Early timing of single balloon enteroscopy is associated with increased diagnostic yield in patients with overt small bowel bleeding

Early double-balloon enteroscopy was not related to better clinical outcomes in patients with suspected overt small bowel bleeding

BACKGROUND

Device-assisted enteroscopy has been used for over 20 years for the management of patients with suspected small bowel bleeding. Unlike esophagogastroduodenoscopy and colonoscopy, the appropriate timing of enteroscopy is still unknown. In recent guidelines, early enteroscopy is suggested to maximize diagnostic yield and therapeutic yield in patients with suspected small bowel bleeding. However, few studies have identified its influence on clinical outcomes, including mortality or rebleeding rate. We conducted this study to evaluate the influence of the timing of double-balloon enteroscopy on clinical outcomes in patients with suspected small bowel bleeding.

METHODS

Patients with overt small bowel bleeding who underwent double-balloon enteroscopy from January 2013 to February 2021 were retrospectively reviewed. Patients were categorized into an early enteroscopy group (≤14 days) and a nonearly enteroscopy group (>14 days). Clinical outcomes, including short-term mortality and rebleeding rate, long-term mortality and rebleeding rate, diagnostic yield, and therapeutic yield, were analyzed.

RESULTS

A total of 100 patients (mean age, 66.2 years; 53% male) were included, and 44 patients were stratified into the early enteroscopy group. The diagnostic yield, therapeutic yield, mortality, and rebleeding rate were similar between two groups. In multivariate conditional logistic regression analysis, there were no significant differences between two groups regarding the 30-day rebleeding rate (adjusted odds ratio [aOR], 1.43; 95% CI, 0.47-4.33), 90-day rebleeding rate (aOR, 1.18; 95% CI, 0.47-2.94), 30-day mortality rate (aOR, 1.29; 95% CI, 0.21-8.13), 90-day mortality rate (aOR, 1.94; 95% CI, 0.48-7.87), and 90-day bleeding-related mortality (aOR, 2.18; 95% CI, 0.24-19.52). The Kaplan-Meier survival curve analysis showed that the timing of DBE was not associated with the long-term rebleeding rate or mortality rate ( p = 0.57 and 0.83, respectively).

CONCLUSION

The timing of enteroscopy did not influence the clinical outcomes, including the short-term mortality rate, short-term rebleeding rate, long-term mortality rate, and rebleeding rate, in patients with suspected overt small bowel bleeding.

Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis

Background and Aim

Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding.

Methods

We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test.

Results

A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009).

Conclusion

Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

Efficacy and Safety of Small Bowel Submucosal Tumors Treated by Endoscopic Submucosal Dissection or Endoscopic Full-thickness Resection During Single-balloon Enteroscopy: Prospective Data From a Single-center Study

BACKGROUND AND OBJECTIVES

Single-balloon enteroscopy (SBE) is a safe and effective modality for the diagnosis and therapeutic treatment of small bowel disorders. However, the efficacy and safety of treating small bowel submucosal tumors (SMTs) with endoscopic submucosal dissection (ESD) or endoscopic full-thickness resection (EFTR) during SBE have not been determined. Hence, the primary aim of this study was to prospectively evaluate the therapeutic yield of SBE in patients with SMTs.

PATIENTS AND METHODS

Twenty-one patients with SMTs were enrolled in this study. Regarding the sex distribution, there were 12 men (57.1%) and 9 women (42.9%). Regarding the age distribution, 42.9% of the patients were 60 years old or older and 57.1% of the patients were under 60 years old. The preoperative characteristics of SMTs were summarized and analyzed, the complete resection incidence of SMTs was determined, and the incidence of postoperative complications was collected. ESD-related and EFTR-related complications and the duration of follow-up after leaving hospital were also summarized and analyzed. The efficacy and safety of SMTs treated by ESD or EFTR during SBE were calculated as percentages.

RESULTS

Among the 21 patients, 10 (47.6%) underwent EFTR and 11 (52.4%) underwent ESD. The mean diameter of SMTs was 113.50 mm (range: 80 to 160 mm). Anterograde and retrograde SBE were conducted in 11 and 10 patients, respectively. The mean follow-up time was 49.3 days (range: 6.0 to 129 d). The complete resection rate of SMTs was 100%. The complete suture rate of SMTs wound was 100%. The SMTs pathology of all patients showed that the margin-negative (R0) resection was 100%. The incidence of physical discomfort complications (ie, infection/fever, abdominal pain, and abdominal distension) of ESD and EFTR was 5 (23.8%) on day 1, 1 (4.8%) on day 2, and 1 (4.8%) on day 3 after operation. Only 1 (4.8%) patient with EFTR had abdominal pain on the sixth day after leaving hospital, and the visual analog scale/score was 1 point, meaning the pain was easily tolerated by the patient. Twenty (95.2%) patients had no abdominal discomfort after leaving hospital. No patients needed additional surgery because of complications after ESD or EFTR during SBE.

CONCLUSIONS

This preliminary study showed that SMTs can be safely and effectively treated by ESD or EFTR during SBE, particularly SMTs <160 mm in diameter.

Clinical characteristics and risk factors for rebleeding in uremic patients with obscure gastrointestinal bleeding undergoing deep enteroscopy: A multi-center retrospective study in Taiwan

BACKGROUND/PURPOSE

Recurrent obscure gastrointestinal bleeding (OGIB) in patients with chronic kidney disease is a challenge often faced by physicians, given the need for repeated hospitalizations, multiple extensive examinations, limited treatment options, and high medical costs. The purpose of this study was to identify the clinical characteristics of uremic patients undergoing deep enteroscopy for OGIB and analyze the risk factors for rebleeding in these patients after undergoing single-balloon enteroscopy (SBE).

METHODS

Out of 765 patients with OGIB who underwent 1004 procedures of SBE in four teaching hospitals, 78 uremic patients with OGIB were enrolled. Clinical characteristics and endoscopic findings were collected, and multiple variables were analyzed to determine the risk of rebleeding after SBE.

RESULTS

The diagnostic yield was 75.6%, and the rebleeding rate was 29.5% in the enrolled uremic patients. The most common etiology was angiodysplasia (74.6%) and the most common site was the jejunum (50.8%). The endoscopic intervention rate was 62.8% and most patients were treated with argon plasma coagulation (75.6%). Among the eight patients with valvular heart disease (VHD), four (50%) had severe aortic stenosis, and the remaining had non-aortic stenosis-VHD. VHD (p < 0.05) and angiodysplasia (p < 0.05) were both associated with a higher rebleeding rate.

CONCLUSION

VHD may be an independent risk factor associated with rebleeding after SBE in uremic patients with OGIB. Moreover, uremic patients with angiodysplasia-related bleeding appear to have a higher rebleeding rate than those with alternative causes of bleeding.

Diagnostic and therapeutic yields of early capsule endoscopy and device-assisted enteroscopy in the setting of overt GI bleeding: a systematic review with meta-analysis

BACKGROUND AND AIMS

Small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) are essential in obscure GI bleeding (OGIB) management. However, the best timing for such procedures remains unknown. This meta-analysis aimed to compare, for the first time, diagnostic and therapeutic yields, detection of active bleeding and vascular lesions, recurrent bleeding, and mortality of "early" versus "nonearly" SBCE and DAE.

METHODS

MEDLINE, ScienceDirect, and Cochrane Central Register of Controlled Trials were searched to identify studies comparing early versus nonearly SBCE and DAE. Random-effects meta-analysis was performed; reporting quality was assessed.

RESULTS

From 1974 records, 39 were included (4825 patients). Time intervals for the early approach varied, within 14 days in SBCE and 72 hours in DAE. The pooled diagnostic and therapeutic yields of early DAE were superior to those of SBCE (7.97% and 20.89%, respectively; P < .05). The odds for active bleeding (odds ratio [OR], 5.09; I² = 53%), positive diagnosis (OR, 3.99; I² = 45%), and therapeutic intervention (OR, 3.86; I² = 67%) were higher in the early group for SBCE and DAE (P < .01). Subgroup effects in diagnostic yield were only identified for the early group sample size. Our study failed to identify differences when studies were classified according to time intervals for early DAE (I² < 5%), but the analysis was limited because of a lack of data availability. Lower recurrent bleeding in early SBCE and DAE was observed (OR, .40; P < .01; I² = 0%).

CONCLUSIONS

The role of small-bowel studies in the early evaluation of OGIB is unquestionable, impacting diagnosis, therapeutic intervention, and prognosis. Comparative studies are still needed to identify optimal timing.

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.

Timing of enteroscopy in overt-obscure gastrointestinal bleeding: a systematic review and meta-analysis

BACKGROUND

the impact of early enteroscopy on the outcome of overt-obscure gastrointestinal bleeding (OGIB) is still unclear. Our aim was to evaluate the impact of early enteroscopy on overt-OGIB.

METHODS

the PubMed-MEDLINE, Web of Science, and Scopus databases were systematically reviewed. Observational retrospective studies comparing early versus non-early enteroscopy in overt-OGIB were identified. Data on diagnosis, treatment, and rebleeding were extracted from each study, and a meta-analysis was performed.

RESULTS

fifteen studies (comprising 1,907 patients) were included. Early enteroscopy was performed in 470 patients and non-early enteroscopy in 1,437 patients. Early enteroscopy was associated with a significantly higher diagnostic yield (odds ratio [OR] = 3.2, 95 % CI: 1.9-5.3; p = 0.002) and therapeutic yield (OR = 4.9, 95 % CI: 1.2-20.5; p = 0.03). However, moderate and high heterogeneity was observed in both analyses (DY I2 = 60.4 %; p = 0.002; TY I2 = 83.1 %; p < 0.001). When considering only studies where enteroscopy was performed during ongoing bleeding or within ≤ 24 h, ≤ 48 h, and ≤ 72 h of bleeding, heterogeneity was removed while the positive effect on diagnostic yield was maintained (OR = 4.7, 95 % CI: 3.4-6.6, p < 0.001, I2 = 0 %). Early enteroscopy did not significantly influence rebleeding rate (OR = 0.87, 95 % CI: 0.40-1.89, p = 0.72) in our analysis.

CONCLUSIONS

in conclusion, early enteroscopy, especially when performed during ongoing bleeding or within 24 h, 48 h or 72 h of the bleeding episode, may increase diagnostic yield. Although an effect on therapeutic yield was observed, the value of early intervention has to be cautiously evaluated due to the high heterogeneity found among results. In our meta-analysis, early enteroscopy did not significantly influence rebleeding rate.

Systematic review and meta-analysis of the diagnostic and therapeutic yield of small bowel endoscopy in patients with overt small bowel bleeding

BACKGROUND

Small bowel endoscopy, including small bowel capsule endoscopy (SBCE) and balloon-assisted endoscopy (BAE), is useful for small bowel bleeding (SBB) assessment. However, the specific management strategy for overt SBB is not well established. This meta-analysis aimed to evaluate the pooled diagnostic yields (DYs) and therapeutic yields (TYs) of small bowel endoscopy in overt SBB and to determine the optimal endoscopy timing.

METHODS

A comprehensive literature search was performed of studies examining the DY and/or TY of small bowel endoscopy in overt SBB. Data on the DY, TY, and timing of small bowel endoscopy were extracted, pooled, and analyzed. The pooled DY and TY of small bowel endoscopy for patients with overt SBB were calculated. Meta-regression and subgroup analysis were performed.

RESULTS

Twenty-two studies were included. The pooled DY was 65.2% and 74.0% for SBCE and BAE, respectively. The pooled TY of SBCE and BAE was 55.9% and 35.8%, respectively. A meta-regression model showed that the timing of endoscopy was significantly associated with the DY of BAE and the TY of SBCE and BAE.

CONCLUSIONS

Small bowel capsule endoscopy and BAE would be useful diagnostic and therapeutic modalities in overt SBB. According to the subgroup analysis, in which the TY seemed to be higher within 2 days after bleeding for SBCE and BAE, the optimal timing of endoscopy would be within 2 days.

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.

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.

The rebleeding rate in patients evaluated for obscure gastrointestinal bleeding after negative small bowel findings by device assisted enteroscopy

BACKGROUND

data on the long-term outcome of patients with obscure gastrointestinal bleeding (OGIB) with positive small bowel findings in capsule endoscopy but negative small bowel findings in device-assisted enteroscopy are scarce.

OBJECTIVE

this study aimed to evaluate the rebleeding rate and time to rebleed in patients with no small bowel findings in enteroscopy, after a positive capsule endoscopy in the setting of OGIB. Baseline predictors for rebleeding were assessed.

METHODS

a retrospective double-center study was performed, including patients with OGIB with positive findings by capsule endoscopy and negative small bowel findings by enteroscopy.

RESULTS

thirty-five patients were included. Rebleeding occurred in 40 % of patients during a median follow-up of 27 months. Further evaluation in patients with a rebleed was performed in 85.7 %, leading to a final diagnosis in 78.6 %. The rebleeding rate increased progressively over time, from 17.2 % at one month to 54.4 % at four years. Overt bleeding at the time of the first episode was a predictor of rebleeding (p = 0.03) according to the multivariate analysis. This was 50 % at one year compared with 21.8 % in patients with occult bleeding on admission.

CONCLUSIONS

in obscure gastrointestinal bleeding, long-term follow-up and further evaluation may be considered after a positive capsule endoscopy. Even if there are no small bowel findings by device-assisted enteroscopy. The rebleeding rate in our study was 40 %, mainly in the presence of an overt bleeding on admission.

Emergent Double Balloon Enteroscopy in Overt Suspected Small Bowel Bleeding: Diagnosis and Therapy

Background

Double balloon enteroscopy (DBE) is a diagnosis and therapy method for suspected small bowel bleeding (SSBB). The data for emergent DBE is limited in overt SSBB cases. The aim of this study was to investigate the role of diagnosis and therapy of emergent DBE in patients with overt SSBB.

Material/Methods

The clinical and endoscopic data for patients with overt SSBB undergoing DBE in a single center from January 2010 to December 2017 were collected and analyzed. Emergent DBE was defined as DBE performed less than 3 days of last bleeding onset.

Results

A total of 265 DBEs in 265 patients with overt SSBB were enrolled (mean age, 44.7±17.3 years; 66.8% males). The patients were divided into 3 groups according to the timing of DBE: less than 3 days (n=32), more than 3 days and less than 7 days (n=146), and more than 7 days (n=87) (first group was the emergent group, the latter 2 groups were the non-emergent groups). The diagnosis yield for the emergent group was significantly higher than the non-emergent groups (84.4% versus 65.1% or 59.8%, respectively, P<0.05), but was not different between the 2 non-emergent groups (P>0.05). The top 3 diagnoses were angioectasias (19.6%), diverticulum (16.2%), and tumor (12.1%). For therapy yield, there was a remarkable reducing trend in the emergent group (<3 days), and the 2 non-emergent groups (3 to 7 days group and >7 days group: 78.1%, 58.2% and 39.1%, respectively, P<0.05. The top 3 endoscopic treatments were hemostatic clips (21.9%), argon plasma coagulation (15.8%), and epinephrine injection (14.0%).

Conclusions

The emergent DBE had the highest yields for diagnosis and therapy. The study finding showed a pivotal role of emergent DBE in overt SSBB.