refractory celiac disease, ulcerative jejunoileitis and neoplastic complications such as adenocarcinoma of the small bowel and enteropathy associated T cell lymphoma. Neoplastic complications described in association with celiac disease have a high mortality rate, due to their aggressive behavior and to the usual advanced stage at the time of diagnosis. In recent years, the detection of small bowel lesions has dramatically improved thank to the availability of highly performing radiologic and endoscopic techniques. The diagnostic delay of malignant complications in patients with celiac disease may be improved by establishing a pragmatic flowchart for the identification and follow up of "at risk" patients. We performed a comprehensive review of the articles published on this issue in order to promote a roadmap to be applied when facing with celiac patients with suspected small bowel complications.

Small bowel polyps, arteriovenous malformations, strictures, and miscellaneous lesions

Deep endoscopic access using double- and single-balloon enteroscopes and rotational endoscopy has vastly improved endoscopic therapeutic options in the small intestine. In this new era of interventional enteroscopy, significant advances have been made in the endoscopic treatment of small bowel polyps, angioectasias, and strictures. Although a decade ago small bowel polyps arising in the setting of a polyposis syndrome such as Peutz-Jeghers would have necessitated surgical resection, today endoscopic resection can typically be performed with positive clinical results. This article describes the current endoscopic management of small bowel polyps, arteriovenous malformations, strictures, and miscellaneous lesions identified within the small intestine.