Retrograde Double-balloon Enteroscopy Research Articles

Efficacy and safety of double- versus single-balloon retrograde enteroscopy.

Data on the safety and efficacy of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE) are conflicting. We aimed to compare the efficacy and safety of retrograde DBE to SBE. We performed a retrospective analysis of all patients who underwent retrograde DBE or SBE at a large tertiary referral center from 2008 to December 2018. Outcomes assessed included technical success, diagnostic yield, therapeutics, depth of insertion, and procedural duration. A total of 523 (403 DBE, 120 SBE) patients underwent retrograde enteroscopy during the study period. The mean age was 59.4 ± 17.24 and 59.57 ± 16.94 years in DBE and SBE groups, respectively. There was no difference in technical success (91.0% vs. 92.5%, P = 0.85), diagnostic yield (40.9% vs. 40.8%, P = 0.95), and therapeutics (17.1% vs. 19.1%, P = 0.61) between DBE and SBE. Compared to SBE, DBE had significantly shorter mean procedure time (26.5 ± 34.5 min vs. 34.8 ± 29.4 min, P = 0.01) and higher maximal depth of insertion from ileocecal valve (108.1 ± 84.1 cm vs. 73.3 ± 63.4 cm, P = 0.001). Safety events were rare and similar in both groups. Retrograde DBE is associated with a significantly higher depth of insertion and shorter procedural duration, but similar diagnostic yield and technical success compared to SBE.

Clinical Features and Management of Small Bowel Masses Detected During Device-Assisted Enteroscopy: A Multi-Center Experience.

Small bowel mass lesions (SBMLs) are rare, span a range of different histologies and phenotypes, and our understanding of them is limited. Some lesions occur in patients with recognized polyposis syndromes and others arise sporadically. The current literature regarding SBMLs is limited to small retrospective studies, case reports, and small case series. This large multi-center study aims to understand the various clinical presentations, histologies and management options for SBMLs. After obtaining Institutional Review Board (IRB) approval, electronic records were used to identify all device-assisted enteroscopy (DAE) performed for luminal small bowel evaluation in adult patients at three US referral centers (Duke, LSU and UMass) from January 1, 2014, to October 1, 2020. We identified all patients within this cohort in whom a SBML was detected. Using a focused electronic medical record chart review, we collected patient, procedure, and lesion-related data and used descriptive statistics to explore relationships between these data and outcomes. A total of 218 patients (49 at Duke, 148 at LSU, and 21 at UMass) in this cohort had at least one SBML found on DAE. The most common presenting symptoms were iron-deficiency anemia/bleeding (73.3%) and abnormal imaging (33.6%). Thirty-five percent of patients had symptoms for more than a year prior to their diagnosis. Most patients (71.6%) underwent video capsule endoscopy (VCE) prior to DAE and 84% of these exams showed the lesion. The lesion was seen less frequently (48.9%) on computed tomography (CT) scan performed prior to DAE. The majority of lesions were found on antegrade (56%) or retrograde (29.8%) double-balloon enteroscopy (DBE). The most common lesion phenotypes were submucosal (41.3%) and pedunculated (33%) with a much smaller number being sessile (14.7%) or obstructing/invasive (11%). They were found equally as commonly in the jejunum (46.3%) and ileum (49.5%). Most lesions were 10 - 20 mm in size (47%) but 22.1% were larger than 20 mm. The most common histologies were neuroendocrine tumors (NETs, 20.6%) and hamartomas (20.6%). Primary adenocarcinoma of the small bowel was rare, constituting only 5% of lesions. The majority of polyps (78.4%) were sporadic, compared to 21.7% associated with a polyposis or hereditary cancer syndrome, most commonly Peutz-Jeghers syndrome (18.3%). After DAE, 37.6% were advised to undergo surgical resection and 48% were advised to undergo endoscopic surveillance or no further management because of benign histology or successful endoscopic resection. In this multi-center retrospective study we found that SBMLs are more likely to be sporadic than syndromic, medium in size and either pedunculated or submucosal. NETs and hamartomas predominated and symptoms, most commonly anemia, can be present for more than a year prior to diagnosis. Close to one half of lesions required either no further intervention or only endoscopic surveillance.

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%)

S551 Efficacy and Safety of Double- versus Single-Balloon Retrograde Enteroscopy

Introduction: Previous studies have reported conflicting results on the outcomes of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE). We aimed to compare efficacy and safety of DBE to SBE via retrograde approach. Methods: We performed a retrospective analysis of all patients who underwent retrograde DBE or SBE at a large, tertiary referral center from 2008 to 2018. Data was collected on demographics, baseline comorbidities, antiplatelet and anti-coagulation use. Outcomes assessed included technical success, diagnostic yield, therapeutics, depth of insertion and procedural duration. The analysis was done using SPSS software. Results: A total of 523 (403 DBE, 120 SBE) patients underwent retrograde enteroscopy during the study period. The mean age was 59.4 ± 17.24 and 59.57 ± 16.94 in DBE and SBE group, respectively. There was no difference in gender, comorbidities, smoking history, clopidogrel, anti-coagulation use, platelet count, and laboratory parameters between both groups. Aspirin use was significantly higher in DBE group (40.8% vs. 29.9%, P = 0.03) (Table 1). The indication for enteroscopy was obscure gastrointestinal bleeding (OGIB) in 66.5% and 55.8% of DBE and SBE procedures, respectively. There was no difference in technical success (91.0% vs. 92.5%, P = 0.85), diagnostic yield (40.9% vs. 40.8%, P = 0.95) and therapeutics (17.1% vs. 19.1%, P = 0.61) between DBE and SBE. Compared to SBE, DBE had significantly shorter mean procedure time (26.5 ± 34.5 min vs. 34.8 ± 29.4 min, P = 0.01) but higher maximal depth of insertion from ileo-cecal valve (108.1 ± 84.1 cm vs. 73.3 ± 63.4 cm, P = 0.001). In addition, proximal ileum was reached in 22.6% of DBE procedure as compared to 6% in SBE (P < 0.001). On subgroup analysis based on OGIB indication, DBE again had significantly higher depth of insertion (113.1 ± 87.07 cm vs. 79.9 ± 66.5 cm, P = 0.02) and rates of proximal ileum reach (23.7% vs. 7.1%, P = 0.006) as compared to SBE but there was no statistically significant difference in diagnostic yield (34.5% vs. 26.9%, P = 0.23) and therapeutics (20.3% vs. 14.9%, P = 0.31). Safety events were rare and similar in both groups (Table 2). Conclusion: Retrograde DBE is associated with significantly higher depth of insertion and shorter procedural duration but similar diagnostic yield and technical success as compared to.Figure:: Baseline and Demographics factors for both groupsTable 2.: Outcomes comparing DBE and SBE

DIEULAFOY’S LESION OF JEJUNUM PRESENTING AS AN OBSCURE GASTROINTESTINAL BLEEDING: A CASE REPORT

Obscure gastrointestinal bleeding has been designated as bleeding of unknown origin that persist or recurs after a negative initial or primary endoscopy (colonoscopy and upper endoscopy). We present a case of 16 years old male who was admitted at our hospital with presentation of black tarry hard foul-smelling stool associated with weakness, dizziness and loss of consciousness for 10-15 minutes. Physical examination showing pallor. Upper GI Endoscopy, colonoscopy and double balloon Enteroscopy (DBE) failed to find out the cause of bleeding whereas, CT angiography shows a prominent submucosal vessel with blush of contrast enhancement seen at mid-jejunum and suggestive of a Dieulafoy’s lesion. As the lesion was not identified properly during both anterograde and retrograde Double Balloon Enteroscopy we decided to go for the conservative management and treated the patient on close monitoring.

Unique Findings of Retrograde Double-Balloon Enteroscopy in a Rare Adult Case of Ileal Duplication.

CASE REPORT Gastrointestinal (GI) duplications are congenital malformations that can be present anywhere from the esophagus to the anus. GI duplications are usually observed in pediatric patients, and their diagnosis in adulthood is quite rare. Preoperative diagnosis of GI duplication is difficult, particularly in the small intestine.1 We encountered a rare adult case of duplication of the ileum that was accidentally diagnosed in an asymptomatic state using double-balloon endoscopy (DBE). A 28-year-old man was admitted to our hospital for assessment of the cause of an abnormal calcification shadow that was incidentally detected on an abdominal x-ray image obtained during the treatment of orthopedic back pain. Abdominal computed tomography revealed a sac-like structure on the mesenteric side of the ileum, containing a calcification inside. Retrograde DBE revealed a bifurcated lumen in the ileum, located approximately 100 cm from the ileocecal valve. The narrow lumen had a sac-like cavity with a blind end and contained a hard white-yellowish spherical substance (Figure 1). Small bowel follow-through showed that the sac-like structure was present on the mesenteric side. The patient underwent partial resection of the ileum, including the sac-like structure. The sac-like structure was approximately 5 cm in diameter and had a giant fecalith inside. On microscopic observation, the lumen of the sac-like structure had normal small intestinal mucosa, without any ectopic gastric mucosa, pancreatic tissue, erosion, or ulcer (Figure 2).Figure 1.: Retrograde double-balloon enteroscopy showing (A) a bifurcated lumen in the ileum approximately 100 cm from the ileocecal valve and (B) a sac-like cavity with a blind end containing a giant fecalith.Figure 2.: Macroscopic and microscopic observation of the excised specimen showing that the lumen of the sac-like structure has normal small intestinal mucosa, without any ectopic gastric mucosa, pancreatic tissue, erosion, or ulcer.Based on these findings, we diagnosed the patient with duplication of the ileum. Here, the unique findings of retrograde DBE aided in making the diagnosis. The present case may be the first case in which ileal duplication with a giant fecalith was directly observed endoscopically. Previously, there have been only 3 reported cases in which intestinal duplication was detected using DBE.2–4 All these cases were adults with ileal duplication. Similar to our case, bifurcated lumen with a blind end was detected by retrograde DBE in 2 of these 3 cases.3,4 A case reported by Ogino et al only had a diverticular-like luminal opening, and a duplication cyst was confirmed postoperatively.2 Our case and previous reports indicate that DBE can be a useful tool for diagnosing intestinal duplication in adults, characterized by either a bifurcated or diverticular-like lumen with a blind end. DISCLOSURES Author contributions: All authors contributed equally to this manuscript. K. Endo is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.

S1852 Retrograde Balloon-Assisted Deep Enteroscopy in the Diagnosis of Metastatic Melanoma

INTRODUCTION: A 74 year old male with past medical history of melanoma, presents to clinic due to persistently abnormal small bowel findings on PET-CT scan. The following case illustrates a unique and unusual case of metastatic gastrointestinal disease, and the utility of both capsule endoscopy and balloon-assisted deep enteroscopy to assist in the diagnosis of metastatic melanoma. CASE DESCRIPTION/METHODS: A 74 year old male with past medical history of previously excised melanoma in remission presented to clinic due to persistently abnormal small bowel findings on surveillance PET-CT scan. Patient reported feeling well. Over the last 2 years, multiple PET scans had shown intense focal FDG uptake in distal small bowel, deemed to be inflammatory in nature although melanoma recurrence remained a possibility. Given recurrent findings, patient underwent capsule endoscopy which revealed ulcerated, nodular, and erythematous mucosa likely in distal ileum. Patient underwent retrograde double balloon enteroscopy which showed ulcerated, edematous mucosa in distal ileum at 95 cm from ileocecal valve, with biopsies consistent with metastatic melanoma as confirmed by the presence of melanin in tumor biopsy and positive staining. The site of the lesion was marked with SPOT Tattoo to allow for intraoperative localization. Patient underwent surgical resection which revealed second area of ileal metastasis, which was safely resected. DISCUSSION: The following case illustrates the utility of capsule endoscopy to identify small bowel metastasis; an atypical use in the current practice of capsule endoscopy. This case details how retrograde double balloon enteroscopy, in combination with diagnostic modalities such as PET scans and capsule endoscopy, can assist in the diagnosis of distal small bowel disease including metastasis. This case also illustrates how SPOT tattoo utilization may assist with intraoperative surgical localization of suspicious lesions. While metastatic melanoma in the small intestine is a well-described phenomenon, small bowel metastasis has been detected clinically in only 2%–5% of patients with malignant melanoma. Although these lesions are typically resected surgically for diagnosis, our case illustrates the role of initial small bowel endoscopic imaging to assist in localization to facilitate intraoperative management, and that the combination of capsule endoscopy and retrograde double balloon enteroscopy is a practical and feasible method to evaluate for metastatic disease in the distal small bowel.Figure 1.: Area of ulcerated, nodular, erythematous and congested mucosa seen on Capsule Endoscopy.Figure 2.: Area of ulcerated, nodular, erythematous and congested mucosa seen on Capsule Endoscopy.Figure 3.: Area of ulcerated, erythematous and congested mucosa identified on Retrograde Deep Balloon Enteroscopy.

S0972 Enteroscopy Enabled Using a Novel Dynamic Rigidizing Overtube: An Initial Single Center Experience

INTRODUCTION: Single or double balloon enteroscopy is able to visualize the small bowel well but is not readily available due to the cost and procedural expertise required. A novel dynamic rigidizing overtube is now available to assist with difficult colonoscopy. In its flexible state, the overtube material is soft and pliable, but in its rigid state becomes 15× stiffer when a vacuum is applied. This aids in stability and minimizing loop formation. The aim of this study was to assess feasibility and safety of this novel device for use in performing antegrade and retrograde enteroscopy. METHODS: This was a retrospective study over a 6 month period in which two endoscopists performed retrograde and antegrade enteroscopies using a novel rigidizing overtube. Retrograde enteroscopy was performed via the anus by advancing the overtube to the cecum in its flexible state with the pediatric colonoscope, reducing the scope and overtube construct, and then rigidizing at the cecum. Following rigidization, the scope was pushed through the ileocecal valve and advanced maximally. Antegrade enteroscopy was performed by inserting the dynamic rigidizing overtube with use of the pediatric colonoscope via the mouth, rigidizing in the duodenum or jejunum, and then advancing maximally. RESULTS: A total of 9 retrograde and 3 antegrade enteroscopies were performed. On retrograde enteroscopy, small bowel depth ranged from 15cm to 70cm from the ileocecal valve, with a mean of 48.9cm. There were no complications associated with use of the dynamic rigidizing overtube, both in antegrade and retrograde evaluation. Of note, in one case, initial attempts at retrograde double-balloon enteroscopy failed due to looping and unfavorable angulation of the ileocecal valve. Multiple attempts at intubation including manual abdominal pressure and position changes were unsuccessful. The dynamic rigidizing overtube was then introduced with successful intubation and subsequent exploration of the ileum. Overall, both endoscopists reported significant ease of enteroscopy compared to traditional double-balloon methods, with lower perceived mental and physical demand. CONCLUSION: In this initial study, the novel dynamic rigidizing overtube successfully facilitated both antegrade and retrograde enteroscopy without adverse events. Our results suggest that use of this dynamic rigidizing overtube may have a role in performing enteroscopy in select patients.Figure 1.: Image of the rigidizing overtube. The overtube is placed at the hub of the colonoscope, allowing free tip movement. When the vacuum is applied, the normally flexible overtube becomes fifteen times as rigid, allowing 1 to 1 movement when force is applied to the shaft of the colonoscope.

Meckel's diverticulum with polypoid hyperplasia of ectopic gastric mucosa diagnosed by double-balloon enteroscopy and single-photon emission computed tomography/computed tomography.

Meckel’s diverticulum (MD) is a relatively common true congenital diverticulum on the ileum. Bleeding caused by polypoid hyperplasia of ectopic gastric mucosa in MD is rare. A 14-year-old Chinese boy presented with intermittent melena and haematochezia for 1 month. Laboratory data showed normocytic anaemia. Gastroscopic findings were normal. The patient underwent exploratory laparotomy without bowel preparation on day 2 because of sudden haematochezia and decreased haemoglobin. Intraoperative colonoscopy revealed inflammatory changes in the terminal ileal mucosa with diffuse haemorrhage. Melena with decreased haemoglobin recurred 20 days after the first operation. Computed tomography (CT) and angiography revealed a tubular lesion that was localised in the right lower abdominal quadrant. Single-photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging with 99m-technetium pertechnetate confirmed moderately increased uptake in the distal ileum. Retrograde double-balloon enteroscopy (DBE) showed a diverticulum with prominent mucosal polypoid hyperplasia at an insertion depth of 100 cm from the anastomotic stoma. Diverticulectomy and end-to-end anastomosis were performed, and MD was confirmed by a histopathological examination. The patient’s postoperative recovery was uneventful during the 2-month follow-up. MD with polypoid hyperplasia of ectopic gastric mucosa is rare. Complementary use of DBE and SPECT/CT can accurately diagnose MD by providing anatomical and functional information.

2561 Not All That Ulcerates Is Crohn's: A Malignant Mimic of Small Bowel Crohn's Disease

INTRODUCTION: Capsule endoscopy (CE) is indicated in the evaluation of suspected Crohn's disease (CD) when ileocolonoscopy and radiographic studies are negative or inconclusive. However, it should be recognized that mucosal breaks or ulcers alone are not always diagnostic of CD. CASE DESCRIPTION/METHODS: A 55 year-old man from India who immigrated to the US as a child was admitted to an outside hospital with 6 months of bilateral lower quadrant abdominal pain and iron-deficiency anemia. After normal upper endoscopy and colonoscopy, CE showed an ulcer and inflamed mucosa in the ileum. On this basis he was diagnosed with CD and treated with prednisone. The next month he was admitted to our institution with ongoing abdominal pain and unintentional weight loss but no diarrhea or hematochezia. On exam his vital signs and body mass index were normal. His abdomen was soft without organomegaly or palpable mass. He was tender to palpation in the bilateral lower quadrants. Stool was brown. Laboratory results were Hgb 8.3 g/dL, iron studies consistent with iron-deficiency, albumin 2.8 g/dL, C-reactive protein 150 mg/L, and erythrocyte sedimentation rate 45 mm/hr. CT enterography showed wall thickening of the mid-ileum with mucosal enhancement and mesenteric root adenopathy. Retrograde double balloon enteroscopy 90 cm into the ileum revealed a 15 mm shallow ulcer 80 cm proximal to the ileocecal (IC) valve and a similar ulcer 15 cm proximal to the IC valve. Biopsies showed ulcerated mucosa with infiltrating atypical cells that stained positive for ERG, a highly specific endothelial marker, and negative for other immunostains, leading to a diagnosis of primary intestinal angiosarcoma. DISCUSSION: Primary intestinal angiosarcoma is a rare soft tissue sarcoma that may present with abdominal pain, GI bleeding, obstruction, or weight loss. Tumors, detected on 2-4% of CEs, are in the differential diagnosis for small bowel CD along with infection, ischemia, vasculitis, lymphoma, Behcet disease, radiation enteritis, and drug-induced enteritis. In suspected CD, there is no reference standard or uniform criteria for diagnosis by CE. And, many of the lesions that lead to a diagnosis of CD are non-specific with the specificity of CE for CD as low as 53% and the positive predictive value &lt;60% in some studies. Thus, findings of CE should be interpreted with an adequate degree of skepticism and a broad differential diagnosis considered to minimize mimics being mistaken for CD.

871 Impact of Patient Screening Process on Diagnostic and Therapeutic Yield of Double Balloon Enteroscopy

INTRODUCTION: Double balloon enteroscopy (DBE) is an important tool for evaluation of obscure GI bleeding but is a limited resource given time and expertise required. Patient selection is important to help optimize diagnostic yield and subsequent successful management of small bowel bleeding. To maximize the efficiency of DBE performed, our endoscopy group established a screening protocol (Figure) prior to approval of any procedure. We developed a quality improvement project to assess the efficacy of this screening protocol and to evaluate which components of screening were most predictive for procedural success. METHODS: A retrospective chart review was performed on all patients who underwent anterograde or retrograde double balloon enteroscopy for suspected GI bleeding from January 2016 to December 2017. Our screening protocol was implemented on February 1st, 2017. Data was obtained on patient demographics, clinical presentation, laboratory evaluation, and prior investigation for bleeding evaluation. Endoscopy outcomes were separated into procedural success, defined as lesion identified, and clinical success, defined as resolution of bleeding. Success rates were compared pre and post intervention. Regression analysis was performed to evaluate which components best predicted a successful procedure. RESULTS: We reviewed 114 DBE procedures in 89 patients, 53.5% male (n = 61) with a mean age of 62.8 + 13.3 years. Of these, 86% (n = 98) were performed prior to initiation of the screening protocol. Overall, there was no significant difference in procedural success pre and post intervention as defined by presence of recurrent bleeding, persistent anemia, or transfusion need (Table 1). On univariate analysis of clinical success, defined as lack of recurrent bleeding, gender, anticoagulation use, and presence of lesion on CE were significant (Table 2). Identification and intervention on a lesion during the balloon endoscopy did not impact future anemia, bleeding, or transfusion requirements. CONCLUSION: The patient screening protocol was successful in decreasing the number of procedures performed but did not improve our lesion detection rate on endoscopy and did not improve clinical outcomes as measured by rebleeding. Patients on anticoagulation and those who had prior lesions identified on capsule endoscopy had higher odds of rebleeding, indicating clinical failure. This data may help modify patient selection to maximize success of DBE procedures in the future.

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.

Composition of the mucosa-associated microbiota along the entire gastrointestinal tract of human individuals.

Background Homeostasis of the gastrointestinal tract depends on a healthy bacterial microbiota, with alterations in microbiota composition suggested to contribute to diseases. To unravel bacterial contribution to disease pathology, a thorough understanding of the microbiota of the complete gastrointestinal tract is essential. To date, most microbial analyses have either focused on faecal samples, or on the microbial constitution of one gastrointestinal location instead of different locations within one individual.ObjectiveWe aimed to analyse the mucosal microbiome along the entire gastrointestinal tract within the same individuals.MethodsMucosal biopsies were taken from nine different sites in 14 individuals undergoing antegrade and subsequent retrograde double-balloon enteroscopy. The bacterial composition was characterised using 16 S rRNA sequencing with Illumina Miseq.ResultsAt double-balloon enteroscopy, one individual had a caecal adenocarcinoma and one individual had Peutz-Jeghers polyps. The composition of the microbiota distinctively changed along the gastrointestinal tract with larger bacterial load, diversity and abundance of Firmicutes and Bacteroidetes in the lower gastrointestinal tract than the upper gastrointestinal tract, which was predominated by Proteobacteria and Firmicutes.ConclusionsWe show that gastrointestinal location is a larger determinant of mucosal microbial diversity than inter-person differences. These data provide a baseline for further studies investigating gastrointestinal microbiota-related disease.

Su1361 THE YIELD OF VIDEO CAPSULE ENDOSCOPY AND DOUBLE-BALLOON ENTEROSCOPY IN THE DIAGNOSIS OF OBSCURE GASTROINTESTINAL BLEED

Deciding to perform antegrade or retrograde double-balloon enteroscopy (DBE) accordingly to identify findings on video capsule endoscopy (VCE) can be challenging. We ought to develop a model to facilitate the decision making process on the DBE approach according to VCE findings and other possible pertinent factors, like intake of opioid and prior bowel surgery.

Obscure Gastrointestinal Hemorrhage Secondary to Meckel’s Diverticulum Diagnosed by Retrograde Double-Balloon Enteroscopy

Obscure Gastrointestinal Hemorrhage Secondary to Meckel’s Diverticulum Diagnosed by Retrograde Double-Balloon Enteroscopy

Impact of Double Balloon Enteroscopy (DBE) on Resource Utilization for Evaluation of Obscure Gastrointestinal Bleeding

Introduction: Gastrointestinal bleeding (GIB) is a common health care issue associated with significant utilization of economic resources. Evaluation requires the use of multiple modalities such as EGD, colonoscopy, video capsule endoscopy (VCE) and CT angiography. In approximately 5% of patients no source is identified via said methods. Double balloon enteroscopy (DBE) has emerged as a diagnostic and therapeutic procedure for obscure GIB. We aimed to determine if performing DBE reduced resource utilization in terms of subsequent procedures and interventions. Methods: A retrospective cohort study was conducted of patients (n=356) who underwent DBE for evaluation of OGIB between Nov 2012 and Aug 2016. Outcomes assessed include procedures performed (EGD, colonoscopy, VCE, blood transfusions) within 6 months prior to initial DBE and for repeat procedures including repeat DBE (antegrade and retrograde) 6 months after initial intervention. The relative risk ratio (RR) and its 95% confidence interval (95%CI) was used indicate the difference between post and pre-intervention. Generalized estimating equation (GEE) approach was used to evaluate the relative risk (RR), accounting for repeated measures. Results: Of 356 patients, a total of 256 were performed in 121 patients prior to initial intervention. Amongst these patients, 25 % (n=89) had at least one EGD, 11.5 % (n=41) colonoscopy, 18.3 % (n=65) VCE and 3.9% (n=14) CT angiography performed before intervention. Post intervention, a total of 145 procedures was applied to 82 patients including antegrade and retrograde DBE. The GEE analysis suggested that the risk of receiving procedures significantly decreased post intervention, with relative ratio RR=0.57 (0.42, 0.76), p<.0001. Similarly, for blood transfusions: before the intervention 311 blood transfusions were applied to 47 patients; while after the intervention, only 181 blood transfusions were applied to 38 patients. The risk of receiving blood transfusions significantly decreased post intervention, with RR=0.58 (0.34, 0.98), p=0.0431. Conclusion: DBE is an effective procedure for identifying and treating obscure gastrointestinal bleeding. It results in a significant decrease in number of procedures employed for identifying GIB, if utilized earlier during the course evaluation. The lack of availability of DBE at most centers is a limitation to its utility. There is a need for more frequent use of DBE for GIB to limit the expenditure on unwanted interventions.

Donʼt Stop Looking: Lower Gastrointestinal Hemorrhage Secondary to Appendiceal Orifice Bleeding

The patient is a 53 year old male who presented to the hospital with anemia and gastrointestinal hemorrhage. The decision was made to pursue an endoscopic work up with upper endoscopy and a colonoscopy. The upper endoscopy was nondiagnostic, however a large amount of hematochezia noted during his colonoscopy. Further work up with a bleeding scan did not reveal active bleeding, prompting us to pursue a capsule endoscopy. There was an area of active bleeding noted in the distal small bowel which led to patient being scheduled for retrograde double balloon enteroscopy. During this procedure, diligent attention was made to irrigate and suction remaining blood throughout the colon. After the cecum was thoroughly cleaned, a slow ooze was noted emanating from the appendiceal orifice. Withdrawal of the scope did not reveal any other potential source of bleeding. The patient subsequently underwent an appendectomy resulting in successful treatment of his hemorrhage. The specimens from surgical pathology did not reveal any obvious abnormality. The patient was subsequently discharged without any signs of overt hemorrhage. Appendiceal orifice hemorrhage is a rare cause of lower gastrointestinal hemorrhage, as there are only few case reports noted in the literature. This type of bleeding can result from ulcers, erosions, angiodysplasias, or malignancy. Appendectomy is generally curative as it was in our patient's case. This case highlights the need to remain persistent while attempting to diagnose an acute lower GI bleed

An Unusual Cause of Obscure Gastrointestinal Bleed: Ileal Inflammatory Polyp

A 58 year old male presented to his primary care physician's office with a complaint of increased fatigue with exercise over the preceding nine months. His blood work at the initial visit was notable for microcytic anemia with a hemoglobin of 8.2 g/dL, hematocrit 28.4% and MCV 65.8 fL. On further investigation, he was also found to be iron deficient. The patient had no history of anemia prior to this visit. His colonoscopy from one year prior had been unremarkable. An EGD was performed and was notable for esophagitis grade B and duodenitis on biopsy, but no other significant findings. A video capsule endoscopy revealed an area of polypoid, ulcerated mucosa in the distal small bowel. This study was followed by a CT enterography notable for a 4.5 centimeter ovoid intraluminal lesion in the distal ileum (Figure 1). A double-balloon retrograde enteroscopy performed at an outside hospital was unremarkable. The patient underwent a diagnostic laparoscopy with findings of an ileal mass proximal to the tattoo-mark of the previous retrograde double-balloon enteroscopy. The ileal segment was resected and a macroscopic examination was notable for a 3 x 2 x 1.6 cm polypoid mass with intraluminal prolapse (Figure 2). Microscopic review was notable for markedly inflamed small intestinal mucosa with edema and enlargement of intestinal villi. The inflammatory infiltrate consisted of lymphocytes, plasma cells and neutrophils with muscle wall in the middle indicating prolapse and attachment of the muscularis propria. There was no evidence of atypia or Crohn's disease. The mass was diagnosed as an inflammatory polyp of the ileum. The patient recovered without complication and his anemia resolved.1992_A Figure 1. 4.5 cm ovoid intraluminal lesion in distal ileum on CT enterography (arrows)1992_B Figure 2. Surgical specimen of ileal resection containing 3 x 2 x 1.6 cm inflammatory polypSmall bowel lesions account for approximately 5-10% of all gastrointestinal bleeding1. The most common etiologies in individuals 41-65 years of age consist of vascular anomalies, small intestinal tumors and non-specific enteritis1-3. Of these etiologies, tumors account for 5-10%4. Inflammatory polyps are nondysplastic lesions consisting of inflamed and regenerating mucosa above the mucosal surface4. These polyps are commonly found in the colon where they can be associated mainly with inflammatory bowel disease and infection5. However, small bowel inflammatory polyps are less commonly reported. When located in the small bowel, inflammatory polyps are associated with abdominal pain, iron deficiency anemia and intussusception6-9.

Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience.

Aim 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 positive diagnostic yield, therapeutic yield, and readmission. Methods We conducted a retrospective cohort study of patients (n = 420) who underwent DBE at a tertiary care center between 2012 and 2016 at a tertiary referral center. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and t-test analyses were used to compare patient characteristics. Logistic regression was used to predict outcomes of interest. Results Of patients included in the study, 59 % were male with a mean age of 61.49 (SD = 15.15) Altered anatomy was noted in 14 %, while 5 % and 13 % of patients had end stage renal disease (ESRD) and current use of anticoagulation, respectively. The most common indication for DBE was obscure gastrointestinal bleed (OGIB) (33 %). Forty-nine patients had obscure and overt gastrointestinal bleeding (GIB) and 22 % had occult GIB with iron deficiency. The cohort’s rate of positive diagnostic yield was 73 % and 35 % for therapeutic yield. The 30-day and 6-month readmission rates were both 11 %. A higher proportion of those readmitted were male (75 % vs 57 %, P = 0.027) and had longer procedural time (38.68 vs 46.57, P = 0.011). Likewise, occult GIB with iron deficiency anemia and iron deficiency alone (OR = 2.45, CI: 1.233 – 4.859, P = 0.011), inpatient status (OR 2.42, CI 1.344 – 4.346, P = 0.003), and longer procedural time (OR = 1.02, CI: 1.004 – 1.029, P = 0.008) were associated positively with readmission. Conclusion DBE procedures have relevant efficacy for both diagnostic and therapeutic yield while evaluating small bowel disease. Readmission rates are low and more in those with GI bleed and iron deficiency with longer index procedural times.

Bleeding Meckel’s Diverticulum in Children: The Diagnostic Value of Double-Balloon Enteroscopy

Background. Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. The purpose of this study was to evaluate the diagnostic value and safety of double-balloon enteroscopy (DBE) for bleeding MD in children. Methods. We included consecutive children who were highly suspected of MD between 2012 and 2013. All patients underwent Meckel's scan. DBE was performed for patient with negative Meckel's scan. An exploratory laparoscopy was performed in children with positive Meckel's scan or DBE. Results. 42 patients met the inclusion criteria. 40 patients were confirmed to have MD by exploratory laparoscopy. Meckel's scan was positive in 36 and negative in 6, with 34 as true positives and 2 as false positives. Six patients with negative Meckel's scan were found to have MD by retrograde DBE and had immediate operation. The distance from the diverticulum to the ileocecal valve was 40 to 60 cm. Ectopic gastric mucosa was present in all 6 patients (100%). After operation, patients were followed in clinic for 20 to 42 months and no evidence of GI bleeding or recurrent anemia was observed. Conclusions. Double-balloon enteroscopy can be a reliable diagnostic tool for bleeding Meckel's diverticulum in children with negative Meckel's scan.