Usefulness of Double-Balloon Enteroscopy for Gastrointestinal Bleeding of Obscure Origin

Abstract

Background: Bleeding of the small bowel is often severe, although its incidence is lower than that of the stomach or colon. Bleeding of the stomach or colon is usually diagnosed without difficulty by means of upper gastrointestinal (GI) endoscopy or colonoscopy; however, because of the difficulty of approach, it has not been easy to identify bleeding sources in the small bowel. A new double-balloon enteroscopy (DBE) method has been developed, making it possible to examine the entire small bowel and to treat some small bowel lesions endoscopically. The aim of this study was to evaluate the usefulness of DBE for patients with GI bleeding of obscure origin. Patients and Methods: DBE was performed in 118 patients (213 examinations) at Hiroshima University Hospital between August 2003 and September 2005. Of these patients, 82 consecutive patients (43 men and 39 women; mean age, 57.3 years) who complained of GI bleeding for which the origin could not be detected by upper GI endoscopy and colonoscopy were enrolled in this study. We evaluated the detectability of the bleeding sources. In addition the final outcome, i.e., whether the bleeding stopped, was evaluated in 23 patients who were available for follow-up (mean follow-up, 8.3 months after DBE). Results: In 50 of the 82 patients (61.0%), DBE revealed the bleeding sources. The bleeding source was located outside the small bowel in 5 patients (duodenum, n = 3; colon, n = 2). In 2 patients, the lesions were not detected by DBE but were revealed by subsequent surgical resection. In these 2 patients, it was difficult to perform DBE because of abdominal adhesions. Among the 45 patients in whom DBE revealed lesions within the small bowel, inflammatory lesions, neoplastic lesions, vascular lesions, and a metabolic lesion were revealed in 22 (48.9%), 16 (35.6%), 6 (13.3%), and 1 (2.2%) patient, respectively. In only 19 patients (42.2%), lesions were detected by other screening modalities (ultrasonography, computed tomography, and/or enteroclysis) before DBE. Medical treatment including endoscopic treatment for 28 patients and surgical treatment for 13 patients was undertaken. In the remaining 4 patients, no treatment was given. In 2 of the 23 patients (91.3%) who were followed up, anemia progressed. One of these 2 patients had multiple bleeding sites and suffered from amyloidosis; the other patient suffered from Osler disease, and the anemia was thought to be due to refractory nasal bleeding. In the other 21 patients, bleeding stopped and anemia improved. Conclusions: DBE appears to be useful in cases of GI bleeding of obscure origin, not only for detecting the small bowel lesions but also in providing treatment.