Anterograde Double-balloon Enteroscopy Research Articles

S1097 Clinical Outcomes of Double Balloon Enteroscopy: An 8-Year Tertiary Center Experience

Introduction: The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting 6-month readmission Methods: We conducted a retrospective cohort study of patients (n=1162) who underwent DBE at an academic tertiary care center between November to December 2020. Baseline patient data as well as DBE related variables were collected. Outcome variables included readmission rates, diagnostic and therapeutic yield. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and student 2 sample t-test were performed to compare patient characteristics. Logistic regression was used for outcome variable analysis. Results: Of the 1162 DBE procedures, 50.95% were male (n= 592) with a mean age of 61.29 (15.33, SD). The most common indications for procedure being GI bleed (61%) and abnormal video capsule endoscopy findings (30%). The cohort’s rate of positive diagnostic yield was 65% and 57% for therapeutic yield. The mean procedural time was 39.80 (21.31, SD) minutes, and 77% of DBE patients received anterograde procedures. Compared to retrograde procedures, a higher proportion of DBE patients with anterograde procedures had positive diagnostic yield (66% vs. 62%, p=.254) (Table). Readmission rates at 30 days and 6 months were 11% and 18% respectively. Anterograde procedures were more likely to be inpatient (37% vs 29%, p=0.018) and associated with shorter procedure time (38.67 ± 204.5 vs 43.7 ± 23.7 minutes, p=0.0008) and higher therapeutic yield (60% vs 46%, p=0.00) ( Figure). Univariate analysis depicted inpatient status, total procedure minutes, and anticoagulation use to be associated with 6-month readmission (all P< 0.05). After controlling for each variable through multivariable analysis, inpatient status [OR:3.56, 95% CI (2.59-4.89), p=0.00] and total procedure minutes [OR:1.01, 95% CI (1.00-1.01), p=0.03] remained significant predictors of 6-month readmission Conclusion: DBE procedures has high efficacy for both diagnostic and therapeutic yield while evaluating GI bleed, abdominal pain, iron deficiency anemia, as well as performing ERCP in patients with altered upper GI anatomy. Patients undergoing anterograde DBE are associated with shorter procedure time and higher therapeutic yield compared to patients undergoing retrograde DBE. DBE patients who are inpatients and higher procedural times are more likely to be readmitted in 6 months.Figure 1.: Univariate and Multivariable Logistic Regression Analysis predicting 6-month readmission rate Table 1. - Patient characteristics and outcome variables stratified based on procedure type (anterograde vs retrograde) Variable Anterograde (n=900) Retrograde(n=262) P-Value Sex Male 459 (51%) 133 (51%) .95 Female 441 (49%) 129 (49%) Age, Range: 35-93, Mean (SD) 61.17 (15.30) 61.69 (15.49) .629 Patient Type Outpatient 571 (63%) 187 (71%) .018 Inpatient 329 (37%) 75 (29%) BMI Less than 25 304 (34%) 77 (29%) .183 25 or more 596 (66%) 185 (71%) Altered Anatomy No 695 (77%) 234 (89%) .000 Yes 205 (23%) 28 (11%) Anticoagulation No 780 (87%) 230 (88%) .636 Yes 120 (13%) 32 (12%) ESRD No 858 (95%) 247 (94%) .485 Yes 42 (5%) 15 (6%) Anesthesia Type General 809 (90%) 97 (37%) .000 Mac 91 (10%) 165 (63%) Total procedural time Mean (SD) 38.67 (20.45) 43.70 (23.70) .0008 Therapeutic Yield No 361 (40%) 141 (54%) .000 Yes 539 (60%) 121 (46%) Positive Finding No 305 (34%) 99 (38%) .244 Yes 595 (66%) 163 (62%) Readmission 30-day No 791 (88%) 238 (91%) .187 Yes 109 (12%) 24 (9%) Readmission 6 Month No 731 (81%) 219 (84%) .383 Yes 169 (19%) 43 (16%)

Bleeding Lesion from Roux-en-Y Hepaticojejunostomy: A Successful Combined Hemostasis with Dual Emission Laser 1.9/1.5 μm.

A 28-year-old woman, with a history of liver transplantation with Roux-en-Y hepaticjejunostomy, was admitted for melena and severe anemia. Bidirectional endoscopy was normal. Capsule endoscopy demonstrated fresh blood in the efferent limb downstream of the jejuno-jejunostomy. Anterograde double-balloon enteroscopy (DBE) showed an adherent clot with a visible vessel oozing next to the hepaticojejunostomy. Bleeding was treated firstly with argon plasma coagulation and endoclips and further treated with dual emission laser, achieving complete hemostasis. At the 3 months follow-up, hemoglobin was stable without evidence of re-bleeding.

2582 Diagnosis of Meckel's Diverticulum With Double Balloon Enteroscopy

INTRODUCTION: Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal (GI) tract, present in 2-4% of the population. Typically, it presents as GI bleeding and is usually diagnosed in childhood. However, some patients may remain asymptomatic through adulthood or present later in life with complications. We describe an unusual case of an adult male presenting with abdominal pain and maroon stools, who underwent an extensive workup and was eventually diagnosed with MD only after a double-balloon enteroscopy (DBE). CASE DESCRIPTION/METHODS: A 29-year-old male with no significant medical history, presented with epigastric pain and melena for 2 days. He was initially hemodynamically stable with an admission hemoglobin of 8 g/dL. During his hospitalization, he passed intermittent maroon blood clots resulting in a hemoglobin drop to 6 g/dL, requiring 4 units of pRBCs. He had an extensive diagnostic workup including an EGD, colonoscopy, Meckel's scan, CT angiogram &amp; push enteroscopy, which did not reveal a source of bleeding. Finally, a video capsule endoscopy showed active bleeding at 67% small bowel transit time. An anterograde DBE was then performed which showed no evidence of bleeding. Afterward, a retrograde DBE revealed a single bleeding diverticulum in the mid-ileum. The area was tattooed, and general surgery performed a laparoscopic small bowel resection of the Meckel's diverticulum. Pathology of the resected specimen was consistent with Meckel's diverticulum. The patient has remained asymptomatic since the surgery. DISCUSSION: We report the case of a young adult patient who presented with typical symptoms of Meckel's diverticulum but negative diagnostic examination with common practice Meckel's workup. A diagnosis was made only after the use of DBE after symptoms persisted, which calls to question whether certain imaging modalities are superior in adult-onset Meckel's than in the pediatric population in detecting MD. The sensitivity and specificity of Meckel's scan in children is 85% and 95%, respectively, but decreases to 62.5% and 9% in adults. A retrospective case-series found that DBE had a significantly higher mean diagnostic accuracy of 85.0% for MD compared to 21.4% for Meckel's scan. Mean diagnostic accuracies of other tests were as follows: VCE (36%), CT (32%), and angiography (10%). We suggest utilizing DBE much earlier in the diagnostic workup, in conjunction with capsule endoscopy, to better optimize diagnostic yield.

Double-balloon enteroscopy: Experience with an innovative endoscopic technique at the Hospital Universitario de la Fundación Santa Fe de Bogotá

Introduction and aimsDouble-balloon enteroscopy is a recently introduced endoscopic method that enables complete visualization of the small bowel, as well as biopsy sampling and therapeutic interventions in that part of the intestine. The aim of the present study was to describe the experience acquired at our hospital to determine the characteristics of the patients that underwent the procedure. Materials and methodsA descriptive, cross-sectional study was conducted on all patients above 18 years of age admitted to the Hospital Universitario de la Fundación Santa Fe de Bogotá for double-balloon enteroscopy, within the time frame of January 2013 to December 2017. ResultsThe study sample included 93 procedures in 73 patients. Mean patient age was 57.91 years, with a similar number of men and women. There were no severe complications. The most frequent indication for the enteroscopy was gastrointestinal bleeding (overt or occult), presenting in 49.46% of the patients, followed by chronic diarrhea (16.13%). Video capsule endoscopy was the previous study most frequently performed (53.76%). Anterograde double-balloon enteroscopy was carried out in 49 patients and 44 patients underwent the retrograde procedure. A total of 86.02% of the enteroscopies were diagnostic procedures and 13.98% were therapeutic. Normal enteroscopy was the most frequent finding (59.68%), followed by the presence of ulcers (15.05%). ConclusionsOur results were similar to those reported worldwide, with respect to indications, insertion route, and insertion depth, and there were no severe complications.

Small Bowel Transit Time Index Demonstrates Good Agreement and Accuracy in Predicting Best Approach for Double Balloon Enteroscopy

Introduction: Advances in capsule endoscopy (CE) have brought enhanced visualization in small bowel mucosa; however, it is limited by its inability to localize and intervene on abnormalities. Double balloon enteroscopy (DBE) allows for tissue acquisition, therapeutic intervention, and improved visualization. A negative procedure often requires repeat procedure from an alternate approach. When performed prior to DBE, CE can help decide the appropriate endoscopic route and reduce unnecessary procedures. The objective of our study was to evaluate the agreement and accuracy of using a small bowel transit time (SBTT) index value of 0.6 in determining the best approach for DBE. Methods: We performed a retrospective analysis of 71 patients with positive findings on CE who underwent DBE at our hospital. Incomplete CE studies or patients with prior GI surgery were excluded. CE was analyzed for transit time to duodenum, culprit lesion, and ileocecal valve. SBTT index was calculated as the time from the duodenum to index lesion divided by the total SBTT (time from duodenum to ileocecal valve). SBTT index of less than 0.6 was chosen to suggest anterograde approach and a value of greater than 0.6 was used to suggest retrograde approach. Cohen's kappa, which accounts for the possibility of the agreement occurring by chance, was used to measure agreement between suggested and actual DBE results. For example, if the lesion was detected on anterograde DBE and SBTT index was less than 0.6, agreement was suggested. Accuracy was calculated as a proportion of correct suggestions. Results: 71 patients (mean age 65, 49% male) with positive findings on CE were included (Table 1). Of these, 53 had SBTT index < 0.6, suggesting that the lesion might be best detected on anterograde approach. The lesion was found in 48 of the 53 patients with the method suggested by SBTT. 18 patients had SBTT index >0.6. 13 of these patients underwent retrograde endoscopy with lesions identified. Cohen's Kappa for the level of agreement between suggested DBE based on SBTT index and actual DBE was 0.63 (0.35, 0.82). The level of accuracy for the suggestion of anterograde compared to retrograde approach was 0.86 (95%CI 0.75, 0.93).Table: Table. Summary of the findings on double-balloon enteroscopy (DBE) with suspected findings on capsule endoscopy (CE)Conclusion: There is good agreement between suggested DBE based on SBTT index of 0.6 and actual DBE results as judged by this study. The accuracy of the SBTT index in choosing the correct route for DBE is 0.86. A SBTT index of 0.6 can reliably be used to predict the best insertion route for DBE.

Periprocedural Outcomes and Sedation Techniques for Double Balloon Enteroscopy (DBE) at a Large Referral Center

Introduction: Double balloon enteroscopy(DBE) is a valuable tool for the diagnosis and treatment of small bowel disorders. Owing to its complexity and duration of procedure, DBE is usually done under sedation. We sought to study the quality and complications arising due to anesthesia in patients undergoing DBE at a tertiary care GI referral center Methods: We designed a retrospective study and data was obtained from the consecutive patients undergoing DBE between May 2013 and March 2014. Data obtained from a quality database included age, procedure indications, procedure outcomes, mode of anesthesia (General, vs. Monitored anesthesia care (MAC), ASA class, method of intubation, type and quantity of medications used, vital signs during the procedure (EtCo2, mean arterial pressure (MAP), Heart Rate (HR), complications during the procedure or any clinical presentation within 30 days following the procedure. Results: Data was compiled out of 126 patients (mean age 58.9, 74 males (58.7%) who underwent DBE procedure during the observation period (Table 1). All patients underwent DBE using an anesthesiologist administered sedation protocol. The average ASA class was 2.96. The most common indication for DBE was obscure GI bleeding (55.48%). 97 patients underwent anterograde and 29 patients underwent retrograde DBE. All patients undergoing anterograde DBE had general anesthesia while 55.2% of patients undergoing retrograde DBE had MAC. A combination of Propofol and Midazolam was the commonest sedative agents used for MAC. The mean duration of the procedure was 40.8 minutes. A total of 10 adverse events (7.93%) happened during or following the procedure. Of this, 3 major adverse events (2.38%) related to anesthesia were documented (intra-procedural cardiac arrest, wheezing following extubation & vomiting with possible aspiration) requiring escalation of care to the ICU. The aspiration event occurred under MAC and the prior two events were under general anesthesia. Other minor adverse events like GI bleed (2.38%), perforation (1.58%), and abdominal pain (1.58%) were procedural related. There was no mortality. Of the medications used, 43% of the patients required phenylephrine to maintain BP during anesthesia.Table 1: Results of the Anesthesia Related Outcomes During Double Balloon EnteroscopyConclusion: From a large referral center, anesthesia related complications are few to rare in patients undergoing DBE. General anesthesia with intubation is preferred for anterograde procedures. Patients can safely undergo DBE with various individualized anesthesia/sedation modalities.

A case series of Meckel’s diverticulum: usefulness of double-balloon enteroscopy for diagnosis

BackgroundMeckel’s diverticulum is a congenital anomaly of the gastrointestinal tract. About 98% of affected patients are asymptomatic. Small intestinal examination has become easier since the development of double-balloon enteroscopy. The present case series describes 10 patients with Meckel’s diverticulum in whom double-balloon enteroscopy was useful for diagnosis.Case presentationTen patients (8 men, 2 women) with Meckel’s diverticulum underwent double-balloon enteroscopy at Kobe City Medical Center General Hospital from May 2004 through May 2013. Their median age was 31.5 years (range, 14–83 years). Ten retrograde and two anterograde double-balloon enteroscopy procedures were performed. Double-balloon enteroscopy showed Meckel’s diverticulum in nine patients, but an inverted Meckel’s diverticulum was diagnosed as a lipoma in one patient. Meckel’s diverticulum was detected by iodinated contrast medium during anterograde double-balloon enteroscopy in one of the two patients who underwent this procedure. Meckel’s diverticulum was suspected using capsule endoscopy in one of two patients who underwent this procedure. Abdominal computed tomography was performed in all patients and revealed abnormalities in six, but Meckel’s diverticulum was suspected in only two. Technetium-99 m pertechnetate scintigraphy and a small bowel series were carried out in six patients, revealing Meckel’s diverticulum in one and three patients, respectively. Surgery was performed in eight patients, and endoscopic resection was carried out in one; the remaining patient was transferred to another hospital. Ulcer formation was found in or near Meckel’s diverticulum in eight patients.ConclusionCompared with other modalities, double-balloon enteroscopy is excellent for the diagnosis of Meckel’s diverticulum because direct observation of both Meckel’s diverticulum and ulceration is possible. Double-balloon enteroscopy should be used complementarily to other less invasive examinations when needed to confirm or establish the diagnosis.

PTH-142 Does Double Balloon Enteroscopy Affect Management In Patients With Suspected Small Bowel Tumours? Experience From A Single Tertiary Centre

IntroductionThe advent of small bowel capsule endoscopy (CE) has greatly improved the diagnosis of small bowel tumours. Double balloon enteroscopy (DBE) is the interventional counterpart to CE and has the...

The prevalence of adverse events associated with double-balloon enteroscopy from a single-centre dataset in Japan.

There are few comprehensive reports detailing the prevalence of major adverse events associated with a double-balloon enteroscopy procedure. We retrospectively investigated the prevalence of major adverse events in 538 patients (262 males and 276 females; median age, 65 years; age range, 12-95 years) who underwent double-balloon enteroscopy at our Institution between April 2008 and October 2011. Of the 17 adverse events recorded (3.2%), acute pancreatitis (n=5; 0.9%) occurred during both diagnostic (n=3) and therapeutic (n=2) anterograde double-balloon enteroscopy, and all of them were treated conservatively. For these cases, the average duration of the examination was 135 min, which was longer than for the other patients (97 min) (P=0.046). Intestinal bleeding (1.3%) was observed in 6 cases after endoscopic polypectomy and in 1 case following a biopsy procedure during a diagnostic double-balloon enteroscopy. The prevalence rates of intestinal perforation and other complications were 0.2% and 0.7%, respectively. The rate of adverse events associated with double-balloon enteroscopy was high compared to that associated with conventional upper/lower gastrointestinal endoscopy (0.042%/0.078%). The occurrence of acute pancreatitis may be significantly dependent on the duration of double-balloon enteroscopy examination.

Obscure GI Hemorrhage due to Idiopathic Ileal Varices in a 14-Year-Old Boy

Background: Ectopic varices (EV) are a rare cause of obscure GI bleeding, and are frequently fatal due to the rapid bleeding and difficulty localizing the source. Typically, EV are associated with portal hypertension from liver disease or disruption of portal circulation, prior surgeries, and tumors. Idiopathic small bowel varices are rare, particularly in the pediatric population, and are often difficult to diagnose due to their location. Bleeding from these lesions can be rapid and fatal Recognition of this condition is thus important to reduce morbidity. We present a rare case of recurrent GI. bleeding due to idiopathic ileal varices in 14-year-old boy. Case: An otherwise healthy 14 -year-old boy was referred to our institution for assessment of overt obscure GI hemorrhage. The patient had been hospitalized on two prior occasions for gastrointestinal hemorrhage, with subsequent Hgb levels as low as 5.0 g/dL. He had undergone a colonoscopy and upper endoscopy during each prior hospitalization, which were unremarkable, with the exception of tortuous, dilated rectal veins. Prior CT of the abdomen and pelvis, barium enema, and Meckel's scan were unremarkable. A Capsule endoscopy was also reportedly unremarkable. Prior to this episode, the patient had been healthy, with only a history of lactose intolerance, but had experienced a similar episode of overt obscure GI hemorrhage 5 years prior, for which imaging and endoscopic assessment were also negative. We performed an anterograde double-balloon enteroscopy (DBE) to the distal ileum, which was unremarkable, with the exception of increased vasculature in the distal ileum. Subsequent retrograde DBE revealed small rectal varices and large varices 15 cm in length in the terminal ileum near the I.C. Valve. The tattoo from the anterograde DBE was identified 20 cm proximal to these varices. Evaluation for coagulopathy, portal hypertension, and liver disease were unremarkable. The venous phase of an angiography revealed large ileal varices. Review of the previous capsule endoscopy images revealed distal ileal varices. Exploratory laparotomy revealed multiple large ileal varices extending into the ileocolonic region, which were resected. No evidence of portal hypertension was detected. Pathology revealed arteriovenous malformation. The patient has experienced no further bleeding over the past 12 months. Discussion: We present a rare case of ileal varices in a juvenile. While this is uncommon, recognition of small bowel varices is essential to avoid misdiagnosis. Since treatment consensus has not been established, early recognition of this entity and the underlying etiology of ectopic varices may facilitate therapeutic decision-making.

Risk of hyperamylasemia and acute pancreatitis after double-balloon enteroscopy: a prospective study

There have been reports, mainly retrospective, of pancreatitis and hyperamylasemia after anterograde double-balloon enteroscopy (DBE). Our aim was to report the incidence of pancreatitis and hyperamylasemia after DBE and investigate possible risk factors associated with its occurrence. In this single-center prospective cohort study, serum samples were taken for amylase and lipase before and 3 hours after anterograde DBE in consecutive patients. Multiple variables were recorded, including total procedure time, insertion depth, and number of passes. Patients were evaluated to 24 hours later for signs of pancreatitis. The main outcome measures were the occurrence of hyperamylasemia and pancreatitis. 92 patients were included in the analysis (58 women, 34 men; mean age 54 years, range 18-89). The mean total procedure time was 62 minutes (range 30-120). The mean post-procedure amylase and lipase levels were significantly higher in comparison with the baseline levels (165 U/L vs. 69 U/L and 144 U/L vs. 28 U/L respectively, P<.05); 36 patients (39%) showed hyperamylasemia after the procedure and three patients developed acute mild pancreatitis. Hyperamylasemia was associated more frequently with procedure duration greater than 60 minutes ( P<.001) and insertion depth greater than 25 cm ( P<.013). The incidence of hyperamylasemia after anterograde DBE is common and particularly associated with longer procedure time and insertion depth. The cumulative incidence of pancreatitis was 3%. We recommend the avoidance of both unnecessarily lengthy procedures and deep insertion distances in patients who undergo anterograde DBE.

Retrograde double balloon enteroscopy: Comparing performance of solely retrograde versus combined same-day anterograde and retrograde procedure

Objective. Retrograde double balloon enteroscopy (DBE) is important for evaluating the distal small bowel, but it is more challenging compared to the oral route. Optimizing small bowel insertion may enhance the diagnostic utility of the examination. We sought to determine if insertion depths achieved with retrograde DBE when performed as an isolated procedure differed significantly from when performed immediately following anterograde DBE. Material and methods. A retrospective analysis was conducted of all retrograde DBE procedures performed at our center with comparisons made between “distal-only” DBE without preceding anterograde DBE and “combined” DBE after a prior same-day anterograde DBE. Results. Two hundred ninety retrograde DBE procedures were performed in 264 patients over 5 years. Success of terminal ileal intubation exceeded 95%. The mean insertion depth into the distal small bowel differed significantly with 112 cm (95% CI 95–129) in the “distal-only” group and 92 cm (95% CI 85–98) in the “combined” group (p = 0.01), with a trend toward a corresponding increased diagnostic yield of 48% versus 37%, respectively (p = 0.15). Multivariate regression analysis identified both insertion route strategy (distal-only > combined; p = 0.01) and type of DBE endoscope (diagnostic > therapeutic; p = 0.02) as significant predictors of retrograde insertion depth. Conclusions. The insertion depth of retrograde DBE is significantly greater when carried out as a separate distal procedure and not in combination with a preceding anterograde DBE, and when performed using a diagnostic as opposed to the therapeutic DBE endoscope. This increased retrograde depth of insertion may be associated with an increased diagnostic yield.

Complications Associated With Double Balloon Enteroscopy at Nine US Centers

Double balloon enteroscopy (DBE) was introduced into the US in 2004. Potential complications include perforation, pancreatitis, and gastrointestinal bleeding. Prevalence and risk factors for complications have not been described in a US population. We conducted a retrospective study of DBE complications in 9 US centers. We obtained detailed information for each complication including patient history, maneuvers performed during the DBE, and presence of altered surgical anatomy. We collected data from 2478 DBE examinations performed from 2004 to 2008. The dataset included 1691 (68%) anterograde DBE, 722 (29%) retrograde DBE (including 5 per-stomal DBEs), and 65 (3%) DBE-facilitated endoscopic retrograde cholangiopancreatography ERCP cases. There were a total of 22 (0.9%) major complications including perforation in 11 (0.4%), pancreatitis in 6 (0.2%), and bleeding in 4 (0.2%) patients. One of 6 cases of pancreatitis occurred post retrograde DBE. Perforations occurred in 3/1691 (0.2%) anterograde examinations and 8/719 (1.1%) retrograde DBEs (P = .004). Eight (73%) perforations occurred during diagnostic DBE examinations. Four of 8 retrograde DBE perforations occurred in patients with prior ileoanal or ileocolonic anastomoses. In the subset of 219 examinations performed in patients with surgically altered anatomy, perforations occurred in 7 (3%), including 1/159 (0.6%) anterograde DBE examinations, 6/60 (10%) retrograde DBEs, and 1 of 5 (20%) peristomal DBE examinations (P < .005 compared with patients without surgically altered anatomy). DBE is associated with a higher complication rate compared with standard endoscopic procedures. The perforation rate was significantly elevated in patients with altered surgical anatomy undergoing diagnostic retrograde DBE examinations.

Cost-effectiveness analysis of management strategies for obscure GI bleeding

Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage. We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period. An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses. The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions. An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.