Retrograde Per Anal Double Balloon Enteroscopy (rDBE) Is a Successful Technique for the Diagnosis and Therapeutic Intervention of a Wide Variety of Small Intestinal Luminal Lesions

Abstract

Background/Aims: Double balloon enteroscopy (DBE) has emerged as a useful endoscopic technique for the diagnosis of, and intervention for, a wide range of luminal pathology, including obscure GI bleeding, inflammatory bowel disease, celiac disease, lymphoma, and vascular lesions. Antegrade (oral) DBE remains the most common approach to the evaluation of the small bowel. The major objectives of this study are to describe our experience with retrograde DBE (rDBE) with regard to procedural success, diagnostic yield, and therapeutic intervention. Methods: A single center retrospective chart review of 72 consecutive patients who underwent rDBE from January 2005 to November 2007. Results: In this study, 38 patients were female (53%), with a mean age of 60 ± 18.1 years (range 17-91 y). The most common indications for rDBE were obscure overt (n = 30, 41.7%) and obscure occult hemorrhage (n = 16, 22.2%). Other indications included polyp or mass (n = 9, 12.5%), mucosal changes including erosions or nodularity (n = 6, 8.3%), stricture (n = 4, 5.6%), angioectasias/vascular abnormalities (n = 3, 4.2%), and altered bowel habits/suspected Crohn's disease (n = 3, 4.2%). Mean procedure duration was 115 ± 16.5 minutes (range 90-165 min). The DBE system was successful in reaching the proximal ileum in 17 patients (23.6%), the mid-ileum (n = 40, 55.6%), the distal ileum (n = 7, 9.7%), the mid-jejunum (n = 2, 2.8%), and the distal jejunum (n = 5, 6.9%). The success rate for small bowel intubation was 98.6%. Findings included angioectasia/vascular lesions (n = 10, 13.9%), mucosal changes (n = 10, 13.9%), ulcers (n = 5, 7%), polyps (n = 3, 4.2%), strictures (n = 3, 4.2%), diverticula (n = 2, 2.8%), and fresh blood (n = 1, 1.4%). Normal variants (including lymphoid hyperplasia or dilated lacteals) were noted in 3 cases (4.2%), and non-small bowel findings (e.g., hemorrhoids or colon polyps) in one (1.4%). Interventions were performed in 38 patients (52.8%), including argon plasma coagulation for angioectasia or overt bleeding (n = 11, 15.3.%), other hemostatic techniques (n = 2, 2.8%), and balloon dilation of strictures (n = 4, 5.5%). Tattoo marking of the proximal extent of the examination was performed in 9 cases (12.5%). Conclusions: In our experience with more than 70 patients over the past 2 years, rDBE is successful in reaching the small intestine in the vast majority of cases. We demonstrate that rDBE is useful for a variety of indications. Mucosal findings were diagnosed in nearly 50% of patients leading to either biopsy or therapeutic intervention. This series highlights the increasing utility of DBE in general, particularly from the retrograde approach for distal small bowel lesions.