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Dam HQ, Brandon DC, Gantz CG, Grantham VV, Low CS, Schroeder HW, Stabin MG, Zuckier LS. The SNMMI Procedure Standard/ACNM Practice Guideline for Gastrointestinal Bleeding Scintigraphy 3.0. J Nucl Med Technol 2025:jnmt.124.269004. [PMID: 39909579 DOI: 10.2967/jnmt.124.269004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Accepted: 10/16/2024] [Indexed: 02/07/2025] Open
Affiliation(s)
| | | | | | | | - Chen S Low
- University Hospitals Coventry and Warwickshire, Coventry, England
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Sun Q, Wang XY, Li DH, Li BR, Tu XZ, Jiang ZM, Ning SB, Sun T. Advances in gastrointestinal vascular bleeding disorders: Successful sirolimus treatment in colonic angioectasia. World J Gastroenterol 2025; 31:100718. [PMID: 39877708 PMCID: PMC11718635 DOI: 10.3748/wjg.v31.i4.100718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Revised: 11/27/2024] [Accepted: 12/09/2024] [Indexed: 12/30/2024] Open
Abstract
BACKGROUND Gastrointestinal (GI) vascular bleeding disorders pose significant clinical challenges due to their complex pathogenesis and varied treatment responses. Despite advancements in diagnostic and therapeutic techniques, optimal management strategies remain elusive, necessitating further research. AIM To assess research trends and clinical advancements in GI vascular bleeding disorders, highlighting key themes and therapeutic progress. METHODS A bibliometric analysis was conducted using the Web of Science Core Collection database, reviewing publications from 2000 to 2024 to identify trends, high-frequency keywords, and key contributions from leading research institutions. In addition, a case study highlighted the effective application of sirolimus in managing colonic angioectasia in a patient with recurrent GI bleeding who had not responded to previous treatments. RESULTS The analysis reviewed 470 scholarly articles from 203 countries, involving 2817 authors across 1502 institutions. The United States led in publication contributions, with strong collaborations with countries like China, England, and Germany. A significant trend was observed in the shift from traditional endoscopic interventions to pharmacological therapies, particularly highlighting the successful use of sirolimus in treating colonic angioectasia. High-frequency keywords such as "angiodysplasia", "colon", and "management" were identified, indicating key research themes. The study also noted a growing interest in drug therapies, as evidenced by the increasing prominence of keywords like "thalidomide" since 2018. CONCLUSION This study links bibliometric analysis and clinical insights, highlighting the shift to pharmacological management in GI vascular bleeding disorders to improve patient outcomes.
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Affiliation(s)
- Qi Sun
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Xiao-Ying Wang
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
- College of Life Science, Northwest University, Xi’an 710069, Shaanxi Province, China
| | - Dong-Hao Li
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Bai-Rong Li
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Xin-Zhuo Tu
- Department of Pathology, Air Force Medical Center, Beijing 100142, China
| | - Zhi-Meng Jiang
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Shou-Bin Ning
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
| | - Tao Sun
- Department of Gastroenterology, Air Force Medical Center, Beijing 100142, China
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Nomura K, Shibuya T, Terai Y, Omu R, Arii S, Yuzawa A, Ikeda Y, Uchida R, Sato S, Murata A, Sato S, Shimada Y, Maruyama T, Nomura O, Fukushima H, Murakami T, Ishikawa D, Hojo M, Genda T, Nagahara A. Small Intestinal Arteriovenous Malformation Treated by Double-balloon Endoscopy. Intern Med 2024; 63:2131-2135. [PMID: 38104993 PMCID: PMC11358740 DOI: 10.2169/internalmedicine.2588-23] [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: 07/11/2023] [Accepted: 10/24/2023] [Indexed: 12/19/2023] Open
Abstract
A 42-year-old man was referred to our hospital because of anemia. The patient underwent gastroscopy and colonoscopy, but no bleeding site was detected. Abdominal contrast-enhanced computed tomography (CT) showed vascular dilatation along the wall of the small intestine. Small bowel capsule endoscopy and antegrade double-balloon endoscopy (DBE) were performed, and the patient was diagnosed with a small intestinal arteriovenous malformation (AVM). The AVM was clipped using DBE. After clipping, abdominal contrast-enhanced CT and small bowel angiography revealed the disappearance of the AVM. DBE may be a viable therapeutic option, helping avoid surgery and its associated risks.
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Affiliation(s)
- Kei Nomura
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Yuichiro Terai
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Rifa Omu
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Shin Arii
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Arisa Yuzawa
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Yuji Ikeda
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Ryota Uchida
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Sho Sato
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Ayato Murata
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Shunsuke Sato
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Yuji Shimada
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Takafumi Maruyama
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Osamu Nomura
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Hirofumi Fukushima
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Dai Ishikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Mariko Hojo
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
| | - Takuya Genda
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Japan
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Nomura K, Shibuya T, Yuzawa A, Omori M, Odakura R, Koma M, Ito K, Kamba E, Maruyama T, Nomura O, Fukushima H, Murakami T, Ueda K, Ishikawa D, Hojo M, Nagahara A. Residual Recurrence of a Small Intestinal Capillary Hemangioma with Obscure Gastrointestinal Bleeding Treated by Double-Balloon Endoscopy: A Case Report and Literature Review. J Clin Med 2024; 13:3415. [PMID: 38929942 PMCID: PMC11204303 DOI: 10.3390/jcm13123415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/03/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024] Open
Abstract
An 86-year-old man presented with anemia. He underwent abdominal contrast-enhanced computed tomography, gastroscopy, and colonoscopy without any bleeding detected. Small bowel capsule endoscopy (SBCE) revealed a reddish polypoid lesion with blood oozing into the jejunum. Antegrade double-balloon endoscopy (DBE) revealed a 5 mm sized protrusion into the jejunum. Endoscopic mucosal resection (EMR) was difficult; the lesion was snared and resected before energization. Clips prevented further bleeding and the lesion's position was marked with a tattoo. Histopathological examination of the lesion led to a diagnosis of capillary hemangioma. After 11 months, the patient was again anemic. A reddish polypoid lesion oozing blood near the tattoo was found by SBCE. Another antegrade DBE showed a 7 mm sized protrusion near the tattoo. The lesion was successfully treated by EMR. Histopathological examination revealed the residual recurrence of a small intestinal capillary hemangioma. The patient recovered from anemia after the EMR. Two months later, SBCE showed no findings around the tattoo. Hemangiomas account for 7-10% of benign small intestinal tumors; most are cavernous hemangiomas, and capillary hemangiomas are rare. We report a rare case of a recurring small intestinal capillary hemangioma detected by SBCE and treated using DBE. We also review the literature.
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Affiliation(s)
| | - Tomoyoshi Shibuya
- Department of Gastroenterology, School of Medicine, Juntendo University, Bunkyo-ku, Tokyo 113-8421, Japan; (K.N.); (A.Y.); (M.O.); (R.O.); (M.K.); (K.I.); (E.K.); (T.M.); (O.N.); (H.F.); (T.M.); (K.U.); (D.I.); (M.H.); (A.N.)
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5
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Kim YS, Kwon JH, Han K, Kim MD, Lee J, Kim GM, Won JY. Superselective transcatheter arterial embolization for acute small bowel bleeding: clinical outcomes and prognostic factors for ischemic complications. Acta Radiol 2021; 62:574-583. [PMID: 32586121 DOI: 10.1177/0284185120936258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Small bowel bleeding (SBB) accounts for 5%-10% of all cases of acute gastrointestinal bleeding. Transcatheter arterial embolization (TAE) plays an important role in the treatment of SBB. PURPOSE To evaluate the safety and efficacy of superselective TAE exclusively for SBB and to assess factors associated with clinical outcomes. MATERIAL AND METHODS From January 2006 to April 2017, 919 patients were admitted with signs and symptoms of gastrointestinal bleeding; 74 patients (mean age = 57.5 years; age range = 14-82 years) with positive angiographic findings for SBB were retrospectively analyzed. The technical success of TAE and clinical outcomes, including recurrent bleeding, major complications, and in-hospital mortality were evaluated. The associations of various clinical and technical factors with clinical outcomes were analyzed. RESULTS The bleeding foci were in the ileum in 48 (65%) patients and the jejunum in 26 (35%). Technical success was achieved in 72 (97%) patients. The rates of recurrent bleeding, major complications, and in-hospital mortality were 12% (7/57), 21% (15/71), and 25% (18/72), respectively. Superselective embolization was a significant prognostic factor associated with fewer major complications (OR = 0.069; P = 0.003). The increased number of embolized vasa recta was significantly associated with a higher probability of major complications (OR = 2.64; P < 0.001). The use of N-butyl cyanoacrylate was associated with lower rates of major complication (OR = 0.257; P = 0.027). CONCLUSION TAE is a safe and effective treatment modality for SBB. In addition, whenever possible, TAE should be performed in a superselective manner to minimize ischemic complications.
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Affiliation(s)
- Yong Seek Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Radiology, Mediplex Sejong Hospital, 20, Gyeyangmunhwa-ro, Gyeyang-gu, Incheon, Republic of Korea
| | - Joon Ho Kwon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kichang Han
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Man-Deuk Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Junhyung Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gyoung Min Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Yun Won
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
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Causes and Clinical Characteristics of Small Bowel Bleeding in Northern Vietnam. Can J Gastroenterol Hepatol 2020; 2020:8884092. [PMID: 33313021 PMCID: PMC7721493 DOI: 10.1155/2020/8884092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/13/2020] [Accepted: 11/23/2020] [Indexed: 11/17/2022] Open
Abstract
AIM Causes, clinical features, and diagnostic approaches for small bowel (SB) bleeding were analyzed to derive recommendations in dealing with this clinical condition. METHODS We included 54 patients undergoing surgical treatment for SB bleeding, from January 2009 to December 2019. Detailed clinical data, diagnosis procedures, and causes of bleeding were collected. RESULTS Among 54 cases with SB bleeding, the most common causes were tumors (64.8%), followed by angiopathy (14.8%), ulcers (9.3%), diverticula (5.6%), tuberculosis (3.7%), and enteritis (1.9%). Most tumors (32/35 cases, 91.4%) and vascular lesions (8/8 cases, 100%) were located in the jejunum. The incidence of tumors was higher in the older (30/41 cases, 73.1%) than that in patients younger than 40 years of age (5/13 cases, 38.5%, P < 0.01). Common initial findings were melena (68.5%) and hematochezia (31.5%). The overall diagnostic yield of computed tomographic enterography (CTE) was 57.4% (31/54 cases), with the figures for tumors, vascular lesions, and inflammatory lesions being 71.4% (25/35 cases), 62.5% (5/8 cases), and 12.5% (1/8 cases), respectively. Double-balloon enteroscopy (DBE) definitively identified SB bleeding sources in 16/22 (72.7%) patients. CONCLUSION Tumors, angiopathy, ulcers, and diverticula were the most common causes of SB bleeding in Northern Vietnamese population. CTE has a high detection rate for tumors in patients with SB bleeding. CTE as a triage tool may identify patients before double-balloon enteroscopy because of the high prevalence of SB tumors.
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Abutalib H, Yano T, Shinozaki S, Lefor AK, Yamamoto H. Roles of Capsule Endoscopy and Balloon-Assisted Enteroscopy in the Optimal Management of Small Bowel Bleeding. Clin Endosc 2020; 53:402-409. [PMID: 32746537 PMCID: PMC7403027 DOI: 10.5946/ce.2020.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/01/2020] [Indexed: 02/06/2023] Open
Abstract
The small bowel had long been considered a dark unapproachable tunnel until the invention of capsule endoscopy and doubleballoon enteroscopy in the 21st century, which revolutionized the diagnosis and management of small bowel diseases, including bleeding. Various imaging modalities such as computed tomographic enterography, angiography, capsule endoscopy, and balloonassisted enteroscopy play vital roles in the diagnosis and management of small bowel bleeding. The choice of modality to use and timing of application differ according to the availability of the modalities, patient’s history, and physician’s experience. Small bowel bleeding is managed using different strategies as exemplified by medical treatment, interventional radiology, endoscopic therapy, or surgical intervention. Balloon-assisted enteroscopy enables endoscopic interventions to control small bowel bleeding, including electrocautery, argon plasma coagulation, clip application, and tattooing as a prelude to surgery. In this article, we clarify the recent approaches to the optimal diagnosis and management of patients with small bowel bleeding.
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Affiliation(s)
- Hani Abutalib
- Department of Gastroenterology, Beni-Suef University, Qism Bani Sweif, Egypt.,Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Tomonori Yano
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | | | | | - Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
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8
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Sey MSL, Yan BM. Optimal management of the patient presenting with small bowel bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101611. [PMID: 31785739 DOI: 10.1016/j.bpg.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
The management of small bowel bleeding, also known as obscure gastrointestinal bleeding, has changed substantially over the past two decades due to revolutionary technological advances in small intestinal endoscopy. This clinical review will summarize the evolving definition of small bowel bleeding, how to perform a detailed initial assessment of patients with the condition, the strengths and limitations of small bowel endoscopy, and the treatment of small bowel bleeding.
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Affiliation(s)
- Michael Sai Lai Sey
- Division of Gastroenterology, London Health Sciences Centre, Canada; Schulich School of Medicine and Dentistry, Western University, Canada; Program for Experimental Medicine, Western University, Canada.
| | - Brian Michael Yan
- Division of Gastroenterology, London Health Sciences Centre, Canada; Schulich School of Medicine and Dentistry, Western University, Canada
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9
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Almadi MA, Barkun AN. Patient Presentation, Risk Stratification, and Initial Management in Acute Lower Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2018; 28:363-377. [PMID: 29933781 DOI: 10.1016/j.giec.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The approach to lower gastrointestinal bleeding (LGIB) has evolved over the last few years to incorporate a multidisciplinary management strategy. Although the causes of LGIB vary depending on the age and comorbid conditions of patients, the initial resuscitation and principles of optimizing patients' condition before endoscopic evaluation, when appropriate, are the cornerstones to clinical care. The role of risk stratification is to triage patients as well as to mobilize health care resources based on predicted outcomes. Individualized management according to patients' comorbid conditions has been a focus in most recent guidelines.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.
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10
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Boonpipattanapong T, Attasaranya S, Kayasut K, Sangkhathat S, Ovartlarnporn B. An Uncommon Cause of Small Bowel Bleeding from Appendiceal Carcinoma. Case Rep Gastroenterol 2017; 11:250-255. [PMID: 28559785 PMCID: PMC5437429 DOI: 10.1159/000468512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/27/2017] [Indexed: 11/19/2022] Open
Abstract
Massive hematochezia caused by a small bowel lesion is a rare entity. Currently, video capsule endoscopy and balloon-assisted enteroscopy are effective in identifying the source of small intestine bleeding. Herein, we report a case of small bowel bleeding caused by a nonmucinous appendiceal adenocarcinoma with ileal invasion which was detected by video capsule endoscopy and single-balloon endoscopy. Despite the advanced disease stage with hepatic and peritoneal metastases, as of September 2016 the patient has had 8 years' disease-free survival after surgical resection and chemotherapy.
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Affiliation(s)
| | - Siriboon Attasaranya
- NKC Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kanita Kayasut
- Anatomical Pathology Unit, Department of Pathology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Surasak Sangkhathat
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Bancha Ovartlarnporn
- NKC Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Tseng CM, Lin IC, Chang CY, Wang HP, Chen CC, Mo LR, Lin JT, Tai CM. Role of computed tomography angiography on the management of overt obscure gastrointestinal bleeding. PLoS One 2017; 12:e0172754. [PMID: 28248993 PMCID: PMC5332096 DOI: 10.1371/journal.pone.0172754] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 02/09/2017] [Indexed: 12/22/2022] Open
Abstract
Background and aim The role of computed tomography angiography (CTA) on the management of acute overt obscure gastrointestinal bleeding (OGIB) remains unclear. We designed a study to evaluate the impact of CTA before enteroscopy for acute overt OGIB. Methods All patients undergoing CTA followed by enteroscopy for acute overt OGIB were enrolled in this retrospective study. Clinical characteristics and diagnosis were compared between patients with positive and negative CTA findings. We evaluated the impact of CTA on subsequent enteroscopy. Results From February 2008 to March 2015, 71 patients including 25 patients with positive CTA findings and 46 patients with negative CTA findings, were enrolled. All 25 patients with positive CTA findings were confirmed to have mid GI lesions, a significantly higher proportion than among patients with negative CTA findings (100% vs. 52.2%, respectively; P <0.001). CTA had a higher diagnostic yield for bleeding from tumor origin than from non-tumor origin (80.0% vs. 23.7%, respectively; P <0.001). The diagnostic yield of CTA and enteroscopy was 35.2% and 73.2%, respectively. The lesions could be identified by the initial route of enteroscopy in more patients with positive CTA findings than in those with negative CTA findings (92.0% vs. 47.8%, respectively; P <0.001). Lesions could be identified in seven of the 25 patients (28.0%) with positive CTA findings by using only push enteroscopy instead of single-balloon enteroscopy (SBE), but all 46 patients with negative CTA findings needed SBE for deep small-bowel examination. Conclusions CTA is useful in the diagnosis of acute overt OGIB, especially in patients with bleeding from tumors. In addition, it also can show the precise location of bleeding, and guide subsequent enteroscopic management.
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Affiliation(s)
- Chao-Ming Tseng
- Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan city, Taiwan
| | - I-Chang Lin
- Department of Radiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Chi-Yang Chang
- Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Hsiu-Po Wang
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan city, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Chih-Cheng Chen
- Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan city, Taiwan
| | - Lein-Ray Mo
- Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
- Division of Gastroenterology, Tainan Municipal Hospital, Tainan City, Taiwan
| | - Jaw-Town Lin
- Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
- School of Medicine and Big Data Research Centre, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chi-Ming Tai
- Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan city, Taiwan
- * E-mail:
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12
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Abstract
Since the introduction of double-balloon enteroscopy 15 years ago, flexible enteroscopy has become an established method in the diagnostic and therapeutic work-up of small bowel disorders. With appropriate patient selection, diagnostic and therapeutic yields of 70% to 85% can be expected. The complication rates with diagnostic and therapeutic DBE are estimated at approximately 1% and 3% to 4%, respectively. Appropriate patient selection and device selection, as well as skill, are the key issues for successful enteroscopy. However, technical developments and improvements mean that carrying out enteroscopy is likely to become easier.
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Affiliation(s)
- Andrea May
- Department of Gastroenterology, Sana Klinikum Offenbach GmbH, Starkenburgring 66, Offenbach am Main 63069, Germany.
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13
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Pasha SF, Leighton JA. Detection of suspected small bowel bleeding: challenges and controversies. Expert Rev Gastroenterol Hepatol 2016; 10:1235-1244. [PMID: 27366927 DOI: 10.1080/17474124.2016.1207525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Detection of small bowel (SB) bleeding remains a challenge to gastroenterologists, with a dearth of standardized recommendations regarding evaluation and management. Areas covered: A recursive literature search was performed using PubMed, Cochrane and Medline databases for original and review articles on SB and obscure gastrointestinal bleeding (OGIB). Based upon the available literature, this review outlines the main challenges and controversies, and provides a practical and cost-effective approach towards SB bleeding. Expert commentary: SB bleeding is suspected in patients with persistent or recurrent bleeding after negative bidirectional endoscopy, and unexplained iron deficiency anemia. Selection of test(s) should be individualized based upon patient presentation and suspicion for type of underlying lesion. Endoscopic or radiologic evaluation and treatment is the mainstay in the majority of patients, while pharmacologic agents may have a role in patients with refractory bleeding, and those unable to undergo evaluation.
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Affiliation(s)
- Shabana F Pasha
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
| | - Jonathan A Leighton
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
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Kwak MS, Cha JM, Han YJ, Yoon JY, Jeon JW, Shin HP, Joo KR, Lee JI. The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding. J Korean Med Sci 2016; 31:1611-6. [PMID: 27550490 PMCID: PMC4999404 DOI: 10.3346/jkms.2016.31.10.1611] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/28/2016] [Indexed: 01/01/2023] Open
Abstract
The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.
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Affiliation(s)
- Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea.
| | - Yong Jae Han
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Young Yoon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung Won Jeon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyun Phil Shin
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kwang Ro Joo
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Joung Il Lee
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Ou-Yang M, Jeng WD, Lai CC, Wu HM, Lin JH. Color calibration of swine gastrointestinal tract images acquired by radial imaging capsule endoscope. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:15010. [PMID: 26803670 DOI: 10.1117/1.jbo.21.1.015010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 12/30/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Mang Ou-Yang
- National Chiao-Tung University, Department of Electrical and Computer Engineering, 1001 University Road, Hsinchu City 30010, Taiwan
| | - Wei-De Jeng
- National Chiao-Tung University, Institute of Electrical Control Engineering, 1001 University Road, Hsinchu City 30010, Taiwan
| | - Chien-Cheng Lai
- LIYO-Machinery Company Limited, 39 Guangqi Road, Taichung City 42949, Taiwan
| | - Hsien-Ming Wu
- Chung-Shan Institute of Science & Technology, 481 Zhongzheng Road, Taoyuan City 32546, Taiwan
| | - Jyh-Hung Lin
- Animal Technology Institute Taiwan, Division of Biotechnology, 52 Kedung Road, Miaoli City 35053, Taiwan
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16
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The role of deep enteroscopy in the management of small-bowel disorders. Gastrointest Endosc 2015; 82:600-7. [PMID: 26253015 DOI: 10.1016/j.gie.2015.06.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 06/23/2015] [Indexed: 12/11/2022]
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17
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ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110:1265-87; quiz 1288. [PMID: 26303132 DOI: 10.1038/ajg.2015.246] [Citation(s) in RCA: 435] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/01/2015] [Indexed: 02/06/2023]
Abstract
Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.
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Liu YY, Pop R, Diana M, Kong SH, Lègner A, Beaujeux R, Marescaux J. Real-time fluorescence angiography by intra-arterial indocyanine green injection to identify obscure gastrointestinal bleeding territory: proof of concept in the porcine model. Surg Endosc 2015; 30:2143-50. [PMID: 26275550 DOI: 10.1007/s00464-015-4460-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/17/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Despite intensive preoperative localization workouts, intraoperative localization of the bleeding source in case of obscure gastrointestinal bleeding (OGIB) can be cumbersome and time-consuming. Our aim was to assess the feasibility of image-guided laparoscopic identification of the small bowel loop containing the bleeding source with and without near-infrared angiographic enhancement. MATERIALS AND METHODS Angiography of superior mesenteric artery (SMA) branches was performed in 11 pigs using a right femoral artery approach, followed by a three-port laparoscopy, using a near-infrared-equipped laparoscope. Two pigs were used to identify the optimal intra-arterial indocyanine green (ICG) dose. Eight pigs were divided into two groups: ICG near-infrared angiography-assisted laparoscopy (n = 4) and fluoroscopic-assisted laparoscopy (n = 4). Finally, in one pig, a novel OGIB model was created and used to evaluate the ICG enhancement pattern in the presence of active bleeding. RESULTS Mean time to identify the fluorescence signal from the small bowel segment fed by the catheterized SMA branch was 13.75 ± 7.8 s, which was statistically significantly shorter than the time required to identify the tip of the catheter by fluoroscopic guidance, i.e., 243.25 ± 107 s (p = 0.02). CONCLUSIONS Near-infrared fluorescence angiography using intra-arterial ICG injection provides a fast image-guided intraoperative localization of the small bowel loop fed by the arterial territory identified as bleeding by digital subtraction angiography and could help target the bleeding source during OGIB surgery.
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Affiliation(s)
- Yu-Yin Liu
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.,Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Raoul Pop
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Michele Diana
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France. .,IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France.
| | - Seong-Ho Kong
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Andras Lègner
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Rémy Beaujeux
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Jacques Marescaux
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.,IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
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Schlag C, Menzel C, Nennstiel S, Neu B, Phillip V, Schuster T, Schmid RM, von Delius S. Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results. Gastrointest Endosc 2015; 81:889-95. [PMID: 25432532 DOI: 10.1016/j.gie.2014.09.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/10/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND In mid-GI bleeding, video capsule endoscopy (VCE) shows the best diagnostic yield for ongoing overt bleeding. To date, the utility of VCE in acute severe GI bleeding has been analyzed rarely. OBJECTIVE To evaluate the impact of VCE when performed on patients with acute severe GI bleeding immediately after an initial negative upper endoscopy result. DESIGN Prospective study. SETTING Tertiary-care center. PATIENTS Patients with melena, dark-red or maroon stool, hemodynamic instability, drop of hemoglobin level ≥2 g/dL/day, and/or need of transfusion ≥2 units of packed red blood cells per day were included. INTERVENTIONS After a negative upper endoscopy result, emergency VCE was performed by immediate endoscopic placement of the video capsule into the duodenum. MAIN OUTCOME MEASUREMENTS Rate of patients in whom emergency VCE correctly guided further diagnostic and therapeutic procedures. RESULTS Upper endoscopy showed the source of bleeding in 68 of 88 patients (77%). In the remaining 20 patients (23%), emergency VCE was performed, which was feasible in 19 of 20 patients (95%; 95% confidence interval [CI], 75%-99%). Emergency VCE correctly guided further diagnostic and therapeutic procedures in 17 of 20 patients (85%; 95% CI, 62%-97%) and showed a diagnostic yield of 75% (95% CI, 51%-91%). LIMITATIONS Single-center study, small sample size. CONCLUSION In patients with acute severe GI bleeding and negative upper endoscopy results, emergency VCE can be useful for the immediate detection of the bleeding site and is able to guide further therapy. (Clinical trial registration number: NCT01584869.)
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Ohmiya N, Nakagawa Y, Nagasaka M, Tahara T, Shibata T, Nakamura M, Hirooka Y, Goto H, Hirata I. Obscure gastrointestinal bleeding: diagnosis and treatment. Dig Endosc 2015; 27:285-94. [PMID: 25559549 DOI: 10.1111/den.12423] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/24/2014] [Indexed: 02/08/2023]
Abstract
Small-bowel bleeding comprises a majority of obscure gastrointestinal bleeding, but is caused by various kinds of diseases. For its diagnosis, history-taking and physical examination is requisite, leading to a suspicion of what diseases are involved. Next, cross-sectional imaging such as computed tomography should be done, followed by the latest enteroscopy, videocapsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient conditions. After comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected.
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Affiliation(s)
- Naoki Ohmiya
- Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake
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21
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Evaluation of the Small Bowel and Colon. Gastrointest Endosc 2015. [DOI: 10.1007/978-1-4939-2032-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Navaneethan U, Vargo JJ, Menon KVN, Sanaka MR, Tsai CJ. Impact of balloon-assisted enteroscopy on the diagnosis and management of suspected and established small-bowel Crohn's disease. Endosc Int Open 2014; 2:E201-6. [PMID: 26135093 PMCID: PMC4423295 DOI: 10.1055/s-0034-1377522] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/10/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND AIMS The role of recently developed balloon-assisted enteroscopy (BAE) in small-bowel Crohn's disease (CD) is not well established. The purpose of this study is to determine the clinical impact of BAE on patients with suspected and established small-bowel CD. METHODS This study included 22 patients (group A) with suspected small-bowel CD and 43 patients (group B) with established small-bowel CD with or without previous surgery, who underwent BAE, in a prospective BAE registry of a US academic medical institution. All underwent abdominal imaging studies including computed tomography (CT) or magnetic resonance (MR) enterography before BAE. The main outcome measurements were diagnostic yield and clinical outcomes. RESULTS In total, 78 BAE procedures were carried out in 65 patients. In group A (n = 22, 25 BAE procedures), enteroscopy led to a diagnosis of CD in six patients (27.3 %). Non-steroidal anti-inflammatory drug-related enteropathy was diagnosed in three patients (13.6 %), whereas no lesions were found in the remaining 13 patients. In group B (n = 43, 53 BAE procedures) enteroscopy revealed active intestinal inflammation with ulcers and/or luminal stenosis in 18 patients (41.9 %), which led to a change and escalation of medical therapy. Five patients without active ulcers underwent successful dilation of small-bowel strictures with resulting resolution of obstructive symptoms. Of the 78 BAE procedures, two patients (2.6 %) had bleeding complications which were successfully treated conservatively. One patient (1.3 %) underwent surgery due to procedure-related perforation. CONCLUSIONS The use of BAE may help improve management in patients with suspected and established small-bowel CD.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - John J. Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - K. V. Narayanan Menon
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Madhusudhan R. Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Chung-Jyi Tsai
- Department of Gastroenterology and Hepatology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
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Sánchez-Capilla AD, De La Torre-Rubio P, Redondo-Cerezo E. New insights to occult gastrointestinal bleeding: From pathophysiology to therapeutics. World J Gastrointest Pathophysiol 2014; 5:271-283. [PMID: 25133028 PMCID: PMC4133525 DOI: 10.4291/wjgp.v5.i3.271] [Citation(s) in RCA: 4] [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: 03/11/2014] [Revised: 06/01/2014] [Accepted: 06/18/2014] [Indexed: 02/06/2023] Open
Abstract
Obscure gastrointestinal bleeding is still a clinical challenge for gastroenterologists. The recent development of novel technologies for the diagnosis and treatment of different bleeding causes has allowed a better management of patients, but it also determines the need of a deeper comprehension of pathophysiology and the analysis of local expertise in order to develop a rational management algorithm. Obscure gastrointestinal bleeding can be divided in occult, when a positive occult blood fecal test is the main manifestation, and overt, when external sings of bleeding are visible. In this paper we are going to focus on overt gastrointestinal bleeding, describing the physiopathology of the most usual causes, analyzing the diagnostic procedures available, from the most classical to the novel ones, and establishing a standard algorithm which can be adapted depending on the local expertise or availability. Finally, we will review the main therapeutic options for this complex and not so uncommon clinical problem.
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24
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Shinozaki S, Yamamoto H, Yano T, Sunada K, Hayashi Y, Shinhata H, Sato H, Despott EJ, Sugano K. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by double-balloon endoscopy. Gastrointest Endosc 2014; 80:112-7. [PMID: 24444670 DOI: 10.1016/j.gie.2013.11.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 11/18/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND GI bleeding secondary to small-intestine vascular lesions (SIVLs) is associated with rebleeding despite initial hemostasis by endotherapy applied at double-balloon endoscopy (DBE). OBJECTIVE To evaluate the long-term outcomes of DBE endotherapy of SIVL (as described by the Yano-Yamamoto classification). The impact of repeat DBE endotherapy for recurrent bleeding also was assessed. DESIGN Retrospective cohort study. The mean (± standard deviation [SD]) follow-up period was 4.9 (± 1.7) years (range 2.4-9.1 years). SETTING Tertiary-care referral center. PATIENTS A total of 43 patients, who underwent 69 sessions of DBE endotherapy of SIVLs. INTERVENTION DBE endotherapy. MAIN OUTCOME MEASUREMENTS Frequency of overt rebleeding after the initial DBE endotherapy. RESULTS Overt rebleeding occurred in 16 of 43 patients (37%). Patients with multiple SIVLs showed a significantly higher rate of overt rebleeding than did those with a solitary SIVL (12/23 [52%] vs 4/20 [20%]; P = .017). The trend toward frequency of rebleeding after the first DBE hemostasis appeared to be higher for patients with type 1a SIVLs than for those with type 1b or type 2 lesions: type 1a (8/16, 50%) versus type 1b (5/19, 26%) (P = .12) and type 1a (8/16, 50%) versus type 2 (2/7, 29%) (P = .31), respectively. In 12 of 16 patients (75%) who underwent repeat DBE endotherapy at each episode of overt rebleeding (median 3 times, range 2-6), the frequency of rebleeding decreased significantly after the first year of follow-up, as compared with the remaining 4 patients who did not undergo repeat DBE; mean (± SD) 0.12 (± 0.19) versus 0.52 (± 0.33) times per year per patient (P = .006). LIMITATIONS Single-center, retrospective study. CONCLUSION Although the presence of multiple SIVLs was associated with rebleeding, repeat DBE endotherapy resulted in an improved long-term outcome in patients with refractory SIVL bleeding.
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Affiliation(s)
- Satoshi Shinozaki
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Tomonori Yano
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Keijiro Sunada
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Yoshikazu Hayashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hakuei Shinhata
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hiroyuki Sato
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, London, United Kingdom
| | - Kentaro Sugano
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
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25
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The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79:875-85. [PMID: 24703084 DOI: 10.1016/j.gie.2013.10.039] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023]
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Abstract
The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.
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Affiliation(s)
- Deepak Gunjan
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder S Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepak K Bhasin
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Farnbacher MJ, Keles M, Meier M, Hagel A, Schneider T. Capsule endoscopy in a network cooperation: assessment of the experience in 822 patients. Scand J Gastroenterol 2013; 48:1088-94. [PMID: 23834066 DOI: 10.3109/00365521.2013.812678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Capsule endoscopy (CE) is firmly established as a standard procedure in the diagnostic algorithm of occult or obscure gastrointestinal bleeding and Crohn's disease. Despite its excellent diagnostic yield, missing expertise, reading time and financial expenditure limit an area-wide availability. A multicentric cooperation might compensate these disadvantages. METHODS CE device was bought by a central hospital (CH). Requested equipment is transported to the network partner (NP) and the procedure performed at the spot in personal responsibility. Video reading is exclusively done in the CH. RESULTS Within 10 years, 822 CE (438 m., 384 f.; 63 ± 17 (13-92) years) were performed by 18 cooperating gastroenterological departments. 587/822 (71%) CE were done at NP, 235/822 (29%) in the CH. Between 2002 (n = 39) and 2011 (n = 123) the annual number of CE increased threefold. 95% of the capital investment in each cooperating hospital could be avoided by sharing one workstation within the network. Leading indication for CE was suspected mid-GI-bleeding (80%). Mean latencies between requested date and actual examination were 0 and between equipment's return and report 2 days. 45/191(24%) flexible enteroscopies performed in the CH followed CE findings from NP. DISCUSSION Our 10 years experience show that mobile use of CE is feasible providing quality parameters similar to a single center solution, increases the number of CE investigations, therefore, improves reading expertise and enables both an area-wide and economic offer for this technique. Additionally, patients with the need for invasive enteroscopy are identified and attracted to that NP who provides an invasive SB endocopy device.
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Affiliation(s)
- Michael Julius Farnbacher
- Department of Medicine 2, Teaching Hospital Klinikum Fuerth, Friedrich-Alexander-University Erlangen-Nuremberg, 90766 Fuerth, Germany.
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Bonnet S, Douard R, Malamut G, Cellier C, Wind P. Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. Dig Liver Dis 2013; 45:277-84. [PMID: 22877794 DOI: 10.1016/j.dld.2012.07.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 06/25/2012] [Accepted: 07/06/2012] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Stéphane Bonnet
- Department of Digestive Surgery, Bégin University Military Hospital, Saint-Mandé, France
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29
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Abstract
Advances in small bowel enteroscopy have led to an increase in the endoscopic evaluation and management of small bowel disorders. The entire small bowel can now be visualized in a noninvasive manner by capsule endoscopy, while therapeutic management can be performed with deep enteroscopy techniques, including balloon-assisted and spiral enteroscopy. Each of these enteroscopy tools has its unique advantages and disadvantages, which need to be taken into consideration during selection of the appropriate tool. Capsule endoscopy and deep enteroscopy are often used as complementary tests in the evaluation of small bowel disorders.
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Affiliation(s)
- Shabana F Pasha
- Division of Gastroenterology, Department of Internal Medicine, Mayo Clinic College of Medicine, Scottsdale, AZ 85259, USA.
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30
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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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Abstract
PURPOSE OF REVIEW Gastrointestinal stents offer a feasible, safe, cost effective, and minimally invasive method for reestablishing luminal patency. Previous clinical reports and systematic reviews have demonstrated the role of enteral stents in both the upper and lower gastrointestinal tract. Over the last two decades, the rapid development of deep enteroscopy in concert with the evolution of various stent devices/deployment mechanisms has enabled placement of enteral stents in the mid-gut; hence this has been increasingly reported. The present article focuses on stenting in the mid-gut, a relatively novel term, referring to the small bowel between the ampulla and the ileocecal valve. RECENT FINDINGS Mid-gut stenting is technically more difficult than stenting in the upper and lower gastrointestinal tract, and therefore requires particular expertise, restricting its widespread utility. In total, 86 reported cases involving mid-gut stent deployment, by either endoscopic approaches (80.2%) or percutaneous approaches (19.8%), have been published. Although limited, these results have demonstrated that mid-gut stenting is reliable, effective, and a minimally invasive method for palliating malignant obstruction, as well as sealing leaks and fistulae. SUMMARY This article reviews the current status of mid-gut stenting, including endoscopic technique. The article also speculates about the potential for future advances within this field.
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Rondonotti E, Sunada K, Yano T, Paggi S, Yamamoto H. Double-balloon endoscopy in clinical practice: where are we now? Dig Endosc 2012; 24:209-19. [PMID: 22725104 DOI: 10.1111/j.1443-1661.2012.01240.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Double-balloon endoscopy (DBE) was developed in 2000 for the diagnosis and treatment of small bowel diseases. Although use rates still differ between Eastern and Western countries, DBE quickly reached a broad global diffusion. Together with capsule endoscopy (CE), DBE represented 'a revolution' for the management of small bowel diseases because of its therapeutic capabilities. At present, the main indications for DBE in clinical practice are obscure gastrointestinal bleeding, Crohn's disease and familial polyposis. In the setting of obscure gastrointestinal bleeding, DBE seems to have similar diagnostic performances as capsule endoscopy, but it allows for a more definitive diagnosis and the treatment of identified lesions. The main contribution of DBE in the management of Crohn's disease patients is its therapeutic capabilities. Indeed, several recently published studies have suggested that endoscopic dilation of small bowel strictures can delay or, in the near future, could even replace surgical interventions. Also, for patients with familial polyposis syndromes, DBE can represent a viable alternative to small bowel surgery. The complication rate of DBE appears to be low; major complications, such as pancreatitis, bleeding and perforation, have been reported in approximately 1% of all diagnostic DBE whereas the complication rate for therapeutic procedures is about 5%.
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Small bowel diagnostics: current place of small bowel endoscopy. Best Pract Res Clin Gastroenterol 2012; 26:209-20. [PMID: 22704565 DOI: 10.1016/j.bpg.2012.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 03/08/2012] [Indexed: 01/31/2023]
Abstract
The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Until the end of the last century, the small bowel follow through was the primary diagnostic tool for suspected small bowel disease. In recent years capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computerized tomography and magnetic resonance enteroclysis or enterography have facilitated the diagnosis, monitoring, and management of patients with small bowel diseases. These technologies are complementary, each with its advantages and limitations. In the present article, we will discuss the different options and indications for modern diagnostic methods for visualization of the small bowel. We also try to provide a clinical rationale for the use of these different diagnostic options in less established, newly emerging, indications for small bowel evaluation.
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Teshima CW. Small bowel endoscopy for obscure GI bleeding. Best Pract Res Clin Gastroenterol 2012; 26:247-61. [PMID: 22704568 DOI: 10.1016/j.bpg.2012.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 01/19/2012] [Indexed: 01/31/2023]
Abstract
Advancements in small bowel endoscopy have revolutionized the investigation and management of obscure GI bleeding. Capsule endoscopy and double balloon endoscopy, followed more recently by single balloon endoscopy and spiral enteroscopy, have progressed into established technologies that have now become integrated within clinical practice. As such, small bowel endoscopy research has matured to focus less on immediate endoscopic findings and ever increasingly on important clinical outcomes with long-term follow-up. The purpose of this paper is to review the role of small bowel endoscopy in obscure GI bleeding, while providing insights that may help guide clinicians in their decision-making.
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Affiliation(s)
- Christopher W Teshima
- Division of Gastroenterology, University of Alberta, 1-51 Zeidler Ledcor Centre, University of Alberta Hospital Edmonton, Alberta T6G 2X8, Canada.
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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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Pennazio M. Introduction to small-bowel bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012; 14:94-99. [DOI: 10.1016/j.tgie.2012.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Diagnostic yield of deep enteroscopy techniques for small-bowel bleeding and tumors. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2012.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Gupta T, Ibrahim M, Deviere J, Gossum AV. Evaluation of Fujinon intelligent chromo endoscopy-assisted capsule endoscopy in patients with obscure gastroenterology bleeding. World J Gastroenterol 2011; 17:4590-4595. [PMID: 22147964 PMCID: PMC3225095 DOI: 10.3748/wjg.v17.i41.4590] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 04/23/2011] [Accepted: 04/30/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the potential benefit of Fujinon intelligent chromo endoscopy (FICE)-assisted small bowel capsule endoscopy (SBCE) for detection and characterization of small bowel lesions in patients with obscure gastroenterology bleeding (OGIB). METHODS The SBCE examinations (Pillcam SB2, Given Imaging Ltd) were retrospectively analyzed by two GI fellows (observers) with and without FICE enhancement. Randomization was such that a fellow did not assess the same examination with and without FICE enhancement. The senior consultant described findings as P0, P1 and P2 lesions (non-pathological, intermediate bleed potential, high bleed potential), which were considered as reference findings. MAIN OUTCOME MEASUREMENTS Inter-observer correlation was calculated using kappa statistics. Sensitivity and specificity for P2 lesions was calculated for FICE and white light SBCE. RESULTS In 60 patients, the intra-class kappa correlations between the observers and reference findings were 0.88 and 0.92 (P2), 0.61 and 0.79 (P1), for SBCE using FICE and white light, respectively. Overall 157 lesions were diagnosed using FICE as compared to 114 with white light SBCE (P = 0.15). For P2 lesions, the sensitivity was 94% vs 97% and specificity was 95% vs 96% for FICE and white light, respectively. Five (P2 lesions) out of 55 arterio-venous malformations could be better characterized by FICE as compared to white light SBCE. Significantly more P0 lesions were diagnosed when FICE was used as compared to white light (39 vs 8, P < 0.001). CONCLUSION FICE was not better than white light for diagnosing and characterizing significant lesions on SBCE for OGIB. FICE detected significantly more non-pathological lesions. Nevertheless, some vascular lesions could be more accurately characterized with FICE as compared to white light SBCE.
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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: 182] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [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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Buscaglia JM, Okolo PI. Deep enteroscopy: training, indications, and the endoscopic technique. Gastrointest Endosc 2011; 73:1023-8. [PMID: 21429487 DOI: 10.1016/j.gie.2011.01.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 01/12/2011] [Indexed: 12/23/2022]
Affiliation(s)
- Jonathan M Buscaglia
- Department of Medicine, Division of Gastroenterology, Stony Brook University Medical Center, State University of New York at Stony Brook School of Medicine, Stony Brook, New York 11794, USA
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Abstract
Enteroscopy, defined as direct visualization of the small bowel (SB) with the use of a fiberoptic or wireless endoscope, has progressed considerably over the past several years. Technological advancements in the field have facilitated endoscopic evaluation of the SB. This comprehensive clinical review summarizes the latest modalities available to aid gastroenterologists in exploring the SB for evaluation of obscure gastrointestinal bleeding, tumors, inflammatory bowel disease, and celiac disease. Previous physical limitations in equipment that made a complete evaluation of the SB difficult have all but disappeared with the advent of capsule endoscopy, balloon-assisted enteroscopy, and spiral enteroscopy.
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Khashab MA, Lennon AM, Dunbar KB, Singh VK, Chandrasekhara V, Giday S, Canto MI, Buscaglia JM, Kapoor S, Shin EJ, Kalloo AN, Okolo PI. A comparative evaluation of single-balloon enteroscopy and spiral enteroscopy for patients with mid-gut disorders. Gastrointest Endosc 2010; 72:766-72. [PMID: 20619404 DOI: 10.1016/j.gie.2010.04.043] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 04/27/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) are recently described device-assisted techniques in endoluminal evaluation of the small bowel. No studies comparing SBE and SE in patients with suspected small-bowel disorders have previously been reported. OBJECTIVE The aims of this study were to compare SBE and SE in terms of diagnostic yield, procedure time, depth of maximal insertion, and complications. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS A retrospective analysis was performed on all patients at our institution undergoing anterograde SBE or SE between 2007 and 2009. Patients with altered anatomy or prior small-bowel surgery were excluded. INTERVENTION Deep enteroscopy. MAIN OUTCOME MEASUREMENT Diagnostic yield. RESULTS During the study period, 92 patients underwent 105 procedures (52 SBE, 53 SE). The most common indication for small-bowel endoscopy was obscure GI bleeding (n = 42). The diagnostic yield was not statistically different between SBE and SE (59.6% and 43.4%, respectively, P = .12). The overall diagnostic yield in patients with obscure GI bleeding was 67%. There was no significant difference between mean SBE and SE procedure times (53 minutes [range 15-99 minutes] vs 47 minutes [range 20-125 minutes], respectively; P = .2). The mean depth of maximal insertion beyond the ligament of Treitz for SE was significantly higher than that for SBE (301 cm [range 175-400 cm] vs 222 cm [range 110-400 cm], respectively; P < .001). Perforation occurred in one SBE procedure. LIMITATIONS Retrospective design and nonstandardized gas insufflation. CONCLUSION This is the first report comparing SE and SBE. Although SE yielded greater depth of maximal insertion than SBE, both techniques had similar diagnostic yields and procedure times. In addition, both techniques were safe and were particularly useful in patients with obscure GI bleeding.
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Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Greer SE, Gupta R. Lower gastrointestinal bleeding of unknown origin: tricks of the trade. Scand J Surg 2010; 99:103-5. [PMID: 20679046 DOI: 10.1177/145749691009900211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- S E Greer
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA
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Riccioni ME, Urgesi R, Spada C, Cianci R, Pelecca G, Bizzotto A, Costamagna G. Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy? Dig Liver Dis 2010; 42:560-6. [PMID: 20227929 DOI: 10.1016/j.dld.2010.01.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 01/11/2010] [Accepted: 01/29/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND In around 30% of iron deficiency anaemia (IDA) cases a definite diagnosis cannot be made. AIM To investigate the role of capsule endoscopy (CE) in detecting lesions in patients with unexplained IDA after a negative endoscopic, serologic and haematologic diagnostic work up and its possible role in influencing clinical outcome. METHODS 138 patients suffering from IDA were identified among 650 consecutive patients undergoing CE at our unit. RESULTS CE revealed the following positive findings in 91/138 patients: angiodysplasias in 51 patients; jejunal and/or ileal micro-ulcerations in 12; tumours/polyps in 9; erosive gastritis in 4; Crohn's disease in 5; jejunal villous atrophy in 5; a solitary ileal ulcer in 1 and active bleeding in the last 4 patients. Follow up data were available for 80/91 patients (87.9%). In 15 out of 46 patients with angiodysplasias IDA spontaneously resolved without any treatment; 9 patients required iron supplementation; 10 patients healed after lanreotide administration; APC was performed in 9 out of 46 patients and 3 patients underwent regular blood transfusion without any success on IDA. 10 out of the 12 patients with small bowel micro-ulcers spontaneously recovered from IDA whilst 2 patients after iron supplementation. All 9 patients affected by tumours/polyps were surgically addressed. In all erosive gastritis cases, patients recovered from IDA after PPI and Helicobacter pylori eradication. Four patients with Crohn's disease diagnosis restored to health with medical therapy. One out of the 4 patients with jejunal villous atrophy and the sole patient with a solitary ileal ulcer spontaneously healed. In 1 out of 3 patients with active bleeding IDA resolved without further treatment after blood transfusion whilst 2 patients were referred for surgical treatment. At follow up, complete resolution of IDA was achieved in 96.25%. CONCLUSIONS Small bowel investigation is a matter of great importance in IDA patients after negative upper and lower gastrointestinal endoscopy.
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Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010; 105:575-81. [PMID: 20051942 DOI: 10.1038/ajg.2009.712] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Double-balloon enteroscopy (DBE) is now an established method for diagnostic and therapeutic small-bowel endoscopy. Single-balloon enteroscopy (SBE) has been introduced to simplify the technique. A prospective randomized study was carried out to compare the two methods. METHODS The study included 100 patients (50 in each group; 63 men, 37 women; mean age 55 years), with no previous small-bowel or colon surgery. The indications for enteroscopy were (suspected) mid-gastrointestinal bleeding, Crohn's disease, small-bowel masses, chronic diarrhea or abdominal pain or both, and other conditions. Fujinon instruments were used, with either two balloons or one. The end point of the study was complete enteroscopy as the most objective parameter. RESULTS No severe complications such as perforation, bleeding, or pancreatitis occurred. Instrument preparation time was significantly faster with SBE than with DBE (P<0.0001). Complete enteroscopy was achieved with the DBE technique in 66% of cases (33 patients), either with the oral route alone or with combined oral and anal approaches. With the SBE technique, the complete enteroscopy rate was significantly lower at 22% (P<0.0001; 11 patients, only with oral and anal routes combined). The rate of therapeutic consequences for the patients based on diagnostic yield and negative complete enteroscopy was significantly higher (P=0.025) in the DBE group at 72%, compared with 48% in the SBE group. CONCLUSIONS The complete enteroscopy rate was three times higher with DBE than with SBE, accompanied by a higher diagnostic yield. DBE must therefore continue to be regarded as the nonsurgical gold standard procedure for deep small-bowel endoscopy.
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Akute gastrointestinale Blutungen. Notf Rett Med 2010. [DOI: 10.1007/s10049-009-1192-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Singh V, Alexander JA. The evaluation and management of obscure and occult gastrointestinal bleeding. ACTA ACUST UNITED AC 2009; 34:311-9. [PMID: 18581161 DOI: 10.1007/s00261-008-9423-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastrointestinal (GI) bleeding is a common clinical presentation increasing in an aging population, frequently requiring hospitalization and emergent intervention, with significant morbidity, mortality, and costs. It may manifest overtly as hematemesis, melena, or hematochezia, or as an asymptomatic occult bleed. Management typically involves an esophagogastroduodenoscopy or a colonoscopy; these in combination sometimes do not identify a source of bleeding, with the source remaining obscure. Further work up to identify an obscure source frequently requires radiologically detecting the leakage of an intravascular tracer (using tagged red blood cells or angiography) with brisk bleeding or in other cases CT enterography (CTE) to detect bowel wall changes consistent with a bleeding source. Recent advances including capsule endoscopy, CTE, and double-balloon endoscopy have helped to identify bleeding sources beyond the reach of conventional endoscopy. Clinical decision-making about their use is complex and evolving. Knowing their relative merits and weaknesses including yield, contraindications, complications, and cost is essential in coming up with an appropriate management plan. This review covers the rationale for clinical management of obscure sources of GI bleeding, mentioning the approach to and the yield of conventional methods, with an emphasis on the recent advances mentioned above.
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Affiliation(s)
- Vijay Singh
- Department of Internal Medicine, Division of Gastroenterology, Miles and Shirley Fiterman Center for Digestive Diseases, Rochester, MN 55905, USA
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Abstract
INTRODUCTION Anemia although a frequent problem in all age groups, is an important cause of morbidity and mortality in the elderly. Despite standard endoscopic diagnostic evaluations with esophagogastroduodenoscopy (EGD) and colonoscopy, up to 30% of patients with iron deficiency anemia (IDA) are without a definitive diagnosis. Obscure gastrointestinal bleeding (OGIB) (occult or overt) from the small bowel, could be the source of IDA in patients with normal EGD and colonoscopy. Wireless capsule endoscopy (WCE), a relatively new diagnostic modality helps in the detection of small bowel mucosal abnormalities. AIM The aim of this study is to report on the diagnostic yield (DY) of WCE for IDA with or without OGIB in older adults and its comparison with younger age groups. MATERIALS AND METHODS In this retrospective study, data is based on652 consecutive WCE performed during a 5-year period (2002 to 2007). RESULTS Total number ofWCE=652 (males=311, females=341). IDA was the indication for WCE in 424 of 652 cases (65%). Most common finding observed by WCE in patients with IDA without OGIB: group 1 (age<50 y)=small bowel erosion (19%) and ulceration (19%), group 2 (age 50 to 64 y)=small bowel erosion (33%), group 3 (age 65 to 85 y, older adults)=small bowel erosion (30%), and group 4 (age>85 y, the oldest old)=small bowel erosion (38%). Most common finding observed by WCE in patients with IDA with OGIB: group 1=small bowel ulceration (19%), group 2=small bowel erosion (26%), group 3=small bowel erosion (38%), and group 4=angiodysplasia (55%). DY of WCE for IDA without OGIB: group 1=50%, group 2=52%, group 3=56%, and group 4=69%. DY of WCE for IDA with OGIB: group 1=38%, group 2=58%, group 3=63%, and group 4=73%. Active bleeding in the small bowel was seen in 48 of 424 (11%) patients with IDA. CONCLUSIONS WCE, a valuable tool for the visualization of entire small bowel mucosa plays a critical role for the evaluation of IDA in patients with negative EGD and colonoscopy. Small bowel erosions, ulcerations, and angiodysplasia observed by WCE are the most frequent findings in patients with IDA. DY of WCE in the evaluation of IDA progressively increases as age advances.
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Xin L, Liao Z, Li ZS. Comparison of capsule endoscopy with other imaging modalities in small bowel. Shijie Huaren Xiaohua Zazhi 2009; 17:1972-1977. [DOI: 10.11569/wcjd.v17.i19.1972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Until only a few years ago, most of the small bowel was beyond the range of conventional examinations because of its special anatomical position. The advent of capsule endoscopy (CE) represents a significant breakthrough for non-invasive and visual diagnosis of diseases in the small bowel. Since CE permits direct acquisition of images from the mucosa with high sensitivity and safety, it has become an important tool for diagnosis and surveillance of obscure gastrointestinal bleeding, Crohn's disease, familial adenomatous polyposis and other small bowel diseases. However, CE also has some weakness such as low specificity and risk of retention. In this review, we will compare CE with other imaging modalities in small bowel.
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