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Dolu S, Arayici ME, Onem S, Buyuktorun I, Dongelli H, Bengi G, Akarsu M. Evaluation of double-balloon enteroscopy in the management of type 1 small bowel vascular lesions (angioectasia): a retrospective cohort study. BMC Gastroenterol 2025; 25:15. [PMID: 39806314 PMCID: PMC11727186 DOI: 10.1186/s12876-025-03591-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 01/03/2025] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND Small-bowel angioectasia is commonly diagnosed and managed using double-balloon enteroscopy; however, rebleeding rates can vary significantly. This study aimed to identify and evaluate the clinical predictors of rebleeding in patients with small-bowel angioectasia. METHODS This retrospective study focused on adult patients who underwent endoscopic management for small bowel vascular lesions (SBVLs). A total of 67 patients were included in the study, all of whom were retrospectively analyzed. The SBVLs were classified using the Yano et al. classification system. Among these, 62 patients with angioectasia who received endoscopic treatment were specifically analyzed. To further investigate the clinical outcomes, the angioectasia group that required endoscopic treatment was divided into two subgroups based on the number of double-balloon enteroscopy (DBE) procedures performed. Univariate and multivariate binary logistic regression analyses were used to establish which predictor variables were significantly related to the recurrence. RESULTS A total of 67 patients (mean age 68.1 ± 8.9 years; 44 males) with SBVL, angioectasia was diagnosed in 62 (92.5%) patients, dieulafoy lesion in 1 (1.5%) patient, and arteriovenous malformation in 4 (6%) patients. Similarly, the prevalence of chronic renal failure and diabetes mellitus were significantly higher in the multiple DBE endotherapy group compared to the single DBE endotherapy group (p < 0.001; p = 0.032, respectively). In multivariate logistic regression analysis, anticoagulant use (OR = 9.648, 95% CI: 1.729-53.817, p = 0.010), chronic renal failure (OR = 15.683, 95% CI: 2.727-90.203, p = 0.002), localization of duodenum (OR = 13.509, 95% CI: 1.598-114.168, p = 0.017), and localization of the ileum (OR = 17.100, 95% CI: 1.477-197.905, p = 0.023) were all independently associated with a higher risk of angioectasia recurrence. CONCLUSIONS The findings of this study demonstrates a high success rate of endoscopic treatment, with a rebleeding rate of 27%, highlighting the significance of this approach. Chronic renal failure, use of anticoagulant, and lesion localization in the duodenum or ileum were identified as independent risk factors for rebleeding, underscoring the need for careful patient monitoring and targeted intervention in these cases.
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Affiliation(s)
- Suleyman Dolu
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey.
| | - Mehmet Emin Arayici
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
- Department of Public Health, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Soner Onem
- Department of Gastroenterology, Gazi State Hospital, Samsun, Turkey
| | - Ilker Buyuktorun
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Huseyin Dongelli
- Department of Internal Medicine, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Goksel Bengi
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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Shao XD, Shao HT, Wang L, Zhang YG, Tian Y. Clinical Outcomes of Negative Balloon-Assisted Enteroscopy for Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:772954. [PMID: 35308514 PMCID: PMC8931682 DOI: 10.3389/fmed.2022.772954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Background For patients with obscure gastrointestinal bleeding (OGIB), finding the bleeding site is challenging. Balloon-assisted enteroscopy (BAE) has become the preferred diagnostic modality for OGIB. The long-term outcome of patients with negative BAE remains undefined. The present study aimed to evaluate the long-term outcomes of patients with negative BAE results for OGIB and to clarify the effect of further investigations at the time of rebleeding with a systematic review and meta-analysis of the available cohort studies. Methods Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following indexes were analyzed: rebleeding rate after negative BAE, rebleeding rate after different follow-up periods, the proportion of patients who underwent further evaluation after rebleeding, the percentage of patients with identified rebleeding sources, and the percentage of patients with rebleeding sources in the small intestine. Heterogeneity was assessed using the I2 test. Results Twelve studies that involved a total of 407 patients were included in the analysis. The pooled rebleeding rate after negative BAE for OGIB was 29.1% (95% CI: 17.2–42.6%). Heterogeneity was significant among the studies (I2 = 88%; p < 0.0001). The Chi-squared test did not show a difference in rebleeding rates between the short and long follow-up period groups (p = 0.142). The pooled proportion of patients who underwent further evaluation after rebleeding was 86.1%. Among the patients who underwent further evaluation, rebleeding sources were identified in 73.6% of patients, and 68.8% of the identified rebleeding lesions were in the small intestine. Conclusion A negative result of BAE in patients with OGIB indicates a subsequently low risk of rebleeding. Further evaluation should be considered after rebleeding.
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Affiliation(s)
- Xiao Dong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- *Correspondence: Xiao Dong Shao
| | - Hao Tian Shao
- School of Basic Medical Sciences, Guangxi Medical University, Nanning, China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yong Guo Zhang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Ye Tian
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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Hashimoto R, Nakahori M, Matsuda T. Impact of Urgent Double-Balloon Enteroscopy on the Short-Term and Long-Term Outcomes in Overt Small Bowel Bleeding. Dig Dis Sci 2019; 64:2933-2938. [PMID: 30997580 DOI: 10.1007/s10620-019-05627-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 04/12/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Double-balloon enteroscopy (DBE) is a safe and useful procedure for managing small bowel bleeding. However, there are limited studies regarding the preferable timing of DBE and its impact on long-term outcomes. AIM We aimed to evaluate the association between the timing of DBE and the long-term outcomes of patients suspected of having overt small bowel bleeding who underwent DBE. METHODS We retrospectively reviewed a prospectively collected database of patients who underwent DBE procedures between May 2004 and April 2016. The electronic medical records were reviewed, and interviews were conducted via mail and telephone. RESULTS One-hundred sixty-five patients could be followed up. The bleeding source was detected during the initial DBE (DBE-positive group) for 102 patients. Sixty-three patients had no definite lesion during the initial DBE (DBE-negative group). Urgent DBE (DBE within 24 h after the last bleeding episode) was performed more often for the DBE-positive group (50/102; 49.0%) than for the DBE-negative group (10/63; 16.1%) (p < 0.0001). Nine patients in the DBE-positive group underwent curative surgery after diagnosis. Among the remaining DBE-positive patients, 38 of 93 (40.9%) had recurrent bleeding during 2675 days of follow-up. Twenty-one of 63 patients (33.3%) in the DBE-negative group had recurrent bleeding during 2490 days of follow-up. There was no significant difference between the two groups in terms of intervals without rebleeding (p = 0.17). CONCLUSION Urgent DBE at the initial bleeding episode was useful for detecting lesions. However, the rebleeding rate was not dependent on the initial DBE results.
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Affiliation(s)
- Rintaro Hashimoto
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, 980-0873, Japan.
| | - Masato Nakahori
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, 980-0873, Japan
| | - Tomoki Matsuda
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, 980-0873, Japan
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Liu Y, Jiang W, Chen G, Li Y. Diagnostic Value and Safety of Emergency Single-Balloon Enteroscopy for Obscure Gastrointestinal Bleeding. Gastroenterol Res Pract 2019; 2019:9026278. [PMID: 31534450 PMCID: PMC6732587 DOI: 10.1155/2019/9026278] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/16/2019] [Accepted: 08/01/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND This study assesses the diagnostic performance of emergency single-balloon enteroscopy (SBE) for obscure gastrointestinal bleeding (OGIB) under general anesthesia versus conscious sedation. STUDY The data of 102 OGIB in-patients from June 2015 to June 2018 were retrospectively analyzed. The diagnosis and detection rates and adverse events were calculated overall and in relation to age, gender, type of operation and anesthesia, bleeding type, different times of examination, and SBE route. All statistical analyses were performed using SPSS 24.0, and the diagnosis and detection rates were compared using the Chi-square test. RESULTS Among the 102 patients, 66 patients had positive findings, while 11 patients had suspected positive findings, and the diagnosis and detection rates were 64.7% and 75.5%, respectively. Ulcers (19.6%) and tumors (16.7%) were the most common causes of OGIB. There were no statistical differences in diagnosis and detection rates between the ages of ≥60 and <60 and between different genders. Patients with emergency SBE had higher diagnosis and detection rates (68.6% vs. 35.3%, P = 0.023; 80.0% vs. 47.1%, P = 0.016, respectively), when compared with nonemergency SBE patients. The diagnosis rate at 24 hours was higher than that at 2-7 days and one week (88.0% vs. 61.5%, P = 0.030; 88.0% vs. 53.8%, P = 0.007). For overt bleeding, the difference in diagnosis rates at 24 hours, 2-7 days, and one week was statistically significant (100.0% vs. 57.1%, P = 0.006; 100.0% vs. 57.1%, P = 0.006). For occult bleeding, the pairwise comparison revealed no statistical difference. Patients with general anesthesia had a higher detection rate, when compared to patients with conscious sedation (87.9% vs. 63.9%, P = 0.004). In addition, adverse events under general anesthesia were lower, when compared to adverse events under conscious sedation (28.8% vs. 69.4%, P = 0.020). There was no significant difference in adverse events at the different time points (P > 0.05). CONCLUSION Emergency SBE under general anesthesia achieves higher diagnosis and detection rates, and fewer adverse events under conscious sedation, when compared to nonemergency SBE, regardless of the route. For patients with overt bleeding, it is easier to find lesions by emergency SBE within 24 hours.
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Affiliation(s)
- Yipin Liu
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province 250012, China
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong Province 264000, China
| | - Weiwei Jiang
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong Province 264000, China
| | - Guoxun Chen
- Department of Nutrition, University of Tennessee, Knoxville, Tennessee 37909, USA
| | - Yanqing Li
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province 250012, China
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Al-Bawardy B, Piovezani Ramos G, Lennon RJ, Gorospe E, Wong Kee Song LM, Bruining DH, Alexander JA, Coelho-Prabhu N, Fidler JL, Rajan E. Outcomes of repeat balloon assisted enteroscopy in small-bowel bleeding. Endosc Int Open 2018; 6:E694-E699. [PMID: 29868634 PMCID: PMC5979197 DOI: 10.1055/a-0599-6085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/20/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS The rate of recurrent small-bowel bleeding (SBB) remains high despite the advent of balloon assisted enteroscopy (BAE). The study aims were to determine: (1) the diagnostic and therapeutic yields, and adverse event rate of repeat BAE in SBB, and (2) the predictors of a positive repeat BAE. METHODS A retrospective review of a BAE database was conducted. Patients who had > 1 BAE for SBB were included. Primary outcomes were diagnostic yield, therapeutic yield, and adverse events of repeat BAE. Secondary outcomes were predictors of a positive repeat BAE. RESULTS A total of 175 patients (55 % men; mean age 64.1 ± 16.3 years) were included. The diagnostic and therapeutic yields of repeat BAE were 55 % and 42 %, respectively. Repeat BAE adverse events occurred in 5 % with self-limited abdominal pain being most common. Patients with a positive repeat BAE were significantly older than the negative group (68.6 ± 13.9 vs. 60.9 ± 17.1; P = 0.001) and were more likely to have cardiac comorbidities (OR 2.4, 95 %CI: 1.3 - 4.6; P = 0.01), chronic kidney disease (OR 2.3, 95 %CI: 1.1 - 4.9; P = 0.04), chronic obstructive pulmonary disease (OR 3.3, 95 %CI: 1.3 - 8.1; P = 0.01), positive initial BAE (OR 3.6, 95 %CI: 1.9 - 6.8; P < 0.001), and antegrade procedure (OR 3.3, 95 %CI: 1.7 - 6.1; P < 0.001). On multivariate analysis, a positive initial BAE and antegrade route were the only significant predictive factors. CONCLUSIONS Performing a repeat BAE for SBB appears safe and provided modest yields. A positive initial BAE and antegrade route were predictive of a positive repeat BAE.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Ryan J. Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Emmanuel Gorospe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - David H. Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Jeff L. Fidler
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,Corresponding author Elizabeth Rajan, MD Division of Gastroenterology & HepatologyMayo Clinic200 First Street, S.W.RochesterMN 55905USA+1-507-284-0538
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Gurudu SR, Bruining DH, Acosta RD, Eloubeidi MA, Faulx AL, Khashab MA, Kothari S, Lightdale JR, Muthusamy VR, Yang J, DeWitt JM. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc 2017; 85:22-31. [PMID: 27374798 DOI: 10.1016/j.gie.2016.06.013] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023]
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Tao Z, Liu GX, Cai L, Yu H, Min XJ, Gan HT, Yang K, Sq L, Yan J, Chen L, Tan QH, Wu JC, Huang XL. Characteristics of Small Intestinal Diseases on Single-Balloon Enteroscopy: A Single-Center Study Conducted Over 6 Years in China. Medicine (Baltimore) 2015; 94:e1652. [PMID: 26496270 PMCID: PMC4620798 DOI: 10.1097/md.0000000000001652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The small intestine has been considered inaccessible for a long term. The development of single-balloon endoscopy has greatly improved the diagnosis and treatment possibilities for small intestinal diseases.In this study, we aimed to explore the demographic characteristics and small intestinal diseases of patients who underwent single-balloon enteroscopy between 2009 and 2014 at our endoscopy center. We determined the enteroscopic findings for each small intestinal disease and the most susceptible age groups.In total, 186 patients were included in the study. Their mean age was 45.87 ± 15.77 years. Patients who underwent single-balloon enteroscopy were found to have neoplasms (most common age group: 14-45 years, most common lesion location: jejunum), lymphoma (46-59 and 60-74 years, ileum), protuberant lesions (45-59 years, jejunum), inflammation (14-45 and 46-59 years, ileum), benign ulcers (14-45 years, jejunum), diverticulum (14-45 years, ileum), vascular malformations (60-74 years, jejunum), polyps (14-45 years, jejunum), Crohn's disease (14-45 years, jejunum), hookworm infection (14-45 years, jejunum), lipid pigmentation (14-45 and 46-59 years, jejunum), undetermined bleeding (46-59 years, ileum), or undetermined stenosis (31 years, duodenum). Each small intestinal disease had distinct enteroscopic findings.
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Affiliation(s)
- Zhang Tao
- From the Gastroenterology, West China Hospital, Sichuan University, Gastroenterology, Nanchong Central Hospital (ZT); Gastroenterology and Geriatrics, West China Hospital, Sichuan University (LGX, YK, YJ); Gastroenterology, West China Hospital, Sichuan University (CL, YH, LC, QHT, JCW, XLH); Endoscopy Center, West China Hospital, Sichuan University (MXJ); and Gastroenterology, Nanchong Central Hospital (LSQ)
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Gao X, Wang ZJ. Idiopathic chronic ulcerative enteritis with perforation and recurrent bleeding: A case report. World J Gastroenterol 2013; 19:4836-4840. [PMID: 23922486 PMCID: PMC3732861 DOI: 10.3748/wjg.v19.i29.4836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 06/04/2013] [Accepted: 07/18/2013] [Indexed: 02/06/2023] Open
Abstract
Idiopathic chronic ulcerative enteritis (ICUE) is a distinct entity without a defined etiology and is rarely seen in the clinic. Patients with ICUE mainly present with insidious abdominal symptoms such as chronic abdominal pain and intermittent gastrointestinal hemorrhage and symptoms of malnourishment in the early stages of the disease. ICUE is always difficult to diagnose. However, as the disease progresses, patients have a variety of acute abdominal complications such as hemorrhage, perforation, or ileus. Surgical intervention is always needed, and the condition can recur and require repeat laparotomy. When diffuse ulceration of the small bowel is present in the absence of recognizable causes, it is classified as nonspecific or idiopathic. The histological examination always demonstrates an acute, chronic inflammatory infiltration without giant cells, granulomas, or villous atrophy. The etiology of ICUE has not been identified, and its pathogenesis is poorly understood; therefore, radical surgical resection is considered the best available treatment. Here, we report a case of ICUE characterized by nonspecific, multiple, small intestinal ulcers resulting in perforation and recurrent bleeding. The differential diagnosis and the treatment are also discussed.
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Gong W, Zhi FC, Bai Y, Xiao B, De Liu S, Xu ZM, Jiang B. Single-balloon enteroscopy for small bowel diseases: results from an initial experience at a single Chinese center. J Dig Dis 2012; 13:609-13. [PMID: 23134075 DOI: 10.1111/j.1751-2980.2012.00642.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to evaluate the performance, diagnostic yield, and safety of single-balloon enteroscopy (SBE) at a Chinese tertiary-care center. METHODS A total of 67 patients with suspected small bowel diseases who underwent SBE via the oral and/or anal routes from January 2009 to August 2011 were retrospectively analyzed. Data were extracted from electronic clinical and endoscopy records. The indications, SBE procedure time, diagnostic yield and complications were summarized and evaluated. RESULTS A total of 42 SBE procedures through the oral route and 38 via the anal route were performed in these 67 patients. Patients were referred mainly for obscure gastrointestinal bleeding (OGIB) (40.3%) and abdominal pain (29.8%). The mean procedure duration was 68.1 min from the oral cavity and 77.5 min from the anus. The estimated depth of insertion was 247.6 ± 80.3 cm from the oral cavity and 131.1 ± 68.7 cm from the anus. The overall significant diagnostic yield was 68.7%. In patients with OGIB and unexplained chronic abdominal pain, the diagnostic yield was 74.1% and 50.0%, respectively. There were no significant complications. CONCLUSION SBE appears to be a safe and effective method for the diagnosis and treatment of deep small bowel disease.
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Affiliation(s)
- Wei Gong
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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Elena RM, Riccardo U, Rossella C, Bizzotto A, Domenico G, Guido C. Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications. World J Gastrointest Endosc 2012; 4:453-461. [PMID: 23189216 PMCID: PMC3506955 DOI: 10.4253/wjge.v4.i10.453] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Enteroscopy, defined as direct visualization of the small bowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past several years. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies one of which is non-invasive, the video capsule, and a type of invasive technique, the device-assisted enteroscopy. In particular, the device-assisted enteroscopy consists then of three different types of instruments all able to allow, in skilled hands, to display partially or throughout its extension (if necessary) the small intestine. Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocarcinoma or gastrointestinal stromal tumors. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.
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Affiliation(s)
- Riccioni Maria Elena
- Riccioni Maria Elena, Unit of Digestive Endoscopy, Catholic University of Rome, Largo A Gemelli, 00168 Rome, Italy
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Lenz P, Domagk D. Double- vs. single-balloon vs. spiral enteroscopy. Best Pract Res Clin Gastroenterol 2012; 26:303-13. [PMID: 22704572 DOI: 10.1016/j.bpg.2012.01.021] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 01/19/2012] [Indexed: 01/31/2023]
Abstract
Starting with the introduction of the double-balloon enteroscope in 2001, two more techniques have been successfully developed for small bowel investigation (single-balloon enteroscopy, spiral enteroscopy). To compare the different enteroscopy systems, within this review, 68 studies were analyzed and put into context. The procedural characteristics (mean insertion depth, diagnostic yields, adverse events) were comparable for DBE, SBE or SE. The higher panenteroscopy rate in DBE might not have any clinical relevance. Therapeutic procedures, such as argon-plasma coagulation, polypectomy, dilation therapy and foreign body extraction are described with the DBE and SBE procedure. With regard to the present literature, the balloon-assisted devices as well as spiral enteroscopy technique seem to be equally suitable in clinical routine for imaging of the small bowel. The choice of the method should be based on availability, physicians' experience and clinical implications. Future randomized, controlled trials with large numbers of patients are needed to work out the subtleties of every single method.
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Affiliation(s)
- Philipp Lenz
- Department of Medicine B, University of Muenster, Albert-Schweitzer-Campus 1, A1, 48149 Muenster, Germany.
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Small Bowel Bleeding. GASTROINTESTINAL BLEEDING 2012. [DOI: 10.1002/9781444398892.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Long-term outcome of patients treated with double balloon enteroscopy for small bowel vascular lesions. Am J Gastroenterol 2012; 107:240-6. [PMID: 21946281 DOI: 10.1038/ajg.2011.325] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Early rebleeding rate after endoscopic therapy with double balloon enteroscopy (DBE) of hemorrhagic small bowel vascular lesions (SBVL) varies between 10 and 50%. In recent reports, long-term follow-up of patients have been described but rebleeding risk factors are still not well established. The aim of the current study was to identify long-term treatment success rate and rebleeding risk factors after DBE therapy in a large cohort. METHODS We conducted a single-center, retrospective cohort study in a large French tertiary-referral center between January 2004 and December 2007. RESULTS Among 261 patients presenting with obscure gastrointestinal bleeding (OGIB), SBVL was present in 133 patients and was treated successfully in 129 (97%) using mainly argon plasma coagulation. Ninety-eight patients were followed up for a mean period of 22.6±13.9 months (range 1-52). Rebleeding rate was 46% (45/98 patients) at 36 months. On multivariate analysis, the total number of observed lesions (hazard ratio (HR): 1.15, 95% confidence interval (CI): 1.06-1.25, P=0.001) and the presence of a valvular and/or arrhythmic cardiac disease (HR: 2.50, 95% CI: 1.29-4.87, P=0.007) were significantly associated with the risk of rebleeding. Complication rate of therapeutic DBE was 2.3% with no mortality. CONCLUSIONS Endoscopic therapy using DBE for SBVL in patients with recurrent OGIB allows a long-term remission in more than half of the patients. Independent rebleeding risk factors after a first endoscopic therapy are an increased number of SBVL and an associated valvular/arrhythmic heart disease.
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Xin L, Liao Z, Jiang YP, Li ZS. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc 2011; 74:563-70. [PMID: 21620401 DOI: 10.1016/j.gie.2011.03.1239] [Citation(s) in RCA: 188] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Accepted: 03/24/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Double-balloon endoscopy (DBE) has been used in clinical practice for nearly 10 years. OBJECTIVE To systematically collect and produce pooled data on indications, detection rate, total enteroscopy, complications, and the composition of positive findings in diagnostic DBE. DESIGN A systematic review. MAIN OUTCOME MEASUREMENTS We searched PubMed between January 1, 2001 and March 31, 2010 for original articles about DBE evaluation of small-bowel diseases. Data on total number of procedures, distribution of indications, pooled detection rate, pooled total enteroscopy rate, and composition of positive findings were extracted and/or calculated. In addition, the data involving DBE-associated complications were analyzed. RESULTS A total of 66 English-language original articles involving 12,823 procedures were included. Suspected mid-GI bleeding (MGIB) was the most common indication (62.5%), followed by symptoms/signs only (7.9%), small-bowel obstruction (5.8%), and Crohn's disease (5.8%). The pooled detection rates were 68.1%, 68.0%, 53.6%, 63.4%, and 85.8% for overall, suspected MGIB, symptoms/signs only, Crohn's disease, and small-bowel obstruction, respectively. Inflammatory lesions (37.6%) and vascular lesions (65.9%) were the most common findings, respectively, in suspected MGIB patients of Eastern and Western countries. The pooled total enteroscopy rate was 44.0% by combined or antegrade-only approach. The pooled minor and major complication rates were 9.1% and 0.72%, respectively. LIMITATIONS Inclusion and exclusion criteria were loosely defined. CONCLUSION The detectability and complication risk of diagnostic DBE are acceptable. Suspected MGIB is the most common indication, with a relatively high detection rate, but there was a difference in its causes between Western and Eastern countries.
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Affiliation(s)
- Lei Xin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Wu J, Zheng CF, Huang Y, Shao CH, Leung YK. Coordination and nursing care of pediatric patients undergoing double balloon enteroscopy. World J Gastroenterol 2011; 17:3049-53. [PMID: 21799652 PMCID: PMC3132257 DOI: 10.3748/wjg.v17.i25.3049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 03/02/2011] [Accepted: 03/09/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To review safety, efficacy, and proper nursing care of double-balloon enteroscopy (DBE) in pediatric patients with small intestinal disease.
METHODS: Our study included 37 patients with abdominal pain, diarrhea, passage of blood in the stools, and other symptoms, who underwent DBE from December 2006 to July 2010. DBE was retrograde in 36 procedures, antegrade in six, and from both ends in five. The diagnostic significance and salient points in nursing care are discussed in this article.
RESULTS: At least one lesion was discovered in 28 out of 37 patients, which yielded a positive diagnosis in 75.7% of cases. Good bowel preparation and skilled nursing care not only shortened the procedure time, but could also alleviate patient discomfort and enhance the quality of examination. No serious procedure-related complications were observed in any cases.
CONCLUSION: DBE is a new modality of endoscopic procedure that improves the standard of diagnosis and treatment of small bowel diseases in children. Good nursing care is essential to the successful execution of the procedure.
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Abstract
OBJECTIVES Double-balloon enteroscopy (DBE) is a newly developed endoscopic modality for diagnosis and treatment of small bowel disorders. Most publications on DBE are from adult medical centers. Publication related to the use and application of DBE in children and adolescents is limited. We present our experience with the use of DBE in the pediatric age group. PATIENTS AND METHODS We reviewed patient information on all of the DBE procedures performed in 2006 through 2008 at a single tertiary pediatric referral center in Columbus, Ohio. Compiled information included patient demographics, procedure indications, diagnostic and therapeutic results, and procedure-associated complications or adverse events. RESULTS Thirteen DBE procedures were performed on eleven 8- to 20-year-old patients. Procedure indications were based on suspicion for organic small bowel pathology after an exhaustive diagnostic evaluation including upper and lower endoscopy failed to uncover an etiology. Clinically significant lesions were identified in 46% (6/13) of the procedures performed. No serious procedure-related complications occurred. Self-limited postprocedure abdominal pain and discomfort from gaseous distension was observed in several patients. CONCLUSIONS DBE appears to be a safe endoscopic modality for the diagnosis and treatment of children and adolescents with suspected small bowel disease. However, performance should be selectively reserved for patients with a high suspicion for small bowel pathology, in which other less invasive techniques have failed to adequately diagnose and treat a patient's disease.
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Fisher L, Lee Krinsky M, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Cash BD, Decker GA, Fanelli RD, Friis C, Fukami N, Harrison ME, Ikenberry SO, Jain R, Jue T, Khan K, Maple JT, Strohmeyer L, Sharaf R, Dominitz JA. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 2010; 72:471-9. [PMID: 20801285 DOI: 10.1016/j.gie.2010.04.032] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 04/19/2010] [Indexed: 02/06/2023]
Abstract
This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).(1) The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "we suggest," whereas stronger recommendations are typically stated as "we recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.
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Hegde SR, Iffrig K, Li T, Downey S, Heller SJ, Tokar JL, Haluszka O. Double-balloon enteroscopy in the elderly: safety, findings, and diagnostic and therapeutic success. Gastrointest Endosc 2010; 71:983-9. [PMID: 20189563 DOI: 10.1016/j.gie.2009.10.054] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 10/20/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Double-balloon enteroscopy (DBE) is an important tool in the evaluation and management of small-bowel disease. Limited data are available on the safety, findings, and outcomes of DBE in elderly patients. OBJECTIVE To determine the safety and efficacy of DBE in elderly patients. DESIGN Single-center, retrospective analysis of prospectively collected database. SETTING Open-access, tertiary care referral center. PATIENTS A total of 176 patients undergoing DBE (216 procedures) for evaluation of small-bowel disease between August 2007 and August 2008. INTERVENTIONS Argon plasma coagulation of bleeding small-bowel lesions. MAIN OUTCOME MEASUREMENTS DBE complication rate, diagnostic/therapeutic success of DBE. METHODS An age cutoff of 75 years and older was used to designate patients as elderly. Data on complications, indications, findings, and diagnostic and therapeutic success of DBE were compared between age groups. RESULTS The mean age of patients was 66 +/- 16.4 years (range 20-95 years). DBE was performed in 185 patients, including 60 patients age 75 years and older and 110 patients younger than age 75. An overall complication rate of 0.9% was seen for DBE in this study, with no significant difference between age groups. No major complications were observed in elderly patients. Elderly patients were more likely to have angioectasias (39% vs 23%; P = .01) and were more likely to require endoscopic therapy during DBE (46.8% vs 29.2%; P = .01). LIMITATIONS Single-center, retrospective study. CONCLUSIONS DBE is safe in elderly patients. Elderly patients are more likely to have angioectasias and to require endoscopic therapy during DBE.
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Affiliation(s)
- Sanjay R Hegde
- Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, Maryland, USA
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Gerson LB, Tokar J, Chiorean M, Lo S, Decker GA, Cave D, Bouhaidar D, Mishkin D, Dye C, Haluszka O, Leighton JA, Zfass A, Semrad C. Complications associated with double balloon enteroscopy at nine US centers. Clin Gastroenterol Hepatol 2009; 7:1177-82, 1182.e1-3. [PMID: 19602453 DOI: 10.1016/j.cgh.2009.07.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 07/01/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Double balloon enteroscopy (DBE) was introduced into the US in 2004. Potential complications include perforation, pancreatitis, and gastrointestinal bleeding. Prevalence and risk factors for complications have not been described in a US population. METHODS We conducted a retrospective study of DBE complications in 9 US centers. We obtained detailed information for each complication including patient history, maneuvers performed during the DBE, and presence of altered surgical anatomy. RESULTS We collected data from 2478 DBE examinations performed from 2004 to 2008. The dataset included 1691 (68%) anterograde DBE, 722 (29%) retrograde DBE (including 5 per-stomal DBEs), and 65 (3%) DBE-facilitated endoscopic retrograde cholangiopancreatography ERCP cases. There were a total of 22 (0.9%) major complications including perforation in 11 (0.4%), pancreatitis in 6 (0.2%), and bleeding in 4 (0.2%) patients. One of 6 cases of pancreatitis occurred post retrograde DBE. Perforations occurred in 3/1691 (0.2%) anterograde examinations and 8/719 (1.1%) retrograde DBEs (P = .004). Eight (73%) perforations occurred during diagnostic DBE examinations. Four of 8 retrograde DBE perforations occurred in patients with prior ileoanal or ileocolonic anastomoses. In the subset of 219 examinations performed in patients with surgically altered anatomy, perforations occurred in 7 (3%), including 1/159 (0.6%) anterograde DBE examinations, 6/60 (10%) retrograde DBEs, and 1 of 5 (20%) peristomal DBE examinations (P < .005 compared with patients without surgically altered anatomy). CONCLUSIONS DBE is associated with a higher complication rate compared with standard endoscopic procedures. The perforation rate was significantly elevated in patients with altered surgical anatomy undergoing diagnostic retrograde DBE examinations.
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Affiliation(s)
- Lauren B Gerson
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305-5202, USA.
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Kramer RE, Brumbaugh DE, Soden JS, Capocelli KE, Hoffenberg EJ. First successful antegrade single-balloon enteroscopy in a 3-year-old with occult GI bleeding. Gastrointest Endosc 2009; 70:546-9. [PMID: 19559431 DOI: 10.1016/j.gie.2009.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Accepted: 04/10/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND Balloon enteroscopy is an emerging technique to allow access to the small intestine for both diagnostic and therapeutic purposes. To date, there have been few published data documenting the safety and efficacy of balloon enteroscopy in small children. OBJECTIVE To describe our experience with single-balloon enteroscopy (SBE) in a 37-month-old toddler with occult GI bleeding. DESIGN A single case report. SETTING A free-standing, academic children's hospital in Denver, Colorado. PATIENT The patient was a 37-month-old, 13.5-kg toddler with persistent heme-positive stools, severe microcytic anemia, and hypoalbuminemia. Previous workup was significant for eosinophilic inflammation in the antrum and a video capsule study showing erythematous lesions in the small bowel. INTERVENTION An antegrade SBE was performed with the child under general endotracheal anesthesia, with biopsy specimens obtained from identified lesions in the jejunum and ileum. MAIN OUTCOME MEASUREMENTS Complications and successful treatment of symptoms were the primary endpoints. RESULTS The procedure was performed successfully in 85 minutes, passing an estimated 200 cm beyond the pylorus, without complications. Identification of the lesions as consistent with eosinophilic enteropathy led to successful treatment with an elimination diet and corticosteroids. LIMITATIONS The primary limitation of this study is that it is a single case report. Therefore, it is difficult to make a generalized statement regarding the safety and efficacy of balloon enteroscopy in toddlers of this size. CONCLUSIONS Antegrade SBE can be a well-tolerated and effective procedure to evaluate occult GI bleeding in children as young as 3 years of age. Further study is needed to better establish safety parameters for balloon enteroscopy in small pediatric patients.
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Affiliation(s)
- Robert E Kramer
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital/University of Colorado Denver, Denver, Colorado, USA
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Abstract
The purpose of this article is to describe the available data regarding the short- and long-term outcomes associated with deep enteroscopy. Deep enteroscopy can be defined as the use of an enteroscope to examine small bowel distal to the ligament of Treitz or proximal to the distal ileum. The term deep enteroscopy includes double-balloon, single-balloon, and spiral enteroscopy. Comparisons are made with push enteroscopy and intraoperative enteroscopy, the major therapeutic endoscopic options available to the gastroenterologist before the introduction of deep enteroscopy. The article concludes with a discussion regarding complications associated with deep enteroscopy and cost-effectiveness of management strategies for obscure bleeding. Proposed changes to the current algorithm for management of obscure bleeding are suggested.
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Affiliation(s)
- Lauren B Gerson
- Division of Gastroenterology & Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305-5202, USA
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Gerson LB, Flodin JT, Miyabayashi K. Balloon-assisted enteroscopy: technology and troubleshooting. Gastrointest Endosc 2008; 68:1158-67. [PMID: 19028224 DOI: 10.1016/j.gie.2008.08.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Accepted: 08/08/2008] [Indexed: 12/22/2022]
Affiliation(s)
- Lauren B Gerson
- Stanford University School of Medicine, Stanford, California, USA
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Abstract
Until the end of the 20th century, push enteroscopy (PE) was the most commonly used method for the endoscopic investigation of the small bowel. However, PE has been almost completely replaced by double balloon enteroscopy (DBE). Undoubtedly the major endoscopic breakthrough of the last decade, DBE has contributed to the better diagnosis and understanding of diseases of the small bowel, opening-up this obscure part of the gastrointestinal tract to visualisation. Modern diagnostic and therapeutic DBE allows for a deeper and more thorough evaluation of the small bowel than PE, enabling the detection of more pathological lesions. In addition, DBE has for the first time enabled endoscopists to observe the entire small intestine, and has provided endoscopic interventions such as cauterisation of bleeding lesions, polypectomy, placement of small bowel stents, and foreign-body extraction.
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Affiliation(s)
- Klaus Mönkemüller
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Leipziger Strasse 44, 39120 Magdeburg, Germany.
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