Double-balloon Enteroscopy In Patients Research Articles

Utility of double-balloon enteroscopy in patients with left ventricular assist devices and obscure overt gastrointestinal bleeding.

Obscure overt gastrointestinal bleeding (OGIB) is a challenge in patients with left ventricular assist devices (LVADs). We evaluated the utility and safety of double-balloon enteroscopy (DBE) in patients with LVADs in an observational consecutive-patient cohort from a single tertiary referral center. Ten patients with LVADs underwent thirteen DBEs for obscure OGIB. The first OGIB event necessitating DBE occurred after a mean of 512 ± 363 days of LVAD support. All patients underwent DBE, eleven anterograde and two retrograde, with a mean insertion depth 176 ± 85 cm. Diagnostic yield was 69 % with the primary bleeding lesion most frequently found in the mid-bowel. The most common lesions were arteriovenous malformations. Therapeutic yield with argon plasma coagulation (APC), epinephrine injection, and/or hemoclip placement was 89 %. There were no procedure-related complications. DBE in patients with LVADs has good diagnostic yield and high therapeutic yield for obscure OGIB and is safe and well tolerated.

Utility of Double Balloon Enteroscopy in Patients With Surgically Altered Bowel Anatomy After Bariatric Surgery

Introduction: To evaluate the diagnostic yield, success and complications rates of double-balloon enteroscopy (DBE) in consecutive patients with GI disorders necessitating endoscopic evaluation. Methods: Single-center, observational, cohort study of consecutive patients with post-obesity surgery undergoing DBE during a 14-month period. Patients’ demographics, procedure indications, findings, endoscopic interventions, and post-procedural recovery data were recorded. Results: A total of 270 DBE were performed at our institution during the study period. Thirty-eight patients (13.3%) with post-obesity surgery were evaluated using DBE. The indications for DBE was obscure GI bleeding (OGIB) (n=12), followed by DBE-ERCP (n=14), and evaluation of and abdominal pain (n=8) and placement of direct feeding jejunostomy (n=3). The excluded stomach was successfully reached in 85% of patients with Roux-en Y gastric bypass. The overall diagnostic yield of DBE-ERCP was 70% (stones n=4, sphincter stenosis n=2, bile leak n=2, bile duct stricture n=2, failed ERCP n=4). The yield of DBE for abdominal pain was 20% (n=2: gastric erosions, gastro-gastric fistula) and DBE for OGIB 75%. Of the 14 patients with OGIB, 10 had active or a source of bleeding at the time of DBE. In all but one case, the bleeding was occurring at the site of the anastomosis, whether that is hepaticojejunal, jejunojejunal, or gastrojejunal. Of these patients, 4 patients had arteriovenous malformations at the anastomotic site, 4 had ulcers or erosions, and 2 were bleeding secondary to Dieulafoy’s lesions. A total of one complication (3%) was observed (small bowel perforation after application of argon plasma coagulation to the jejunojejunal anastomosis). Conclusion: DBE is a feasible and relatively safe technique to evaluate the small intestines, stomach and biliary tract and is associated with reasonably high diagnostic and therapeutic yield in patients with surgically altered bowel anatomy in the setting of bariatric surgery.

Double balloon enteroscopy: Bangladesh experience.

Double balloon enteroscopy (DBE) is a newly developed endoscopic modality for diagnosis and treatment of small bowel disorders. The aim of this study was to evaluate the diagnostic and therapeutic impact of DBE in patient with suspected small bowel disease. This was a prospective study. Sixty one double balloon enteroscopy procedures (30 antegrade 31 retrograde) were done in thirty six patients (20M/16F, mean age 40 ± 12.5 range 16-65 years ) at gastroenterology department, Sir Salimullah Medical College, Dhaka between October 2011 and September 2012. Indications for DBE included chronic abdominal pain 14 (38.9%), obscure GI bleeding 11 (30.56%), Small bowel obstruction 05 (13.89%), and chronic diarrhea 06 (16.67%). The morphologic findings were ulcerations 13 (36.11%), growth 03 (8.33%), vascular ectasia 03 (8.33%) and polyp 01 (2.78%). Therapeutic interventions were performed in one patient only. No serious complications were observed. Diagnostic yields in case of chronic abdominal pain, chronic diarrhea, obscure GI bleeding and small bowel obstruction were 50%, 66%, 63% and 40% respectively. The findings were adenocarcinoma 04 (11%), lymphoma 03 (8.4%), tuberculosis 03 (8.4%), non specific findings 05 (13.9%), IPSID 01(2.8%), Crohn's disease 01 (2.8%), vascular ectasia 03 (8.33%) and normal 16 (44.44%). DBE is well tolerated, feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders.

Tips for double balloon enteroscopy in patients with Roux‐en‐Y reconstruction and modified Child surgery

Pancreatobiliary disease in patients with altered anatomic intestine is one of the most difficult cases for pancreatobiliary endoscopic therapies and diagnosis. There are two major challenges to overcome to complete the procedure. The first challenge is the deep insertion to the blind end. The second challenge is the endoscopic retrograde cholangiopancreatography (ERCP)-related intervention. Impairing either success means the incompletion of the procedure. The double balloon enteroscope (DBE), which has been recently developed, enabled the deep intubation to the blind end. Especially, using the scopes with a short working length allowed us to perform the ERCP-related interventions with a high success rate. Generally, ERCP using double balloon endoscope (DB-ERCP) in patients with altered gastrointestinal anatomy has been established. We introduce our standard technique for DB-ERCP and provide several tips for insuring a successful procedure.

The Ulility of Urgent Video Capsule Endoscopy and Double Balloon Enteroscopy to Identify, Treat, and Diagnose a Bleeding Ileal Carcinoid Tumor

Purpose: Video Capsule Endoscopy (VCE) and double balloon enteroscopy (DBE) are frequently utilized modalities to evaluate the small bowel in an elective outpatient setting. We present a case in which an actively bleeding carcinoid tumor was identified, treated for hemostasis, and localized with tattoo on an urgent, inpatient basis. This process assisted the surgeons in their pre-operative planning and inpatient management of the patient.Figure: Left image: hemoclip placed for active bleeding. Right image: bleeding ileal carcinoid.Case presentation: A 26-year-old otherwise healthy female presented with four episodes of rectal bleeding at home, initially described as hematochezia which evolved to appear more consistent with melena. At the time of presentation she was anemic with hemoglobin of 7.4 mg/dL. She was admitted and underwent an EGD and colonoscopy. The EGD was normal and the colonoscopy revealed coagulated blood in the terminal ileum without a source of bleeding. She then had a Meckel's scan that was negative. Due to the persistence of ongoing bleeding, VCE was performed, which identified active bleeding in the distal small bowel. The following morning the patient underwent an enterograde DBE which identifi ed an ulcerated, actively bleeding polypoid lesion at 400cm beyond the ligament of Treitz. A hemoclip was placed on to the visible vessel, leading to hemostasis. The lesion was then tattooed and general surgery was consulted. She underwent a laparoscopic partial small bowel resection and was discharged on post-op day 3. Pathology of the lesion revealed a 1.6-cm carcinoid tumor. She was later evaluated for metachronous lesions with CT imaging, Octreoscan, and labs; all which were unremarkable. This case demonstrates the effectiveness of urgent small bowel evaluation with video capsule endoscopy and double balloon enteroscopy in patients with ongoing overt obscure gastrointestinal hemorrhage.

Characteristics of Incidental Colonic Lesions Found at Retrograde Double Balloon Enteroscopy for Obscure GI Bleed

Purpose: There is limited data on colonic lesions found during retrograde double-balloon enteroscopy (DBE) following a negative colonoscopy in patients with obscure gastrointestinal bleeding (GIB). This study evaluates the location of colonic angioectasias and the location and size of colonic polyps found incidentally at retrograde DBE in patients with obscure GIB. Methods: We did a retrospective chart review on all patients undergoing retrograde DBE for obscure GIB between 2008-2012. The median days from colonoscopy to DBE were 12.89 days. Lesions are defined as polyps and angioectasias not seen at colonoscopy. Results: 136 patients, 56 women (41.18%) with a median age of 65.5 and 80 men (58.82%) with a median age of 59.4 are reported. DBE detected lesions not seen on colonoscopy in 35 patients (25.74%). 27 patients (19.85%) had polyps and 8 patients had angioectasias (5.88%). Of the polyps found, the largest percentage were found in the cecum (12, 44.44%), followed by the sigmoid (7, 25.93%), transverse colon (4, 14.81%), ascending colon (3, 11.11%), and descending colon (1, 3.70%). The median size of all polyps was 0.5 cm, with a range of 0.5-1.5 cm. Of the angioectasias, 6 were in the cecum (75.00%), and 1 angioectasia was found in the sigmoid and transverse colon (12.5% each). Conclusion: Retrograde DBE following negative colonoscopy detects significant number of clinically relevant colonic lesions in patients with obscure GIB. Most lesions were detected in the cecum and sigmoid colon. This data suggests that careful re-examination of the colon with particular attention to the cecum and sigmoid colon at retrograde DBE is warranted.

Erratum to: ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery

Erratum to: ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery

ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery

Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy. Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician. Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p < 0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022). GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.

Double-balloon enteroscopy in the elderly with obscure gastrointestinal bleeding

Double-balloon enteroscopy (DBE) is a novel endoscopic procedure to access the small bowel. There is paucity of data on its use in the elderly. The aim of this study was to assess the utility of DBE in patients with obscure gastrointestinal bleeding (OGB) in terms of safety and feasibility. A prospective review of consecutive patients who underwent DBE for OGB was conducted. Data were collected on demographics, dose of sedation/analgesia, diagnostic yield, and management and complications. Patients were divided into group 1, age of at least 70 years, and group 2, age less than 70 years. A total of 148 DBE procedures were carried out for OGB. Group 1 (age≥70 years) comprised 27% (n=40) of the cohort with a mean age of 77 years (range 70-83 years). The mean age in group 2 (n=108) was 54 years, 44% women. The diagnostic yield in group 1 was 53 versus 35% in group 2 (P=0.06). Subsequent management was altered more frequently in group 1 (50 vs. 28%, P=0.01, odds ratio 2.6, 95% confidence interval 1.2-5.5). Sedation requirement was less in the elderly (median dose of midazolam, group 1: 4.5 mg versus group 2: 6 mg, P<0.001; fentanyl, group 1: 50 mcg vs. group 2: 75 mcg, P<0.001). There was no significant difference in complications between the two groups (0/40 vs. 1/108, P=0.54). On logistic regression, increasing age (P=0.008) was associated with a higher yield with DBE in all patients. DBE is safe, has a high diagnostic yield and has a positive impact on patient management in the elderly.

Mo1618 Retrograde Double Balloon Enteroscopy Detects Significant Colonic Lesions When Performed for Obscure GI Bleeding

Retrograde Double Balloon Enteroscopy Detects Significant Colonic Lesions When Performed for Obscure GI Bleeding David Tenembaum*, Masud Habibullah, Jose E. Najul, Moshe Rubin New York Hospital Queens Medical Center, Weill-Cornell Medical College, New York, NY Background: Evaluation of the distal small bowel with Double Balloon Enteroscopy (DBE) requires passage of the scope through the colon prior to intubation of the ileum. Nevertheless, careful inspection of the colon may not be performed in all cases since patients with obscure GI bleeding have already undergone a complete colonoscopy with reportedly negative results. There is limited data on the frequency of clinically significant colonic findings missed at colonoscopy and subsequently detected at retrograde DBE. Objectives: To evaluate the detection rate of missed colonic angioectasia, ulcers and polyps at retrograde DBE in patients with obscure GI bleeding. Methods: We performed a retrospective cohort study on 134 sequential patients undergoing retrograde DBE. All patients had a negative colonoscopy (excluding diverticulosis and hemorrhoids) and were referred for obscure bleeding. The median time between colonoscopy and DBE were 12.89 days. The detection rate of angioectasia, ulcers and polyps ( 5 mm) were calculated. Results: 134 patients, ages 24-94 with a mean age of 63.2 were evaluated. There were 56 women (41.18%) with a median age of 65.5 and 78 men (58.82%) with a median age of 59.4. DBE detected colonic lesions in 36 patients (28.36%) overall. Of those patients, 28 (20.90%) had polyps, 13 had angioectasia (9.70%) and 2 had ulcers (1.49%). Conclusions: Retrograde DBE following reportedly negative colonoscopy detects a significant number of clinically relevant colonic lesions in patients with obscure bleeding. This data suggests that a careful reexamination of the colon at the time of retrograde DBE may be warranted.

Double Balloon Enteroscopy Procedure in Patients with Surgically Altered Bowel Anatomy: Analysis of a Large Prospectively Collected Database

Patients with surgically altered bowel anatomy frequently undergo the double balloon enteroscopy (DBE) procedure to evaluate various small bowel diseases. There are limited data on the diagnostic yield and safety of DBE in these patients. We evaluated the diagnostic yield and complication rates of DBE in patients with surgical altered bowel anatomy. We also evaluated the success rate of DBE in achieving complete examination of the excluded segment of the small bowel and excluded stomach in these patients. Our study was a single-center retrospective analysis of a large prospectively collected DBE database. Patients with a history of surgically altered bowel anatomy who had a DBE procedure performed between January 2006 and August 2011 were included in the study analysis. Patients' demographics, procedure indications, findings, endoscopic interventions, and postprocedural recovery data were recorded. We used frequency statistics to calculate the diagnostic yield and complication rates of DBE in these patients. In total, 1215 DBEs were performed at our institution during the study period. Sixty-two patients with a history of altered bowel anatomy underwent 53 DBEs and 11 DBE-assisted endoscopic retrograde cholangiopancreatographies (ERCPs). The overall diagnostic yield of DBE was 61%, and that of DBE-assisted ERCP was 64%. No serious early or delayed DBE-associated complications were identified. In patients with surgically altered bowel anatomy containing excluded small bowel and excluded stomach, DBE success rate to achieve their complete examination was 92% (n=46). DBE including DBE-assisted ERCP is feasible, safe, and associated with reasonably high diagnostic yield in patients with surgically altered bowel anatomy.

Double-balloon Enteroscopy in Patients With Previous Incomplete Colonoscopy

Double-balloon Enteroscopy in Patients With Previous Incomplete Colonoscopy

Mo1513 Double Balloon Enteroscopy in Patients With Surgically Altered Bowel Anatomy: Analysis of Large Prospectively Collected Database

Mo1513 Double Balloon Enteroscopy in Patients With Surgically Altered Bowel Anatomy: Analysis of Large Prospectively Collected Database

Mo1379 Double Balloon Enteroscopy in Patients With Previous Incomplete Colonoscopy: Should We Perform Them More Often?

Mo1379 Double Balloon Enteroscopy in Patients With Previous Incomplete Colonoscopy: Should We Perform Them More Often?

Su1362 Therapeutic ERCP Using Short Double-Balloon Enteroscopy in Patients With Surgically Altered Anatomy

Although ERCP is technically challenging in patients with surgically altered anatomy, with the advent of double-balloon enteroscopy (DBE), endoscopic access to the pancreaticobiliary system can be more effectively achieved in such patients, so various therapeutic interventions have become possible.

Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding

Correction to: Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleedingEndoscopy 2011; 43(09): 759-765DOI: 10.1055/s-0030-1256388

Clinical Usefulness of 64-Channel Multidetector Computed Tomography, Capsule Endoscopy, and Double-Balloon Enteroscopy in Obscure Gastrointestinal Bleedings

Objective: Obscure gastrointestinal bleeding primarily originates from small-bowel lesions. It is difficult to detect the lesions by us ing classical diagnostic modalities, and thus, new methods have been developed. The aim of study was to evaluate the clinical usefulness of 64-channel multidetector computed tomography, capsule endoscopy, and double-balloon enteroscopy for detection of obscure gastrointestinal bleeding. Methods: This retrospective study analyzed the findings of 64-channel multidetector computed tomography, capsule endoscopy, and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding treated at Soonchunhyang University Seoul Hospital between January 1, 2008 and September 30, 2010. Results: Five of 22 positive findings (22.7%) were obtained using 64-channel multidetector computed tomography. The computed tomography could not detect active bleeding lesions but it played an important role on the evaluation of extraluminal lesions. The diagnostic yield of capsule endoscopy was 82.4%. No cases of capsule retention were detected in this study. Bleeding lesions were identified in all cases through the use of double-balloon enteroscopy. One hemoclipping and 2 biopsies were performed. Conclusion: Sixty-four-channel multidetector computed tomography can be used to evaluate extraluminal lesions. Capsule endoscopy is the most convenient endoscopy method. Invasive procedures can be performed using double-balloon enteroscopy. These methods can be used complementarily to diagnose and treat occult gastrointestinal bleeding. Use of capsule endoscopy after screening with 64-channel multidetector computed tomography in the case of patients with occult gastrointestinal bleeding is suggested. In case of lesions wherein invasive procedures are required, use of double-balloon is preferred.

Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding

Vascular malformations are the most common sources of bleeding in the small bowel. They can be treated with argon plasma coagulation (APC) during double-balloon enteroscopy (DBE). This study aimed to evaluate the long-term follow-up of the effectiveness of APC for small-bowel bleeding by means of a single-center retrospective study. Between June 2003 and December 2005, APC treatment for small-bowel lesions was carried out during DBE in 63 patients with known or suspected mid-gastrointestinal bleeding. Fifty patients were included in the analysis. Main outcome measurements were comparison of hemoglobin values and blood transfusion requirements before and after APC, and rebleeding rates. Twenty-nine patients (58%) had only oral DBE, whereas 21 patients (42%) underwent combined oral and anal approaches. The most frequent bleeding sources treated with APC were angiodysplasias in 44 patients (88%). Hemoglobin levels increased distinctly and stabilized after APC during a mean long-term follow-up of 55 ± 7 months, with mean levels of 7.6 g/dL before APC and 11.0 g/dL afterwards. Blood transfusion requirements substantially declined, from 30 patients (60%) before APC to 8 (16%) afterwards. However, small-bowel bleeding recurred in 21 patients (42%), particularly in patients with Osler disease (6 of 8 patients, 75%). Bleeding sources in the small bowel can be effectively treated with APC using DBE, and long-term follow-up data show a clear increase in hemoglobin levels and reduced blood transfusion requirements after APC. Further efforts are needed to reduce the rebleeding rate, possibly through more intensive initial treatment.

Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: An updated meta‐analysis

Uncertainty remains about the best test to evaluate patients with obscure gastrointestinal bleeding (OGIB). Previous meta-analyses demonstrated similar diagnostic yields with capsule endoscopy (CE) and double balloon enteroscopy (DBE) but relied primarily on data from abstracts and were not limited to bleeding patients. Many studies have since been published. Therefore, we performed a new meta-analysis comparing CE and DBE focused specifically on OGIB. A comprehensive literature search was performed of comparative studies using both CE and DBE in patients with OGIB. Data were extracted and analyzed to determine the weighted pooled diagnostic yields of each method and the odds ratio for the successful localization of a bleeding source. Ten eligible studies were identified. The pooled diagnostic yield for CE was 62% (95% confidence interval [CI] 47.3-76.1) and for DBE was 56% (95% CI 48.9-62.1), with an odds ratio for CE compared with DBE of 1.39 (95% CI 0.88-2.20; P = 0.16). Subgroup analysis demonstrated the yield for DBE performed after a previously positive CE was 75.0% (95% CI 60.1-90.0), with the odds ratio for successful diagnosis with DBE after a positive CE compared with DBE in all patients of 1.79 (95% CI 1.09-2.96; P = 0.02). In contrast, the yield for DBE after a previously negative CE was only 27.5% (95% CI 16.7-37.8). Capsule endoscopy and double balloon enteroscopy provide similar diagnostic yields in patients with OGIB. However, the diagnostic yield of DBE is significantly higher when performed in patients with a positive CE.

Su1456 Therapeutic ERCP Using Short Double-Balloon Enteroscopy in Patients With Surgically Altered Anatomy

Su1456 Therapeutic ERCP Using Short Double-Balloon Enteroscopy in Patients With Surgically Altered Anatomy