Enteroscopy in the diagnosis and management of obscure gastrointestinal bleeding

A rare case of bleeding jejunal ulcer diagnosed by intraoperative use of enteroscopy

INTRODUCTION

Small bowel bleeding can be overt or occult. Despite advances in imaging and endoscopy, the diagnosis and treatment of small bowel bleeding remain challenging due to its length and location. Diagnostic procedures such as push enteroscopy, capsule endoscopy and intraoperative enteroscopy are recommended to identify the source of bleeding.

CASE PRESENTATION

A 33-year-old female with no prior history of bleeding diathesis presented with massive lower GI bleeding. Although she was in hypovolemic shock from bleeding, physical exam, splanchnic angiography and colonoscopy were unable to localize the source of bleeding. The patient continued to bleed and deteriorate despite transfusions. Exploratory laparotomy was done but localizing the source with manual palpation of small bowel was difficult. Intraoperative enteroscopy was done and showed a 2 by 1 cm ulcerative lesion at mid jejunum. Part of jejunum containing the ulcer was resected and anastomosis done. The patient did well postoperatively and on follow up.

CLINICAL DISCUSSION

A bleeding primary jejunal ulcer is rare clinical scenario difficult to diagnose. Intraoperative enteroscopy is useful in cases where initial diagnostic workups are inconclusive. It can be performed using various types of endoscopes, such as a standard or pediatric colonoscope, push enteroscope, or a sonde enteroscope, during laparotomy.

CONCLUSION

Primary jejunal ulcer is a rare cause of massive lower GI bleeding. Although minimally invasive deep endoscopic techniques to diagnose small bowel ulcers are evolving, intraoperative enteroscopy remains to be technically easy and helpful tool to make a diagnosis and guide intervention especially in a patient undergoing laparotomy for bleeding small bowel ulcer.

The evolving role of device-assisted enteroscopy: The state of the art as of August 2023

Device-assisted enteroscopy (DAE), balloon-assisted enteroscopy (BAE) in particular, has become a routine endoscopic procedure which has revolutionized our approach to small-bowel disease. Evidence demonstrating the efficacy and safety of BAE spans over 22-years of experience, making it an established pillar of minimally invasive care. The robust evidence for BAE's safety and efficacy has now been incorporated into international clinical guidelines, technical reviews, benchmarking performance measures and curricula. The more recently introduced motorized spiral enteroscopy (MSE) which had replaced the previous manual version, abruptly ended its 7-year stint in clinical practice, when it was withdrawn and recalled from the market by its manufacturing company in July 2023, due to several associated serious adverse events (including fatalities). This article, written by the original developer of double-balloon enteroscopy (DBE) and other recognized international experts and pioneers in this field, focuses mainly on the technical aspects, evolving indications, and equipment-related technological advances. Despite the very recent withdrawal of MSE from clinical practice, for completeness, this technology and its technique is still briefly covered here, albeit importantly, along with a short description of reported, associated, serious adverse events which have contributed to its withdrawal/recall from the market and clinical practice.

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.

Intraoperative Enteroscopy: Is There Still a Role?

Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.

Timing of single balloon enteroscopy: significant or not?

BACKGROUND

The development of balloon assisted enteroscopy (BAE) has revolutionized diagnostic and therapeutic modalities for small-bowel disorders. Although the role of emergent esophagogastroduodenoscopy and colonoscopy for upper and lower gastrointestinal bleeding is well defined, there is scarce data with regard to emergent BAE for gastrointestinal bleeding.

STUDY

We performed a retrospective cohort study including 110 hospitalized patients with obscure gastrointestinal bleeding who underwent single balloon enteroscopy (SBE) between January 2010 and August 2013. Patients were divided into two groups based on procedures performed emergently (within 24 hours) versus non-emergently (greater than 24 hours). Data on patient demographics, hemodynamic characteristics, type of obscure bleed, lesions identified, location of lesions, endoscopic intervention performed, need for further surgical or radiological intervention, diagnostic and therapeutic yield, and adverse events were compared between groups. Independent samples t test and Fisher's exact test were used to assess the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and 95 % confidence intervals (CI), and for binary as odds ratio and 95 %CI.

RESULTS

Although patients in the group where enteroscopy was performed within 24 hours had a significantly higher incidence of radiological intervention (10.0 % vs. 0.0 %, P = 0.019), the diagnostic and therapeutic yields between the two groups were not significantly different. Additionally, there were no statistically significant differences between the groups for overt and occult bleeding, transfusion requirements, type and location of lesions, endoscopic intervention performed, or adverse events. Hospital stay was shorter in the patients who had SBE within 24 hours of admission (6.2 vs. 11.3 days, P < 0.001).

CONCLUSIONS

Although the diagnostic and therapeutic yields of SBE were not significantly different between patients having the procedure within 24 hours and those having it later, the early SBE group required more interventional radiology procedures. While endoscopists may not necessarily have to perform emergent assessment within 24 hours in patients with obscure gastrointestinal bleeding (OGIB) for greater diagnostic or therapeutic yield, early intervention may allow for earlier stabilization and thus shorter hospital stays. Prospective studies further evaluating these findings are indicated.

Enteroscopy

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.

Capsule endoscopy followed by single balloon enteroscopy in children with obscure gastrointestinal bleeding: a combined approach

BACKGROUND

This prospective single-centre study aims to evaluate a new diagnostic algorithm using capsule endoscopy, colon capsule endoscopy and single-balloon enteroscopy in the work-up of obscure gastrointestinal bleeding in children.

METHODS

The usefulness of a new diagnostic algorithm was assessed comparing the clinically relevant findings revealed by each technique, and evaluating the clinical outcomes during the follow-up.

RESULTS

A total of 22 paediatric patients were evaluated (14 male; mean age 12.5 years ± 3.9). Capsule endoscopies were positive in 14 (63.6%), suspicious in 5 (22.7%) and negative in 3 (13.6%). A second look with colon capsule identified new lesions in 2/3 (67%) of previous negative cases. Enteroscopies were able to reach the positive and suspicious findings in all but 2, in which an intraoperative enteroscopy was needed. This combined approach showed positive findings in 21/22 of cases with a diagnostic yield of 95%. Eighteen patients (82%) had a complete resolution after therapy. One patient resolved his symptoms spontaneously. Despite diagnosis, in three patients (13.6%) the gastrointestinal bleeding was not resolved after therapy.

CONCLUSION

This algorithm achieves optimal levels of diagnostic yield (95%) and therapeutic outcome (82%). This approach deserves to be studied in a larger multicentre cohort of patients and for a longer follow-up period.

The outcome and role of drugs in patients with unexplained gastrointestinal bleeding

OBJECTIVE

Studies on unexplained gastrointestinal bleeding (GIB) are lacking. We aimed to study the clinical outcomes of patients with unexplained GIB and to determine the incidence of obscure GIB.

MATERIAL AND METHODS

A population-based study on all patients undergoing endoscopy at the National University Hospital of Iceland in 2010. Indications, results of endoscopies and drug history were prospectively registered with a follow-up of 3 years. A national pharmaceutical database containing prescription data was utilized. Patients were categorized into unexplained overt and occult GIB and obscure GIB. Patients undergoing endoscopy and without GIB acted as controls.

RESULTS

Of 2471 patients undergoing endoscopy, 11% had unexplained GIB. Of those, 46% had unexplained overt GIB, 44% had unexplained occult GIB and 11% had obscure GIB. Multivariate analysis showed that patients with unexplained GIB and unexplained overt GIB had greater odds of NSAID use than controls, OR 1.8 (CI 1.03-3.03) and OR 2.0 (CI 1.01-3.77), respectively. Warfarin was strongly associated with all bleeder groups, OR 4-4.8. The incidence of obscure GIB was 10/100,000 inhabitants annually. Two (0.8%) patients were diagnosed with colon cancer 16 and 30 months after the index colonoscopy. Of patients with unexplained overt, unexplained occult GIB and controls, 5%, 6% and 3.5% (NS) had another overt bleeding episode, during the study period.

CONCLUSIONS

NSAIDs and warfarin seem to play an important role in unexplained GIB. The incidence of obscure GIB is low and missed cancers are very rare. The probability of a repeat bleeding episode is similar to that of controls.

Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding has long been a diagnostic challenge because of the relative inaccessibility of small bowel to standard endoscopic evaluation. Intraoperative enteroscopy indications have been reduced by the development of deep enteroscopy techniques and video capsule endoscopy. In light of the current advances, this review aimed at evaluating the intraoperative enteroscopy technical aspects, study results and an ongoing role for intraoperative enteroscopy in obscure gastrointestinal bleeding management. Intraoperative enteroscopy allows complete small bowel exploration in 57-100% of cases. A bleeding source can be identified in 80% of cases. Main causes are vascular lesions (61%) and benign ulcers (19%). When a lesion is found, intraoperative enteroscopy allows successful and recurrence-free management of gastrointestinal bleeding in 76% of cases. The reported mortality is 5% and morbidity is 17%. The recurrence of bleeding is observed in 13-52% of cases. With the recent development of deep enteroscopy techniques, intraoperative enteroscopy remains indicated when small bowel lesions (i) have been identified by a preoperative work-up, (ii) cannot be definitively managed by angiographic embolization, endoscopic treatment or when surgery is required and (iii) cannot be localized by external examination during surgical explorations. Surgeons and endoscopists must exercise caution with intraoperative enteroscopy to avoid the use of a low yield, highly morbid procedure.

The American Society for Gastrointestinal Endoscopy (ASGE) diagnostic algorithm for obscure gastrointestinal bleeding: eight burning questions from everyday clinical practice

The diagnosis and management of patients with obscure gastrointestinal bleeding are often long and challenging processes. Over the last 10 years the introduction in clinical practice of new diagnostic and therapeutic procedures (i.e. Capsule Endoscopy, Computed Tomographic Enterography, Magnetic Resonance Enterography, and Device Assisted Enteroscopy) has revolutionized the diagnostic/therapeutic work-up of these patients. Based on evidence published in the last 10 years, international scientific societies have proposed new practice guidelines for the management of obscure gastrointestinal bleeding, which include these techniques. However, although these algorithms (the most recent ones are endorsed by the American Society for Gastrointestinal Endoscopy - ASGE) allow the management of the large majority of patients, some issues still remain unsolved. The present paper reports the results of the discussion, based on the literature published up to September 2011, among a panel of experts and gastroenterologists, working with Capsule Endoscopy and with Device Assisted Enteroscopy, attending the 6th annual meeting of the Italian Club for Capsule Endoscopy and Enteroscopy. Eight unresolved issues were selected: each of them is presented as a "Burning question" and the "Answer" is the strategy proposed to manage it, according to both the available evidence and the discussion among participants.

Recent advances in small bowel diseases: Part II

As is the case in all areas of gastroenterology and hepatology, in 2009 and 2010 there were many advances in our knowledge and understanding of small intestinal diseases. Over 1000 publications were reviewed, and the important advances in basic science as well as clinical applications were considered. In Part II we review six topics: absorption, short bowel syndrome, smooth muscle function and intestinal motility, tumors, diagnostic imaging, and cystic fibrosis.

Small intestinal vascular malformation bleeding: diagnosis by double-balloon enteroscopy combined with abdominal contrast-enhanced CT examination

Aim

The purpose of this study was to explore the value of double-balloon enteroscopy combined with abdominal vascular-enhanced CT examination for the diagnosis of intestinal vascular malformation bleeding, to explore a simple and effective method for the diagnosis of small intestinal vascular malformation bleeding.

Methods

Ten patients with intestinal bleeding were first examined with double-balloon enteroscopy. If active bleeding considered as vascular malformation was observed, the patient underwent abdominal vascular-enhanced CT examination. If no active bleeding was observed with double-balloon enteroscopy, the patient also underwent abdominal vascular-enhanced CT examination. When intestinal vascular malformation bleeding was diagnosed with double-balloon enteroscopy and/or abdominal vascular-enhanced CT examination, the patient underwent surgical operation and vascular malformation was confirmed with pathologic diagnosis.

Results

In ten patients who underwent double-balloon enteroscopy examination, active intestinal bleeding was observed in seven patients and no active bleeding was observed in three patients. All ten patients underwent abdominal vascular-enhanced CT examination and vascular malformation was detected in all the patients with confirmation by pathologic diagnosis.

Conclusion

Double-balloon enteroscopy combined with abdominal vascular enhanced CT examination is a simple and effective method for the diagnosis of intestinal vascular malformation bleeding.