Mid-gastrointestinal Bleeding Research Articles

Deep learning and capsule endoscopy: Automatic multi-brand and multi-device panendoscopic detection of vascular lesions.

Background and study aims Capsule endoscopy (CE) is commonly used as the initial exam for suspected mid-gastrointestinal bleeding after normal upper and lower endoscopy. Although the assessment of the small bowel is the primary focus of CE, detecting upstream or downstream vascular lesions may also be clinically significant. This study aimed to develop and test a convolutional neural network (CNN)-based model for panendoscopic automatic detection of vascular lesions during CE. Patients and methods A multicentric AI model development study was based on 1022 CE exams. Our group used 34655 frames from seven types of CE devices, of which 11091 were considered to have vascular lesions (angiectasia or varices) after triple validation. We divided data into a training and a validation set, and the latter was used to evaluate the model's performance. At the time of division, all frames from a given patient were assigned to the same dataset. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and an area under the precision-recall curve (AUC-PR). Results Sensitivity and specificity were 86.4% and 98.3%, respectively. PPV was 95.2%, while the NPV was 95.0%. Overall accuracy was 95.0%. The AUC-PR value was 0.96. The CNN processed 115 frames per second. Conclusions This is the first proof-of-concept artificial intelligence deep learning model developed for pan-endoscopic automatic detection of vascular lesions during CE. The diagnostic performance of this CNN in multi-brand devices addresses an essential issue of technological interoperability, allowing it to be replicated in multiple technological settings.

Transcatheter arterial embolization for gastrointestinal bleeding: Clinical outcomes and prognostic factors predicting mortality.

We evaluated clinical outcome and prognostic factors predicting mortality of transcatheter arterial embolization (TAE) for acute gastrointestinal (GI) bleeding. Fifty-nine patients (42 men, 17 women; mean age 66.1 ± 17.0) who underwent 59 TAE procedures for GI bleeding during 2013–2018 were retrospectively evaluated. Clinical outcomes included technical success, adverse events, and rebleeding and mortality rate within 30 days. The technical success rate was 100%. Angiography showed contrast extravasation in 41 (69.5%) patients and indirect signs of bleeding in 16 (27.1%) patients. Two (3.4%) patients underwent prophylactic embolization. TAE-related adverse events occurred in 7 (11.9%) patients; adverse events were more common for mid GI or lower GI bleeding than for upper GI bleeding (22.6% vs 0%, P = 0.007). Rebleeding within 30 days was observed in 22 (37.3%) patients after TAE. Coagulopathy was a prognostic factor for rebleeding (odds ratio [OR] = 3.53, 95% confidence interval 1.07–11.67, P = .038). Mortality within 30 days occurred in 11 (18.6%) patients. Coagulopathy (OR = 24, 95% confidence interval 2.56–225.32, P = .005) was an independent prognostic factor for mortality within 30 days. TAE is an effective, safe, and potentially lifesaving procedure for GI bleeding. If possible, coagulopathy should be corrected before TAE as it may reduce rebleeding and mortality.

Deep Learning and Device-Assisted Enteroscopy: Automatic Detection of Gastrointestinal Angioectasia.

Background and Objectives: Device-assisted enteroscopy (DAE) allows deep exploration of the small bowel and combines diagnostic and therapeutic capacities. Suspected mid-gastrointestinal bleeding is the most frequent indication for DAE, and vascular lesions, particularly angioectasia, are the most common etiology. Nevertheless, the diagnostic yield of DAE for the detection of these lesions is suboptimal. Deep learning algorithms have shown great potential for automatic detection of lesions in endoscopy. We aimed to develop an artificial intelligence (AI) model for the automatic detection of angioectasia DAE images. Materials and Methods: A convolutional neural network (CNN) was developed using DAE images. Each frame was labeled as normal/mucosa or angioectasia. The image dataset was split for the constitution of training and validation datasets. The latter was used for assessing the performance of the CNN. Results: A total of 72 DAE exams were included, and 6740 images were extracted (5345 of normal mucosa and 1395 of angioectasia). The model had a sensitivity of 88.5%, a specificity of 97.1% and an AUC of 0.988. The image processing speed was 6.4 ms/frame. Conclusions: The application of AI to DAE may have a significant impact on the management of patients with suspected mid-gastrointestinal bleeding.

Direct oral anticoagulants are associated with potentially bleeding lesions in suspected mid-gastrointestinal bleeding

Background and aim Direct oral anticoagulants (DOACs) became a widespread alternative in anticoagulant therapy. Nevertheless, concerns are raised about their safety, with increased gastrointestinal bleeding rates being described. There are scarce studies regarding DOACs effect on small-bowel capsule endoscopy (SBCE) findings. We aimed to assess if the detection of lesions with high bleeding potential on SBCE was significantly different in patients treated with DOACs when compared to non-anticoagulated patients and to patients anticoagulated with other agents. Methods Cohort study including consecutive patients who underwent SBCE for suspected mid-gastrointestinal bleeding (MGIB) in 2019 and 2020. Results From 148 patients, 38 (25.7%) were anticoagulated, of which 26 (68.4%) with DOACs. P2 lesions were detected in 36.5% (n = 54) of the patients. These lesions were more frequently detected in patients under DOACs treatment when compared to non-anticoagulated patients (69.2% vs. 29.1%; p=.001), and also when compared to patients treated with other anticoagulants (69.2% vs. 33.3%; p=.037). No differences in P2 lesions detection were observed between patients treated with other anticoagulants and non-anticoagulated patients (33.3% vs. 29.1%; p=.747). In multivariate analysis, DOACs usage was significantly associated with higher detection rates of P2 lesions on SBCE, when adjusted for classical risk factors for MGIB (OR: 3.38; 95%CI = 1.23–9.26; p=.018). Conclusions Despite their undeniable cardiovascular benefits and easy applicability, DOACs should still be considered with caution. These drugs were significantly associated with higher risk of potentially bleeding lesions on SBCE when compared to other anticoagulants and represent an independent risk factor for MGIB when adjusted for other variables.

RHEMITT score: Predicting the risk of mid gastrointestinal rebleeding after small bowel capsule endoscopy: A prospective validation.

The RHEMITT score (Renal disease; Heart failure; Endoscopic findings; Major bleeding; Incomplete SBCE; Tobacco; Treatment by enteroscopy) was the first score to accurately predict the individual risk of small bowel rebleeding after capsule endoscopy (SBCE). The aim of the study is on the prospective validation of the RHEMITT score. Cohort of consecutive patients with mid-gastrointestinal bleeding (MGIB) submitted to SBCE and followed prospectively, during at least 12months, since 2017 until 2020. Rebleeding was defined as an overt bleeding event (melena or hematochezia) or a hemoglobin decrease of at least 2g/dL. The RHEMITT score was calculated for each patient and the rebleeding rates compared. The performance of the score was tested by calculating the area under curve of the receiver operator characteristic curve. A rebleeding-free survival was assessed, corresponding to the period between the date of SBCE and the date of the first post-SBCE rebleeding event. We included 162 patients, 102 (62.9%) were female, with a mean age of 64years old. The sensitivities and specificities of the score grades for predicting rebleeding were as following: for low-risk patients, 0% (0-10%) and 28.8% (21.1-36.5%); for intermediate-risk patients, 23.3% (8.2-38.4%) and 72% (64.3-79.7%); for high-risk patients, 76.7% (61.6-91.8%) and 99.2% (97.7-100%), corresponding to an area under curve of the receiver operator characteristic of 0.988 (P<0.001). Kaplan-Meyer plots were statistically different according to the attributed risk (log-rank P value <0.001; Breslow-Wilcoxon P value <0.001). The RHEMITT score performed with excellent discriminative power in predicting rebleeding risk, and we herewith propose a surveillance of MGIB patients guided by the RHEMITT score.

RHEMITT Score: Predicting the Risk of Rebleeding for Patients with Mid-Gastrointestinal Bleeding Submitted to Small Bowel Capsule Endoscopy

Introduction: Small bowel capsule endoscopy (SBCE) is the gold standard for mid-gastrointestinal bleeding (MGIB). No score has been developed to predict the risk of small bowel rebleeding after SBCE. Objective: Creating a predictive small bowel rebleeding risk score for MGIB, after initial SBCE. Methods: Retrospective, single center study, including SBCEs for MGIB, from June 2006 to October 2016. The minimum follow-up was 12 months. Univariate analysis and a multivariable Cox regression model tested the association with rebleeding. Statistically significant variables were used to compute the score. The score’s accuracy was tested through a receiver operating characteristic (ROC) curve. A classification tree identified risk groups. For internal validation, we performed a 5-fold cross validation. Results: We assessed 357 SBCEs for MGIB, of which 88 (24.6%) presented rebleeding during follow-up. Seven variables were used to compute a risk-predicting score – the RHEMITT score – namely, renal disease; heart failure; endoscopic capsule P1/P2 lesions; major bleeding; incomplete capsule; tobacco consumption; and endoscopic treatment. The score presented good accuracy toward the outcome (area under the curve ROC 0.842, 95% CI 0.757–0.927). We established 3 rebleeding risk groups: low (0–3 points); intermediate (4–10 points); and high (+11 points). Conclusion: A new MGIB score, named RHEMITT, accurately anticipates the individual risk of small bowel rebleeding after initial SBCE.

Clinical Outcomes of Angiography and Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding: Analyses according to Bleeding Sites and Embolization Types

The clinical outcomes of angiography and transcatheter arterial embolization (TAE) for acute gastrointestinal bleeding (GIB) have not been completely assessed, especially according to bleeding sites. This study aimed to assess the efficacy of angiography and safety of TAE in acute GIB. This was a retrospective study evaluating the records of 321 patients with acute GIB who underwent angiography with or without TAE. Targeted TAE was conducted in 134 patients, in whom angiography showed bleeding sources. Prophylactic TAE was performed in 29 patients when the bleeding source was not detected but a specific vessel was strongly suspected by other examinations. The rate of technical success, clinical success, and complications were analyzed. The detection rate of bleeding source via angiography was 50.8% (163/321), which was not different according to the bleeding sites. The detection rate was higher if the probable bleeding source had already been found by another investigation (59.7% vs. 35.8%, p<0.001). TAE sites were upper GIB in 67, mid GIB in 74, and lower GIB in 22. The technical success rate was 99.3% (133/134), and the clinical success rate was 63.0% (104/163). The prophylactic embolization group showed lower clinical success rate than the targeted embolization group (44.8% vs. 67.9%, p=0.06). The TAE-related complication rate was 12.9% (21/163). Ischemia and/or infarction was more common after TAE for mid and lower GIB than for upper GIB (15.6% vs. 3.0%, p=0.007). Angiography with or without TAE was an effective method for acute GIB. Targeted embolization should be performed if possible given that it has a higher clinical success rate.

PWE-149 5 Years of A DGH Delivered Regional Double Balloon Enteroscopy (DBE) Service

<h3>Introduction</h3> Double Balloon Enteroscopy (DBE) allows visualisation and interventional therapy throughout the small bowel. It was commenced in South Tyneside District Hospital (STDH) in January 2010 to complement the existing capsule endoscopy service. <h3>Methods</h3> Records were examined retrospectively for all DBEs at STDH between 1/1/2010 &amp; 31/12/2015 to determine the indication, route &amp; depth of insertion, findings &amp; therapies performed &amp; the complications. <h3>Results</h3> 92 procedures were performed from 172 referrals: (47%) via oral route, (52%) via anal route and (1%) via ileostomy. Procedures were done under conscious sedation or propofol, with GA for planned therapeutic cases. The average depth of insertion for the oral route was 174 cm &amp; 96 cm for the anal route. The overall average insertion time was 71 minutes. (61%) had tattoo applied. The indications were to evaluate suspected or confirmed Crohn’s disease (38%), obscure mid gastrointestinal (GI) bleeding (28%), suspected malignancy or abnormal imaging (20%), detect polyps in suspected or confirmed polyposis syndrome (7%) and refractory coeliac (1%). 25% of patients had more than one indication for DBE. DBE findings: 50% had normal examinations, 11% Crohn’s disease, 16% non-specific inflammation, 10% polyps, 4% tumours and 1% coeliac disease. Other diagnoses included small bowel angioectasia and radiation enteritis. The overall diagnostic yield was 50%. The diagnostic yield for suspected Crohn’s disease was 29%, evaluation of obscure mid GI bleeding was 31%, suspected polyps was 40%, refractory Coeliac was 100% and the evaluation of malignancy and abnormal imaging was 11%. 95% of patients who had a normal DBE had prior abnormalities in their imaging. Limitations: 10 procedures were incomplete due to equipment failure (5), persistent looping (4) &amp; inability to pass strictures (1). 1 was abandoned due to poor bowel preparation. Therapy was performed in 13 (14%) procedures: 3 dilatation of strictures, 5 had Argon Plasma Coagulation, 4 polypectomies and 1 had a bleeding ulcer clipped. No complications were recorded at DBE for any patients <h3>Conclusion</h3> Our DBE service is safe and complements other imaging modality. Our overall diagnostic yield is 50%. Our main indication for DBE is to evaluate suspected Crohn’s (38%) rather than for obscure GI bleeding as in the literature.¹ Even with stringent case selection the diagnostic yield for DBE was lower than the preceding VCE. <h3>Reference</h3> 1 Seong Ran, <i>et al</i>. Changes over time in indications, diagnostic yield, and clinical effects of double-balloon enteroscopy. <i>Clin Gastroenterol Hepatol</i> 2012;<b>10</b>(10):1152–1156. <h3>Disclosure of Interest</h3> None Declared

Double-Balloon Enteroscopy-detected Lipid Islets in the Small Bowel are Strong Predictors of Cardiovascular Disease when associated with Angiectasia and Bleeding.

Double-balloon enteroscopy (DBE) is a sensitive and safe procedure for the detection and treatment of mid-gastrointestinal bleeding (MGIB). It combines the possibility of a panenteroscopy with the immediate chance for intervention. This study evaluates the yield of DBE for the detection and treatment of MGIB in an unselected patient cohort. In a five-year period a total of 119 DBEs were carried out on 62 patients due to MGIB. Inclusion criteria were hematochezia, melena, anemia, positive hemoccult-test and iron deficiency. All pre-existing diseases or comorbidities were evaluated. Two main statistical methodologies were used in data analysis: descriptive statistics to describe the basic features of our data and Fisher's exact test for comparisons of proportions. The diagnostic yield was 69% (pathological findings in 43/62 patients) and the main diagnoses in all DBE-procedures were angiodysplasia (22%, 26/119 DBE), followed by lipid islets (18%, 21/119 DBE). In all patients with lipid islets this diagnosis was significantly connected with cardiovascular diseases. The combination of lipid islets and a relevant bleeding source appeared in 79% of the 19 patients with these findings. Of these, 53% had to be treated due to the bleeding event. The overall therapeutic intervention rate was 58%. Serious complications such as perforation or pancreatitis did not occur. Double-balloon enteroscopy as the gold standard for small bowel investigation in MGIB confirmed its high diagnostic yield in an unselected cohort of patients. A new strong combination of lipid islets with cardiovascular disease was revealed, with a high incidence of angiectasia bleeding. This combination should be evaluated in more detail as a new risk factor for MGIB, and should be regarded in this population when therapeutic anticoagulation is needed.

Mo1615 Suspected Mid-Gastrointestinal Bleeding: How Often the Source of Bleeding Is Detected… Outside of the Small Bowel?

212 (37%) had rDBE. There was no difference in age, gender or indications between the two groups. Mean age of patients who underwent aDBE was 68.5 years (21-94); and rDBE was 61.2 years (21-92). Gender distribution for aDBE: 181 (50%) male, 180 (50%) female. For rDBE, the gender distribution was 104 (49%) male, 108 (51%) female. Indications for aDBE were obscure overt GI bleed (OGIB) 158 (44%), occult GI bleed 131 (36%), abdominal pain 35 (10%), diarrhea 19 (5%), nausea & vomiting 10 (3%), suspected inflammatory bowel disease (IBD) 13 (4%) and surveillance of familial polyposis syndrome (FPS) 5 (1 %). Indications for rDBE were OGIB 67 (32%), occult GIB 59 (28%), abdominal pain 48 (22%), diarrhea 20 (9%), suspected IBD 18 (8%) and FPS surveillance 3 (1%). There was a significantly higher diagnostic yield with aDBE for vascular lesions(table 1). There was no difference between aDBE and rDBE for SB inflammation or tumors. There was also a significantly higher therapeutic yield with aDBE (table 2).There was a higher complication rate of bleeding with antegrade DBE (nZ10, 3%) compared with retrograde DBE (nZ1, 0.4%). There was one perforation (n Z 1, 0.4%) with retrograde DBE. Conclusion: Antegrade DBE has a significantly higher diagnostic and therapeutic yield than retrograde DBE for all SB lesions, mainly angioectasias. Our results support antegrade DBE as the initial approach for majority of patients with suspected SB disorders. Retrograde DBE may be useful when antegrade DBE is negative, and in management of patients with known distal SB lesions. Table 1. Diagnostic Yield with Antegrade and Retrograde DBE

Examining the whole bowel, double balloon enteroscopy: Indications, diagnostic yield and complications.

Double balloon enteroscopy (DBE) is an advanced type of endoscopic procedure which brings the advantage of reaching the whole small bowel using anterograde or the retrograde route. This procedure is both diagnostic and interventional for a variety of small intestinal diseases, such as vascular lesions, tumors, polyps and involvement of inflammatory bowel diseases. Main indication is the diagnosis and treatment of mid-gastrointestinal bleeding according to the recent published data all over the world. The complication rates seem to be higher than conventional procedures but growing experience is lowering them and improving the procedure to be safe and well tolerated. This review is about the technique, indications, diagnostic importance and complications of DBE according to the literature growing since 2001.

Capsule endoscopy in a supra-regional network corporation: experience in more than 1000 cases

Capsule endoscopy (CE) is firmly established as a standard procedure in the diagnostic algorithm of mid gastrointestinal (GI) bleeding. Despite its excellent diagnostic yield, missing expertise, reading time and financial expenditure limit an area-wide availability. A multicentric cooperation might compensate these disadvantages. The CE device was bought by a centrally located hospital (CH). CE-equipment is transported to the network partner (NP) on request and the procedure performed at the spot. Video reading is exclusively done in the CH. Between January 2002 and July 2013, 1026 CE (548 m, 478f; 64 ± 16, 13 - 93 yrs.) were performed within the network. 744/1026 (73 %) CE were done at 17 NP, 282/1026 (27 %) in the CH. Between 2002 (n = 39) and 2012 (n = 136) the annual number of CE increased threefold. Leading indication for CE was suspected mid GI-bleeding (80 %). Mean latencies between requested date and actual examination were less than 24 h and 2 days between CE performance and report. 95 % of the capital investment in each cooperating hospital could be avoided by sharing one workstation within the network. The experience from more than 1000 CE show that long-term multicentric utilization of CE equipment is feasible. Such a network runs at stable procedural quality levels similar to an in-house supply, allows an economic as well as area-wide availability of CE and improves reading expertise by centralized video evaluation.

Mittlere gastrointestinale Blutung – die Endoskopie bringt Licht ins Dunkel

Mid-gastrointestinal bleeding is defined as a bleeding of the small bowel and is the most common indication for small bowel endoscopy. Intraoperative enteroscopy has been regarded as gold standard for a long time. With the introduction of different endoscopy techniques, they play now the central role, whereas intraoperative enteroscopy has become a reserve method for selected patients. Actually, there are, beside capsule endoscopy, five non-surgical, flexible enteroscopy techniques available. In Germany and Europe balloon-assisted enteroscopy (double balloon and single balloon enteroscopy) is mainly used. Double balloon enteroscopy (DBE) is the "oldest" flexible enteroscopy technique and has become established throughout the world for diagnostic and therapeutic examinations of the small bowel. The majority of the studies have been performed with DBE and it provides the highest rate of complete enteroscopy. Nevertheless, technical improvements to make enteroscopy easier and faster are still required. In patients with chronic MGI or problematic situations capsule endoscopy is an ideal screening option. In case of acute MGI the flexible enteroscopy techniques should be preferred because of the high diagnostic yield combined with the possibility of endoscopic therapeutic interventions. In difficult cases with unsuccessful enteroscopy, CT angiography and conventional angiography with the option of embolisation had proved their value.

Small bowel pleomorphic liposarcoma: a rare cause of gastrointestinal bleeding.

In this case report we present a 60-year-old male patient with overt midgastrointestinal bleeding of a primary ileal pleomorphic liposarcoma diagnosed by video capsule endoscopy (VCE). Clinical work-up for final diagnosis and the pathological background of this uncommon tumorous entity of the small bowel will be discussed in this paper.

Large Jejunal Diverticulum

Jejunal diverticula are rare and usually asymptomatic. Possible complications include bacterial overgrowth, mid-gastrointestinal bleeding, and inflammation. Here the authors demonstrate a patient with recurrent abdominal inflammation and abscess formation that could be attributed to a large jejunal diverticulum. This article is part of an expert video encyclopedia.

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

Capsule Endoscopy in Patients with Cardiac Pacemakers and Implantable Cardioverter Defibrillators: (Re)evaluation of the Current State in Germany, Austria, and Switzerland 2010.

Background and Aims. The study was a repeated evaluation of the experience of capsule endoscopy (CE) in patients with cardiac pacemaker or implantable cardioverter defibrillator (ICD). Patients and Methods. A standardized questionnaire was sent by the manufactors Given Imaging and Olympus to all centers in Germany, Austria, and Switzerland providing capsule endoscopy service. The questionnaire covers the number of examined patients, monitoring during CE, check of the electric implants before and after CE, occurrence of arrhythmia, quality of CE video, complications, indication of CE, and type of institution. Results. Overall 580 questionnaires were sent to the users. 26/5% (Germany/Austria + Switzerland) of the questionnaires were sent back anonymously to the authors. 114 centers (82 hospitals, 11 surgeries, 21 without specification) replied. In 58 centers (51%), patients with cardiac pacemaker (n = 300) and ICDs (n = 80) underwent uneventful capsule endoscopy. The predominant indication (patients with CP 97%, patients with ICD 100%) was mid gastrointestinal bleeding. Conclusion. The results of our inquiry show that in spite of formal contraindication CE is increasingly applied in bleeding patients with cardiac pacemakers/ICDs and seems to be safe even in a large cohort.

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.

Prospective, cross-over, single-center trial comparing oral double-balloon enteroscopy and oral spiral enteroscopy in patients with suspected small-bowel vascular malformations

Spiral enteroscopy is a new, promising rapid enteroscopy technique. A prospective cross-over study was carried out to compare this new method with the established technique of double-balloon enteroscopy (DBE). From an initial group of 18 patients with suspected mid-gastrointestinal bleeding due to vascular malformations but no previous history of small-bowel or colonic surgery, 10 patients (mean age 69 years) completed the study. Patients underwent both enteroscopy techniques with an oral approach, in a randomized sequence. The deepest point reached during advancement in the first enteroscopy was marked with India ink. The primary end point of the study was the total examination time. For spiral enteroscopy, the mean examination time was significantly shorter than with DBE (43 minutes vs. 65 minutes; P = 0.007), as was the mean time required for advancement of the enteroscope to the deepest point (24 minutes vs. 43 minutes; P = 0.03). However, the median maximum insertion depth was greater in the DBE group than in the spiral enteroscopy group (310 cm vs. 250 cm; P = 0.004). In all cases in which DBE followed spiral enteroscopy, DBE passed the India ink mark by a mean of over 100 cm. When DBE was performed first, spiral enteroscopy was either unable to reach the mark or else unable to advance deeper into the small bowel. No severe complications occurred. The results confirm that the new spiral enteroscopy technique reduces the examination time, although the insertion depth with DBE is at present superior.

Prospective Multicenter Trial Comparing Push-and-Pull Enteroscopy With the Single- and Double-Balloon Techniques in Patients With Small-Bowel Disorders

Double-balloon enteroscopy (DBE) is now an established method for diagnostic and therapeutic small-bowel endoscopy. Single-balloon enteroscopy (SBE) has been introduced to simplify the technique. A prospective randomized study was carried out to compare the two methods. The study included 100 patients (50 in each group; 63 men, 37 women; mean age 55 years), with no previous small-bowel or colon surgery. The indications for enteroscopy were (suspected) mid-gastrointestinal bleeding, Crohn's disease, small-bowel masses, chronic diarrhea or abdominal pain or both, and other conditions. Fujinon instruments were used, with either two balloons or one. The end point of the study was complete enteroscopy as the most objective parameter. No severe complications such as perforation, bleeding, or pancreatitis occurred. Instrument preparation time was significantly faster with SBE than with DBE (P<0.0001). Complete enteroscopy was achieved with the DBE technique in 66% of cases (33 patients), either with the oral route alone or with combined oral and anal approaches. With the SBE technique, the complete enteroscopy rate was significantly lower at 22% (P<0.0001; 11 patients, only with oral and anal routes combined). The rate of therapeutic consequences for the patients based on diagnostic yield and negative complete enteroscopy was significantly higher (P=0.025) in the DBE group at 72%, compared with 48% in the SBE group. The complete enteroscopy rate was three times higher with DBE than with SBE, accompanied by a higher diagnostic yield. DBE must therefore continue to be regarded as the nonsurgical gold standard procedure for deep small-bowel endoscopy.