Diagnostic and Therapeutic Value of Balloon Assisted Enteroscopy in Patients with Suspected Small Bowel Acute-Overt GI Bleeding

Abstract

Background: Balloon assisted enteroscopy (BAE), using double balloon (DBE) or single balloon enteroscopy (SBE), is currently the standard endoscopic investigation for the small bowel. In patients with overt-occult gastro-intestinal (OGIB) BAE has an established place in the diagnostic and therapeutic algorithm. About the role of BAE in patients with acute-overt bleeding little is known so far. The aim of this study was to evaluate the diagnostic and therapeutic outcome of BAE in case of acute-overt GI bleeding. Methods: Retrospectively, all patients referred for BAE with suspicion of small bowel acute-overt GI bleeding were included. Patient characteristics, prior investigations, BAE procedure related data and outcome were evaluated. An acute-overt bleeding was defined as hematemesis, rectal blood loss and/or melena. Results: In the period 2005-2008 in 22 patients had BAE for acute-overt GI bleeding: 12 males, mean age 65 (35-87) years. All patients had negative upper- en ileocolonoscopy. Clinical presentation was rectal blood loss in 11 (50%), melena and blood cloths in 7 (32%) and hematemesis and melena in 4 (18%) patients. In 18 (82%) transfusion was necessary; 11 (50%) patients presented with hemodynamic instability. Mean hemoglobin at presentation was 7.0 (5.3-10.1) g/dL (mean MCV 88). In 11 (50%) patients use of NSAID's, steroids and/or oral anticoagulation was reported. The enteroscopes used were diagnostic DBE in 12, therapeutic DBE in 7, and SBE in 3 patients. Mean insertion depth was proximal 247 (130-400) cm and distal 96 (30-150) cm. During BAE a likely cause of bleeding was found in 10 (45%) patients: in 4 (40%) tumoreus laesions (2 GIST and 2 adenocardinoma), in 4 (40%) vascular abnormalities (3 angiodysplasia and 1 jejunal varices), and 2 Dieulafoy-like-lesions were found. The pathologic findings were all located in the jejunum: 5 proximal and 5 in the mid-distal jejunum. Endoscopic therapy was applied in 6 (60%) patients, 4 patients had surgery. Two patients died due to other causes, all other patients were symptom free at mean follow-up of 23 (3-38) months. In 5 (23%) patients, wireless capsule endoscopy (WCE) was performed before BAE: in 1 case WCE was true positive, WCE was false negative in 3 cases (1 angiodysplasia and 2 tumors) and in 1 case false positive. Conclusion: BAE found the source of GI bleeding in nearly half of patients presenting with an acute-overt GI bleeding, with an initial negative upper- and lower endoscopy. Cause of bleeding could be treated endoscopically in majority of patients. The sensitivity for detection of acute small bowel bleeding seems higher for BAE as compared to WCE.