Additional Value of Distal DBE in Patients with Occult GI Bleeding and Normal Findings On Previous Incomplete Proximal DBE

Abstract

Background: Double balloon enteroscopy (DBE) is currently the standard endoscopic investigation when small bowel pathology is suspected. In patients with occult gastro-intestinal (GI) bleeding, gastric and colonic pathology has been previously excluded by gastroduodeno- and ileocolonoscopy (mostly in repeated fashion). In 50 - 70% of these patients the cause of the GI blood loss can be find using wireless capsule endoscopy (WCE) and / or DBE. Angiodysplasia are the most common cause of occult GI bleeding in the small bowel. The majority of these angiodysplasia are located in the proximal small bowel and can be detected, and treated, by the proximal DBE approach. In patients with occult GI bleeding and normal findings at proximal DBE, without visualization of the entire small bowel, a distal DBE approach is considered. Aim: To establish the additional value of a distal DBE procedure, following a proximal approach, in patients with occult GI bleeding. Methods: From our DBE-database all patients referred for occult GI bleeding, and who had a proximal DBE followed by a distal DBE procedure, were retrospectively included in this study. All patients had gastroduodenoscopies and ileocolonoscopy prior to DBE. None of the patients had WCE before DBE. Excluded from evaluation were patients presenting with overt GI blood loss and patients in which introduction of the distal ileum failed during distal DBE. Results: Thirty-one patients had both a proximal and distal DBE for occult GI bleeding; 1 patient was excluded because of failure to intubate the distal ileum. In 2 patients a WCE was performed before the DBE. Thirty patients were eligible for evaluation: M/F 19/11, mean age 58 (18 - 65) yrs, mean Hb 10,5 g/dl. Mean introduction on proximal DBE was 286 (130 - 340) cm, and 102 (20 - 200) cm on the distal procedure. In 2 patients (7 %) a complete visualization of the small bowel was achieved (both combined procedures, using ink for marking). In 8 patients (27 %) significant lesions were found during distal DBE procedure: 4 patients with angiodysplasia, 3 patients with ulcerations (pathology: suggestive for chronic inflammation) and in 1 patient a Meckel's diverticulum. In 2 patients (7 %) a pathologic finding was identified in the colon (2 times angiodysplasia). Conclusion: In 27% of patients with occult GI bleeding, a (likely) cause of blood loss was identified in the distal part of the small bowel using the distal DBE route. These data suggest that in patients with occult GI blood and persistent complaints after a negative proximal DBE, without visualization of the entire small bowel, an additional distal DBE has to be considered.