Therapeutic Double Balloon Enteroscopy Reduces Transfusion Requirements in the Management of Occult or Obscure Gastrointestinal Bleeding

Abstract

Introduction: Patients with occult or obscure gastrointestinal (GI) bleeding can be challenging to manage. Double Balloon Enteroscopy (DBE) is a novel procedure enabling therapeutic interventions within most of the small bowel. Further research regarding the clinical impact of these interventions is needed. Aim: To evaluate the impact of therapeutic DBE on packed red blood cell transfusion requirements in patients with occult or obscure GI bleeding. Methods: This is a retrospective review of patients who underwent DBE at two tertiary care centers from 5/07 to 10/08 with a focus on patients who had therapeutic endoscopic interventions for occult or obscure GI bleeding. A Student's T-test and Chi square analysis were used for comparison of samples with significance considered if the P value was less than 0.05. Results: There were 77 patients, mean age 64 years (14-89), who underwent DBE in the 18 month period. Of the 77 patients, 70 had occult or obscure GI bleeding. Forty-seven (67%) of the 70 patients had endoscopic findings potentially accounting for the blood loss. These small bowel lesions varied in location from the mid-Jejunum to proximal-mid Ileum and were out of reach via standard small bowel enteroscopy or colonoscopy with Ileoscopy. Forty patients had arterio-venous malformations(AVMs), 4 patients had small bowel ulcerations, 1 patient had celiac disease, 1 patient had a bleeding small bowel (mid-Ileum)polyp and 1 patient had bleeding jejunal diverticula. Forty-two (60%) of the 70 patients had therapeutic DBE interventions including argon plasma coagulation (N=41), hemoclip placement (N=3) and snare polypectomy (N=1). Among the patients with therapeutic interventions, there was a statistically significant per patient decrease in the amount of blood units transfused during the preceding 6 months, [mean 1.8 units (range = 0-20)] compared to the 6 months after the DBE exam, [mean 0.3 units (range = 0-5)]; (P=0.04). There were 3 patients who had post procedure GI bleeding within 30 days after therapeutic DBE; all were managed conservatively. This was not significantly higher compared to the group of patients who did not have a therapeutic intervention (P = 0.17). Conclusions: 1) Therapeutic DBE results in a long-term and clinically significant beneficial outcomes among patients with occult or obscure GI bleeding as noted by a decrease need for red blood cell transfusion requirements. 2) AVMs are the most commonly treated lesion in patients with occult or obscure GI bleeding. 3) Therapeutic DBE is a safe procedure. 4) Gastroenterologists who perform DBE need to be aware of the its potential therapeutic benefits.