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

Small-Bowel Angioectasias: Are They Responsible for a Real Impact on Survival?

Introduction

This study aimed to evaluate the effect of small-bowel angioectasia on survival, given the hypothesis that angioectasia might be an independent risk factor of frailty and poor outcomes.

Methods

In this retrospective cohort study, all patients undergoing small-bowel capsule endoscopy between 2010 and 2013 for obscure gastrointestinal bleeding from a Portuguese tertiary centre were included. Follow-up started after capsule endoscopy and ended upon death or end of the study (November 2020). Survival analysis was performed using a Cox proportional-hazards model, in order to analyse the effect of small-bowel angioectasia on survival as well as potentially confounding factors (age, vascular diseases and chronic kidney disease).

Results

A total of 176 patients were included in this study (50.6% male), with a median age of 68.5 years (IQR 24). The median follow-up was 7 years (IQR 4), during which 67 (38.1%) patients died. Seventy-three (41.5%) patients had at least one small-bowel angioectasia on capsule endoscopy. On multivariate Cox regression analysis, only age, peripheral arterial disease, history of previous mesenteric ischaemia and chronic kidney disease were independent risk factors of death. The presence of small-bowel angioectasia did not affect survival in this analysis (HR 1.30; 95% CI 0.75-2.23; p = 0.35).

Conclusion

In this retrospective cohort study, some comorbidities and age were independent predictors of poor survival. The presence of small-bowel angioectasia per se did not affect survival.

Small Bowel Bleeding: Clinical Diagnosis and Management in the Elderly

INTRODUCTION

With the global increase in life expectancy, there is an increase in gastrointestinal presentations in the elderly. Small bowel bleeding (SBB) is a cause of significant morbidity in the elderly requiring multiple hospital visits, investigations and potentially expensive therapy.

AREAS COVERED

In this review we will outline the different modalities which are used for the diagnosis and management of SBB. We will also discuss the common causes of SBB in the elderly.

EXPERT OPINION

SBB in elderly has a significant impact on the quality of life of the elderly. Larger randomized studies in the elderly are urgently required to help guide clinicians on the best and most cost-effective treatment algorithm in this challenging cohort.

Outcomes of Double Balloon-Enteroscopy in Elderly vs. Adult Patients: A Retrospective 16-Year Single-Centre Study

Background and Aim: Double-balloon enteroscopy (DBE) is a well-established procedure for direct visualisation of the entire small bowel mucosa, and, in contrast with other imaging techniques, allows to perform biopsies and therapeutic interventions. The aim of this study was to evaluate the indications, diagnostic yield, therapeutic yield, and complications of DBE in a cohort of consecutive patients according to patients’ age. Methods: We conducted a retrospective study of consecutive patients who underwent DBE in our endoscopy unit between January 2006 and December 2021. Results: A total of 387 consecutive patients who underwent 460 DBE procedures were included. Mean age of the patients was 63 years. The overall diagnostic yield was 67.6%; vascular lesions were the predominant endoscopic findings (31.5%), followed by polyps or neoplastic masses (17.6%). Older patients (≥65 years) showed statistically higher rates of clinically relevant findings than adult patients (18–65 years) (p = 0.001). Crohn’s disease and polyps or neoplastic masses were more frequent in the younger group (p = 0.009 and p = 0.066, respectively), while vascular lesions and non-specific inflammation were the most common findings in the older group (p < 0.001 and p < 0.001, respectively). The therapeutic intervention rate was 31.7%. Rates of endoscopic treatment were significantly higher in the older group (p < 0.001). Total complications occurred in five procedures (1.1%). Conclusion: In clinical practice, DBE is an efficient diagnostic and therapeutic tool with a high safety profile, particularly in the elderly population.

Management of Non-Variceal Upper GI Bleeding in the Geriatric Population: An Update

PURPOSE OF REVIEW

Upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality in the geriatric (age > 65 years) population and presents a unique management challenge in the context of multiple medical comorbidities, polypharmacy, and increased risk of adverse outcomes and is confounded by an increased prevalence of obscure GI bleeds. A review of relevant guidelines, literature, and personal observations will enhance management strategies in the elderly.

RECENT FINDINGS

Non-variceal bleeding represents a significant proportion of upper GI bleeding (UGIB) in geriatric patients. Peptic ulcer disease (PUD) remains the most common cause in geriatric patients hospitalized for UGIB, but its incidence is decreasing. Esophagogastroduodenoscopy (EGD) is the gold standard for treating UGIB in geriatrics with a therapeutic yield of approximately 75%. Scoring systems such as Glasgow-Blatchford (GBS) and AIMS-65 may be useful for risk stratification but are not validated in trials. Obscure bleeds account for up to 30% of hospitalizations and must be considered during triage and management. Video capsule endoscopy (VCE) technology is efficacious for detecting obscure jejunal bleeding after failed EGD and may enhance the yield of balloon-assisted enteroscopy (BAE). The most significant factor for the increased morbidity and mortality in the geriatric population is the presence of multiple medical comorbidities and polypharmacy. An EGD should be done within 24 h of hospital presentation. If non-diagnostic, VCE may be a viable option for diagnosing an obscure small-bowel bleed, representing up to 30% of GI bleeds in this population.

Does urgent balloon-assisted enteroscopy impact rebleeding and short-term mortality in overt obscure gastrointestinal bleeding?

BACKGROUND AND AIMS

The diagnostic yield (DY) and therapeutic yield (TY) of balloon-assisted enteroscopy (BAE) in overt obscure gastrointestinal bleeding (OGIB) is higher in the first 72 h. This study aimed to evaluate if this higher DY and TY after urgent BAE impacted the rebleeding rate, time to rebleed and short-term mortality.

METHODS

Retrospective cohort-study, which consecutively included all patients submitted to BAE for overt OGIB, between 2010 and 2019. Patients were distributed in 2 groups: (1) Urgent BAE; (2) Non-urgent BAE. Rebleeding was defined as an Hb drop >2 g/dL, need for transfusional support or presence of melena/hematochezia.

RESULTS

Fifty-four patients were included, of which 17 (31.5%) were submitted to BAE in the first 72 h. DY and TY of urgent BAE (DY 88.2%; n = 15; TY 94.1%; n = 16) was higher compared to non-urgent BAE (DY 59.5%; n = 22; TY 45.9%; n = 17) (DY p = .03) (TY p = .001). The rebleeding rate at 1, 2, and 5 years was 32.0%, 34.0%and 37.0%, respectively. Rebleeding was lower after urgent BAE (17.6%; n = 3) compared to non-urgent BAE (45.9%; n = 17) (p = .04). Rebleeding tended to occurr earlier in non-urgent BAE, being at 6-months (32.5%) and 36 months (41.3%) (p = .05). OGIB related 30-day mortality was 5.4% (n = 2) for non-urgent BAE and 0% for urgent BAE (p = .5).

CONCLUSION

Urgent BAE might be associated with higher DY and TY with lower rebleeding and trend toward higher rebleeding-free time.