Outcome of Double-Balloon Enteroscopy After Capsule Endoscopy in Patients with Suspected Small-Bowel Disease

Abstract

Capsule endoscopy (CE) is a purely diagnostic method with no capability to sample tissue or perform therapy. Double-balloon enteroscopy (DBE), offers the potential for complete small-bowel examination and treatment of previously-inaccessible lesions. Aims: The study assessed technical and clinical outcomes of DBE in patients (pts) previously submitted to CE and with suspected small-bowel disease. Methods: Between January and November 2005,44 pts. were enrolled (30 men; mean age 58 yrs) who were suffering from obscure bleeding (28),polyposis syndromes (10), refractory celiac disease (2),or suspected Crohn's disease (4). The double-balloon enteroscope (Fujinon EN-450P5/20) was used. The choice of first approach with DBE (oral or anal) was made on the basis of CE findings. DBE was performed under sedoanalgesic medication,and the small-bowel examination progressed until either a lesion was discovered or scope progression was blocked.If the suspected lesion had not been reached,the small-bowel mucosa was marked with a tattoo at the most distal site reached during oral DBE or at the most proximal site during transanal DBE,and a second procedure was performed through the opposite route the following day. Fluoroscopy was used whenever endoscope progression was blocked during insertion. Results: 30 out of 44 pts.had CE findings located only in the jejunum: AVMs (6), mass (6), ulcers (6), polyps (6), hyperemic mucosa (6). 8 out of 44 had CE findings located only in the ileum: AVMs (2), polyps (4), mass (2). 6 pts. had CE findings located both in the jejunun and in the ileum: AVMs (4), polyps (2). A total of 62 DBE procedures were carried out in the 44 pts: 30 (48%) through the oral route alone, 8 (13%) through the anal route alone, and 24 (39%) through both routes. DBE through the anal approach was not possible in two pts. On an average 220 ± 85 cm (60-350) small bowel were visualized using the oral route and 115 ± 80 cm (35-270) using the anal route. The mean duration of examinations was 79 ± 23 min (30-135) through the oral route, and 88 ± 21 min (50-130) through the anal route. No complications were recorded. In comparison with the CE findings, the prior diagnosis was confirmed by DBE in 77% of pts; a new diagnosis was made in 14%; a suspected diagnosis was excluded in 9%. The DBE findings played a role in subsequent treatment in 32 (73%) of 44 pts. Endoscopic treatments were carried out in 14 (44%); 14 (44%) pts. were referred for surgery and medical treatment was started in 4 (12%). Conclusions: DBE is a useful tool for the further characterization and management of small-bowel lesions suspected at capsule examination. Prior CE can help to decide which approach should be attempted first with DBE.