Retrograde Single-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.

Efficacy and Safety of Small Bowel Submucosal Tumors Treated by Endoscopic Submucosal Dissection or Endoscopic Full-thickness Resection During Single-balloon Enteroscopy: Prospective Data From a Single-center Study.

Single-balloon enteroscopy (SBE) is a safe and effective modality for the diagnosis and therapeutic treatment of small bowel disorders. However, the efficacy and safety of treating small bowel submucosal tumors (SMTs) with endoscopic submucosal dissection (ESD) or endoscopic full-thickness resection (EFTR) during SBE have not been determined. Hence, the primary aim of this study was to prospectively evaluate the therapeutic yield of SBE in patients with SMTs. Twenty-one patients with SMTs were enrolled in this study. Regarding the sex distribution, there were 12 men (57.1%) and 9 women (42.9%). Regarding the age distribution, 42.9% of the patients were 60 years old or older and 57.1% of the patients were under 60 years old. The preoperative characteristics of SMTs were summarized and analyzed, the complete resection incidence of SMTs was determined, and the incidence of postoperative complications was collected. ESD-related and EFTR-related complications and the duration of follow-up after leaving hospital were also summarized and analyzed. The efficacy and safety of SMTs treated by ESD or EFTR during SBE were calculated as percentages. Among the 21 patients, 10 (47.6%) underwent EFTR and 11 (52.4%) underwent ESD. The mean diameter of SMTs was 113.50mm (range: 80 to 160mm). Anterograde and retrograde SBE were conducted in 11 and 10 patients, respectively. The mean follow-up time was 49.3 days (range: 6.0 to 129d). The complete resection rate of SMTs was 100%. The complete suture rate of SMTs wound was 100%. The SMTs pathology of all patients showed that the margin-negative (R0) resection was 100%. The incidence of physical discomfort complications (ie, infection/fever, abdominal pain, and abdominal distension) of ESD and EFTR was 5 (23.8%) on day 1, 1 (4.8%) on day 2, and 1 (4.8%) on day 3 after operation. Only 1 (4.8%) patient with EFTR had abdominal pain on the sixth day after leaving hospital, and the visual analog scale/score was 1 point, meaning the pain was easily tolerated by the patient. Twenty (95.2%) patients had no abdominal discomfort after leaving hospital. No patients needed additional surgery because of complications after ESD or EFTR during SBE. This preliminary study showed that SMTs can be safely and effectively treated by ESD or EFTR during SBE, particularly SMTs <160mm in diameter.

S2004 Colonic Varices as a Complication of Pancreatic Adenocarcinoma: A Case Report and Literature Review

Introduction: Colonic varices are a rare subtype of ectopic varices with unknown prevalence rates, likely due to under-diagnosis. They form due to venous anomalies, portal hypertension, splenic or portal vein (PV) thrombosis and mesenteric vein obstruction. We present a rare case of isolated colonic varices related to pancreatic cancer. Case Description/Methods: A 64-year-old male with pancreatic cancer presented with hematochezia. Endoscopic evaluation at an outside facility showed fresh blood in the colon and terminal ileum. His hemoglobin dropped from 13 to 6 mg/dL and a tagged RBC scan identified extravasation in the right lower quadrant, localizing to the ileum. He was transferred to our hospital for a retrograde single balloon enteroscopy, which noted isolated ascending colon and hepatic flexure varices (felt to be the source of bleeding) and normal ileum. A CT angiogram revealed the pancreas mass encased the celiac axis, superior mesenteric artery, and portal confluence with occlusion of the superior mesenteric vein (SMV) and extensive collateral vessels in the hepatic flexure/ascending colon. Interventional radiology and surgical oncology were consulted for management. Given extensive vasculature involvement, no interventions were possible, and patient was medically managed. Discussion: Pancreatic cancer is a cause of left sided portal hypertension through occlusion of either the splenic vein or a non-splenic vein branch of the PV. Isolated colonic varices secondary to pancreatic cancer are rarely described. The gold standard for diagnosis is CT or selective mesenteric angiography. Often, they are diagnosed by colonoscopy for lower GI bleed evaluation but can be missed due to flattening with insufflation or blood precluding visualization. Treatment options are limited and mostly based on recommendations from case reports as there are no guidelines. For uncomplicated cases, conservative management with laxatives and iron supplementation is reasonable. For SMV occlusion, stenting of the SMV can reduce PH (table 1). In active bleeding, options include embolization, endoscopic therapy (sclerotherapy, cyanoacrylate injection, argon plasma coagulation, and band ligation), or transjugular intrahepatic portosystemic shunt (TIPS). However, if significant bleeding, laparoscopic ligation or colectomy may be indicated. Management of colonic varices due to pancreatic malignancy remains controversial and may require a multidisciplinary approach.

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

Evaluation of the diagnostic and therapeutic utility of retrograde through-the-scope balloon enteroscopy and single-balloon enteroscopy.

BACKGROUNDRetrograde single balloon enteroscopy (SBE) is a minimally invasive procedure which is less frequently performed compared with antegrade SBE. There are few studies on the retrograde through–the-scope enteroscopy (TTSE), a novel technique for evaluation of the small bowel.AIMTo compare the clinical utility and safety of retrograde TTSE with retrograde SBE.METHODSClinical data and complications of retrograde TTSE (2014-2018) and retrograde SBE (2011-2018) performed in a community hospital were reviewed and presented as mean ± SD or frequency (%) and compared using proper statistical tests. Technical success was defined as insertion of the enteroscope > 20 cm beyond ileocecal valve.RESULTSData obtained from 54 retrograde SBE in 49 patients and 27 retrograde TTSE in 26 patients were studied. The most common indication for retrograde enteroscopy was iron deficiency anemia (41 patients) followed by gastrointestinal bleeding (37 patients), and chronic diarrhea (7 patients). The duration of retrograde SBE procedure (91.9 ± 34.2 min) was significantly longer compared with retrograde TTSE (70.5 ± 30.7 min) (P = 0.04). Technical success was comparable in TTSE [23/27 (85.2%)] and SBE [41/54 (75.9%) (P = 0.33)]. The mean depth of insertion beyond the ileocecal valve in retrograde SBE (92.5 ± 70.0 cm) tended to be longer compared with retrograde TTSE (64.6 ± 49.0 cm) (P = 0.08). No complication was observed in this study.CONCLUSIONBoth retrograde TTSE and retrograde SBE are feasible and safe. Retrograde TTSE takes a shorter time and has a comparable technical success with SBE. TTSE has a lower capacity of small bowel insertion.

Single balloon enteroscopy in children for evaluation of small bowel diseases in children: A large, tertiary center study

Background and AimDevice assisted enteroscopy is the cornerstone for small bowel evaluation. However, the data are limited in pediatric patients. In this study, we aim to evaluate the safety and utility of single balloon enteroscopy (SBE) in children. MethodsThe data of children (≤18-years) who underwent SBE from November 2010 to July 2020 was analyzed, retrospectively. The safety and diagnostic yield of SBE were assessed. Results189-SBE procedures (males 117, mean age 15.1 ± 2.76, range 3–18 years) were performed in 174-children. The indications for SBE were chronic abdominal pain in 119 (68.4%), gastrointestinal bleed 17 (9.8%), chronic diarrhea 17 (9.8%) and vomiting 13 (7.5%). Antegrade, retrograde and combined SBE were performed in 98 (51.8%), 77 (40.7%), 7 (3.7%) children, respectively. The mean length of small bowel intubation in antegrade and retrograde SBE groups were 168.9 ± 58.6 cm and 120.7 ± 52.1 cm, respectively. Overall, a positive finding was seen in 117 (67.2%) cases. The most common findings were ileal and jejunal ulcers with or without strictures in 76 (64.9%) children. A total of 18 therapeutic enteroscopic procedures were performed. There were no major adverse events. ConclusionSBE is a safe and effective procedure for the evaluation and management of small bowel diseases in children.

Technical and Clinical Aspects of Diagnostic Single-Balloon Enteroscopy in the First Decade of Use: A Systematic Review and Meta-Analysis.

Background/AimsSingle-balloon enteroscopy (SBE) has been widely used in diagnosing small bowel disease. We conducted this study to systematically appraise its technical and clinical performance.MethodsStudies on SBE published by September 2018 were systematically searched. Technical and clinical performance data were collected and analyzed with descriptive or meta-analysis methods.ResultsIn total, 54 articles incorporating 4,592 patients (6,036 procedures) were included. Regarding technical parameters, the pooled insertion depths (IDs) for anterograde and retrograde SBE were 209.2 cm and 98.1 cm, respectively. The pooled retrograde ID in Asian countries was significantly greater than that in Western countries (129.0 cm vs 81.1 cm, p<0.001). The pooled anterograde and retrograde procedure times were 57.6 minutes and 65.1 minutes, respectively. The total enteroscopy rate was 21.9%, with no significant difference between Asian and Western countries. Clinically, the pooled diagnostic yield of SBE was 62.3%. Obscure gastrointestinal bleeding (OGIB) was the most common indication (50.0%), with a diagnostic yield of 59.5%. Vascular lesions were the most common findings in Western OGIB patients (76.9%) but not in Asian ones (31.0%). The rates of severe and mild adverse events were 0.5% and 2.5%, respectively.ConclusionsSBE is technically efficient and is clinically effective and safe, but total enteroscopy is relatively difficult to achieve with this technique. Etiologies of OGIB in Asian countries differ from those in Western countries.

1950 An Unexpectedly Large Vascular Anomaly Causing Chronic Obscure GI Hemorrhage: A Case Report

INTRODUCTION: Approximately 5–10% of patients who present with an acute gastrointestinal (GI) hemorrhage have a primary small bowel source. While small bowel angioectasias are one of the most common causes of small bowel hemorrhage, it is rare to find large vascular anomalies in the small bowel as a cause of chronic GI bleed. CASE DESCRIPTION/METHODS: We present a case of a 56-year-old woman referred to our institution for management of obscure GI bleeding, associated with severe iron deficiency anemia. She had intermittent melena and occasional dark red blood mixed with stool. Extensive work up in an outside facility including 2 endoscopies, 2 colonoscopies, and a capsule endoscopy were unrevealing. After referral to our institution; push enteroscopy, colonoscopy and retrograde single balloon enteroscopy were performed and were negative for source of bleeding. Capsule endoscopy revealed a small oozing angioectasia in proximal jejunum. The lesion was treated with heater probe via anterograde single-balloon enteroscopy. Due to persistent melena and anemia, antegrade balloon enteroscopy was repeated and demonstrated an abnormal cluster of vascular-appearing lesions in the proximal jejunum that were marked with two hemostatic clips. CT angiogram was consistent with a large arteriovenous malformation (AVM). Interventional radiology performed glue embolization of the high-flow jejunal arteriovenous malformation. The post procedure course was complicated by ischemic proximal jejunum which was confirmed on repeat enteroscopy. Fortunately, her symptoms completely resolved with conservative management without surgical intervention. DISCUSSION: AVMs are abnormal lesions with a direct connection between the arterial and venous blood supply without any true capillary bed connecting them. While extremely rare within the GI tract, they can cause significant amount of bleeding and must be considered in patients with obscure GI bleeding or chronic iron deficiency anemia. Studies have shown that AVMs typically only account for 1–2% of upper GI bleeds. More common sites for AVMs include the cecum and ascending colon, while other sites like the small bowel are much more rare. Diagnostic work up typically begins with upper endoscopy followed by colonoscopy. However, these tests are often unrevealing when dealing with small bowel AVMs. Patient’s typically undergo capsule endoscopy for further evaluation, as seen in our patient. If the source of bleeding is still un-identified, then angiography or bleeding scans may be required.

Antegrade versus Retrograde Single Balloon Enteroscopy - Which Is Better?

Introduction: There are 2 major approaches of single balloon enteroscopy- through mouth or ante-grade approach (AG), or through anus or retrograde (RG)approach. Aim of this study was to assess the differences in performance and complications of both these approaches. Methods: A retrospective cohort study was conducted using a registry of consecutive cases of single balloon enteroscopy at the Cleveland Clinic over 8 years from January 1, 2008- December 31,2016. Electronic medical records were utilized to collect variables including patient demographic, status of antiplatelet agents (at time of procedure), and coexisting comorbid diseases (cardiovascular, renal, and hepatic). Data on endoscopic findings, intervention (if received) was also obtained. Performance of procedures was assessed on the basis of scope time (in minutes), extent reached and need for repeat procedures within 30 days. Numerical values were assigned based on the depth of scope insertion to assess extent reached: 1 = unable to reach small bowel, 2 = proximal jejunum for ante-grade and distal ileum for retro-grade, 3 = mid jejunum for ante-grade and mid ileum for retro-grade, and 4 = distal jejunum for ante-grade and proximal ileum for retro-grade studies. Results: Of 510 patients who underwent SBE, 124 386 (75.7%) patients underwent AG procedures. At baseline patients in both groups were similar, except for older age (68.5 for RG vs 71 for AG, p=0.043) and higher antiplatelet use (34.7% for RG vs 42.5% for AG, p=0.042) in AG group. Deeper scope insertion depth (depth level 3 for AG vs 1 for RG, p < 0.001) and lesser scope time (37.4 mins in AG vs 48.9 mins in RG, p<0.001) was observed with AG procedures. On multivariate analysis AG procedures were found to have 118 higher odds (95% CI 60.5-229.9, p <0.001) of having a deeper scope insertion than RG, and RG procedures had 11.9 higher odds (95% CI 6.7-17, p <0.001) of longer scope time compared to AG. No difference in the rates of adverse outcomes including, bleeding, perforation, aspiration and change in level of care were noted between the two modalities. (Table 1&2)2793_A Figure 1 No Caption available.Conclusion: AG approach is less time consuming and more likely to have a deeper extent of insertion compared to RG approach, with similar rates of complications. Unless the lesion of interest is in close proximity to the ileo-cecal valve, it may be more prudent to proceed with AG approach rather than RG approach.2793_B Figure 2 No Caption available.

Insertability comparison of passive bending single-balloon prototype versus standard single-balloon enteroscopy: a multicenter randomized non-blinded trial.

Background and study aims Traversing the ileocecal valve (ICV) is technically challenging with a retrograde approach to single-balloon enteroscopy (SBE). A novel technique called responsive insertion technology (RIT) colonoscopy was developed to obtain a higher cecal intubation rate in this setting. A prototype long SBE equipped with RIT (P-SBE) was developed to obtain superior insertability. The aim of this study was to compare the insertability of a standard single-balloon enteroscope (S-SBE) versus a P-SBE. Patients and methods This study was a multicenter, randomized, non-blinded, trial of 62 patients with small bowel pathologies. All procedures were performed with SBE via the trans-anal route. Procedure success was defined as stable intubation of the terminal ileum (TI) 20 cm beyond the ICV. The primary variable was time to reach stable TI intubation 20 cm beyond the ICV (TSTII). If stable TI intubation was not achieved within 10 minutes, the initial SBE was removed through the indwelling overtube and replaced with another SBE. Results Sixty patients were examined with two patients excluded from this study. TSTII using P-SBE was significantly decreased compared to S-SBE (mean P-SBE vs S-SBE: 98.3 vs 169.4 second, P = 0.006). The completion rates for stable intubation within 10 minutes of using P-SBE and S-SBE were 96.8 % and 86.2 %, respectively ( P = 0.19). On endoscope replacement, all patients had achieved stable TI intubation. Conclusions SBE with RIT improves insertability when traversing the ileocecal valve in retrograde SBE.

Outcome and Safety of Anterograde and Retrograde Single-Balloon Enteroscopy: Clinical Experience at a Tertiary Medical Center in Taiwan.

Single-balloon enteroscopy (SBE) is designed for identifying possible small bowel lesions with balloon-assisted enteroscopy that allows deep intubation of the intestine. However, data regarding the outcome and safety of SBE remain limited. We conducted this study to evaluate the outcome and safety of anterograde and retrograde SBE approaches. This retrospective review from a tertiary medical center in Taiwan included endoscopic reports and chart data from 128 patients with 200 anterograde and retrograde procedures from September 2009 to November 2014. In this study, the most common indication for both anterograde and retrograde SBE was obscure gastrointestinal bleeding (64.4% vs. 60.6%). There were no significant differences between anterograde and retrograde approaches in terms of the diagnostic yield (69.3% vs. 52.5%) and intervention rate (23.8% vs. 17.2%). The procedure time was shorter for anterograde SBE than for retrograde SBE (68.1 ± 23.9 vs. 76.8 ± 27.7 min, P = 0.018). In addition, among the subgroup of patients with obscure gastrointestinal bleeding, the most common etiologies for those in different age-groups were angiodysplasia (≥ 65 years), non-specific ulcers (30–64 years), and Meckel’s diverticulum (< 30 years). The major complication rate during the study was 1.5%; the rate of asymptomatic hyperamylasemia was higher for patients who underwent anterograde SBE than for those who underwent retrograde SBE (13.9% vs. 2%, P = 0.005). The outcome and safety of anterograde and retrograde SBE are similar. However, anterograde SBE has a shorter procedural time and a higher rate of asymptomatic hyperamylasemia.

Cap-assisted retrograde single-balloon enteroscopy results in high terminal ileal intubation rate.

Background and study aims: Retrograde single-balloon enteroscopy (RSBE) facilitates evaluation of the distal small bowel and provision of appropriate therapy when necessary. Intubation of the terminal ileum (TI) is a major rate-limiting step, with failure rates as high as 30 %. Cap-assisted endoscopy has proven beneficial in other aspects of endoscopy. We have noticed that it similarly aids in TI intubation during RSBE by facilitating opening of the ileocecal valve (ICV). The primary aim of this study was to measure the TI intubation rate using cap-assisted RSBE. Other procedural details and outcomes were also measured. Patients and methods: A total of 36 consecutive RSBEs performed between July 2011 and May 2014 at the Medical University of South Carolina were retrospectively reviewed. All procedures were performed or supervised by our center’s small bowel endoscopist (ASB). Outcomes measured included TI intubation rate, procedure time, depth of maximal insertion (DMI), diagnostic yield (DY), therapeutic yield (TY), and complications. Results: The TI intubation rate was 97 % (35 /36). The one failure was due to stool completely obscuring the cecum. Median procedure time was 54 minutes, with a mean DMI of 68 cm beyond the ICV. The technical success rate was 86 %, whereas DY and TY were 61 % and 25 %, respectively. There were no complications. The study was limited in that it involved a single endoscopist at a single center. Conclusions: Cap-assisted RSBE results in a high TI intubation rate, without compromise to safety or procedural yield.

Performance characteristics of retrograde single-balloon endoscopy: A single center experience.

To evaluate the technical success, diagnostic yield (DY) and therapeutic potential of retrograde single balloon enteroscopy (rSBE). A retrospective review of 136 rSBE procedures performed at a tertiary academic referral center from January 2006 and September 2013 was completed. Patient characteristics including age, gender and inpatient status were collected. The indication for the procedure was categorized into one of three groups: Obscure gastrointestinal bleeding (GIB), evaluation for Crohn's disease and abnormal imaging. Procedural characteristics including insertion depth (ID), procedure time, concordance with pre-procedural imaging and complications were also recorded. Lastly, DY, defined as the percentage of cases producing either a definitive diagnosis or findings that could explain clinical symptoms and therapeutic yield (TY), defined as the percentage of cases in which a definitive intervention was performed, were determined. Mucosal tattooing and biopsy alone were not included in the TY. A total of 136 rSBE procedures were identified. Mean patient age was 57.5 (± 16.2) years, 67 (49.2%) were male, and 110 (80.9%) procedures were performed on an outpatient basis. Indications for rSBE included GIB in 55 (40.4%), evaluation of inflammatory bowel disease (IBD) in 29 (21.3%), and imaging suggestive of pathology other than GIB or IBD in 43 (31.6%). Nine (6.6%) rSBEs were performed for other indications. Mean ID was 68.3 (± 39.3) cm proximal to the ileocecal valve and mean time to completion was 41.7 (± 15.5) min. Overall, 73 (53.7%) cases were diagnostic and 25 (18.4%) cases were therapeutic in which interventions (argon plasma coagulation, stricture dilatation, polypectomy, etc.) were performed. Pre-procedural imaging was performed in 88 (64.7%) patients. Endoscopic concordance of positive imaging findings was seen in 31 (35.2%) cases. Follow up data was available in 93 (68.4%) patients; 2 (2.2%) reported post-procedural abdominal pain within 30 d following rSBE. There were no other reported complications. rSBE exhibits an acceptable diagnostic and TY, rendering it a safe and effective procedure for the evaluation and treatment of small bowel diseases.

The safety and efficacy of single balloon enteroscopy in the elderly.

Single balloon enteroscopy (SBE) is an important tool in the management of small bowel disease with limited data available on its performance in the elderly. We aimed to evaluate the safety, efficacy, diagnostic and therapeutic outcomes of SBE in the elderly. A retrospective review was performed on 366 patients undergoing 428 SBEs from 2010 to 2014. Patients were divided into different age groups: control <55, 55-64, 65-74 and ⩾75 years. Data on comorbidities, complications, findings, diagnostic and therapeutic yield were compared between groups. Anterograde and retrograde SBE were performed in 340 and 49 patients, respectively, with 63 patients requiring more than 1 procedure. Diagnostic yield was significantly higher for age ⩾75 years compared with <55, 66.3% versus 50%, odds ratio (OR) 1.97 [95% confidence interval (CI) 1.14-3.41]. Therapeutic yield was significantly higher in all three older age groups compared with <55 years, 20.3%: 55-64 years, 44.4%, OR 3.13(95% CI 1.7-5.78); 65-74 years, 42%, OR 2.84 (95% CI 1.59-5.06); and >75 years, 47.5%, OR 3.55 (95% CI 1.96-6.43). No significant difference was seen between age groups in complications or failures. Our overall complication rate was 2.3% with 5 minor and 5 major complications. There was a higher yield of angioectasias in the elderly. Argon plasma coagulation (APC) and multipolar electrocoagulation were used more often in older age groups. SBE is safe in elderly patients and delivers higher diagnostic and therapeutic yields compared to younger patients. The elderly are more likely to have angioectasias and undergo APC and electrocoagulation.

Pyogenic Granuloma: A Rare Cause of Obscure Gastrointestinal Bleeding

Pyogenic granuloma is a lobular capillary hemangioma that occurs mostly on the skin, and occasionally on the mucosal surface of the oral cavity, but very rarely in the gastrointestinal tract. We report a case of a 63-year-old man who suffered from iron deficiency anemia with multiple syncopal episodes and intermittent melenic stools for the past 1 year. Multiple studies at various centers including esophagogastroduodenoscopies (EGDs), push enteroscopies, colonoscopies, bleeding scintigraphies, and abdominal CT scans during this time period could not reveal the bleeding source. He had not received medical treatment except for oral iron. The patient was transferred to our University hospital for further assessment after he presented to an outside facility with presycope, moderate volume melena, and a hemoglobin of 4.0 g/dl. Initially, a colonoscopy was done which only showed a scant amount of dark blood in the terminal ileum. Next, a video capsule endoscopy revealed a bleeding focus in the jejunum without a distinct etiology. Afterwards, antegrade and retrograde single balloon enteroscopies were planned to locate the source. During retrograde single balloon enteroscopy, a 15 mm pedunculated polypoid mass, with active bleeding, was found in the small intestine 90 cm away from the ileocecal valve (Image 1 and Image 2). The bleeding was controlled with epinephrine injection and hemoclip placement. The following day, surgical resection of the small bowel segment was performed. The histological features revealed a capillary hemangioma with a pyogenic granuloma pattern (Image 3). Shortly after resection, the patient's anemia improved and he had no further bleeding episodes. The small bowel is the source of gastrointestinal bleeding in 2% to 10% of all bleeding episodes. Vascular tumors of the small bowel are very rare, accounting for only 7% to 10% of all benign tumors of the small bowel. Pyogenic granulomas of the small bowel are difficult to diagnose, as they are usually inaccessible via conventional endoscopic techniques. This patient underwent a total of 8 endoscopic and radiologic procedures prior to finally visualizing this rare source of bleeding. This case demonstrates the challenges in the diagnosis and management of obscure GI bleeding. One should be aware of the rare causes of obscure GI bleeding such as pyogenic granuloma and utilize the appropriate diagnostic modalities such as capsule endoscopy and balloon-assisted enteroscopy in finding the source.Figure 1Figure 2Figure 3

Isolated Small Bowel Crohn’s Disease Diagnosed With Retrograde Single-Balloon Enteroscopy

Crohn’s disease (CD) can occur throughout the entire gastrointestinal tract with the ileocecal segment being the most common site. However, CD may involve segments of the small bowel other than the ileum and isolated small bowel CD can present a diagnostic challenge. A 41-year-old Filipino female presented with recurrent, moderate to severe abdominal pain lasting for almost 11 months which later became associated with vomiting and progressive abdominal distention. Gastroscopy and colonoscopy were insignificant. CT scan of the abdomen showed diffuse long segment wall thickening of the small bowel segments at the right upper quadrant of the abdomen with focal dilatation at the distal segment. Retrograde single-balloon enteroscopy revealed stenosis at the distal jejunum/proximal ileum segment with the proximal and middle ileum exhibiting granular mucosa, blunted villi, inflammatory polyps, and multiple longitudinal aphthous ulcers. Biopsies taken were suggestive of CD. Due to signs of progressive bowel obstruction, the patient underwent laparotomy resulting in resection of the affected small bowel segment. During laparotomy, thickened segments with fat wrapping of the ileum 20 centimeters from the ileocecal junction were noted. A 64 centimeter jejunoileal segment was resected. The middle 24 cm segment was indurated with granular mucosa and obliterated mucosal folds. Histopathology showed a non-caseating granuloma with transmural inflammation up to the prevocalic fat and cryptitis. The patient did well post-operatively and infliximab infusion was started soon after discharge. She has been in remission since, having completed the 6th week of her infliximab induction therapy. Diagnosing small bowel diseases has always been a challenge before and mostly depended on radiographic imaging. Single balloon enteroscopy has proven to be useful in the diagnosis and management of isolated small bowel CD.

Mo1613 CAP-Assisted Retrograde Single Balloon Enteroscopy Results in High Terminal Ileal Intubation Rate

Retrograde single-balloon enteroscopy (RSBE) is an established modality for diagnosis and treatment of distal small bowel lesions that are beyond the reach of standard ileocolonoscopy. However, it is a challenging and complicated procedure requiring significant time and skill beyond standard endoscopy. A major barrier to retrograde enteroscopy is intubation of the terminal ileum (TI), with failure rates documented as high as 30% [1]. This is due to the lack of stiffness in the relatively small-caliber enteroscope, which often results in looping of the instrument when trying to intubate the TI. Cap-assisted endoscopy has previously proven beneficial for several aspects of endoscopy, including cecal intubation, adenoma detection, and visualization of the ampulla of Vater by peeling away mucosal folds [2–4]. Similarly, we have found that a distal cap aids in many aspects of retrograde balloon enteroscopy, including intubation of the TI, by facilitating opening of the ileocecal valve (ICV). Therefore, we set out to determine the terminal ileal intubation rate during RSBE while utilizing a distal cap, as well as procedural outcome variables.

Ileal ulcers in a patient with Henoch-Schönlein purpura

Summary Henoch-Schonlein purpura (HSP) is a systemic vasculitis characterized by a classic tetrad of nonthrombocytopenic palpable purpura, arthritis, gastrointestinal, and renal involvement. The most common gastrointestinal complaint is abdominal pain. The characteristic endoscopic findings are ulcers seen in the second portion of the duodenum. We present the case of a 45-year-old man suffering from abdominal pain. Erythematous purpura over bilateral lower extremities and soreness of the joints developed 3 days before abdominal pain. An abdominal computed tomography showed an edematous change of the intestinal wall and the distal part of the ileum. A retrograde single balloon enteroscopy revealed several discrete ulcers and hyperemic mucosa in the distal ileum. The middle, proximal, and terminal ileum and ileocecal valve to the rectum were not affected. Under the impression of HSP, nonsteroidal anti-inflammatory drugs and prednisolone were administered. We concluded that balloon-assisted enteroscopy is helpful for differential diagnosis of small bowel lesions in adult patients with HSP.

Success of single-balloon enteroscopy in patients with surgically altered anatomy

Single-balloon enteroscopy (SBE) was introduced in 2007 to diagnose and treat small-bowel disorders. No study to date has evaluated SBE in patients with surgically altered anatomy outside of ERCP. To evaluate the efficacy, yield, and safety of SBE in patients with surgically altered anatomy. Retrospective study. Tertiary-care academic medical center. All patients with altered surgical anatomy who underwent SBE at the Medical University of South Carolina from July 2007 to September 2013. SBE. Diagnostic yield, therapeutic yield, technical success, and adverse events. A total of 48 patients met inclusion criteria. Mean age was 56 years (77% female). Eleven patients underwent single-balloon PEG placement, 8 single-balloon ERCP, 22 non-PEG/non-ERCP anterograde SBE, and 7 retrograde SBE. Previous surgeries included Roux-en-Y gastric bypass (n=26), small-intestine resection (n=6), colon resection (n=5), Whipple procedure (n=4), choledochojejunostomy (n=3), hepaticojejunostomy (n=1), Billroth I (n=1), Billroth II (n=1), and Puestow procedure (n=1). Procedural indications were PEG tube placement (n=11), choledocholithiasis (n=2), biliary stricture (n=2), obstructive jaundice (n=1), cholangitis (n=1), ampullary mass (n=1), sphincter of Oddi dysfunction (n=1), anemia and/or bleeding (n=15), abdominal pain (n=9), radiologic evidence of obstruction (n=3), and Peutz-Jeghers syndrome (n=2). The technical success rate was 73% in single-balloon PEG placement, 88% in single-balloon ERCP, 82% in other anterograde SBEs, and 86% in retrograde SBEs. No intraprocedural or postprocedural adverse events were observed. Single center, retrospective study. SBE is safe and effective in patients with surgically altered anatomy.

Successful Treatment of Bleeding Portal Hypertensive Polypoid Ileopathy by a Combined Endoscopic and Surgical Approach

Introduction: Portal hypertensive enteropathy (PHE) has been recognized more frequently due to an increased accessibility of the small bowel. PHE typically presents as angiodysplasias and varices. A polypoid lesion is a rare manifestation of PHE, with most reported cases involving the duodenum and jejunum. Here, we report the first case of gastrointestinal bleeding from isolated portal hypertensive polypoid ileopathy. A 47-year-old white male with alcoholic cirrhosis presented with a 2-month history of recurrent melena of unknown source requiring multiple hospitalizations. He underwent an esophagogastroduodenoscopy and a colonoscopy, which revealed 2 isolated gastric varices without bleeding stigmata and fresh blood in the terminal ileum without an identifiable bleeding source. A video capsule endoscopy was then performed and found an actively bleeding area in the distal ileum, but no obvious lesion was seen. A subsequent retrograde single-balloon enteroscopy (RSBE) revealed distal ileitis with an oozing 1-cm polyp at 30 cm from the ileocecal valve. Epinephrine injection was performed to control the bleeding after the biopsy. Pathology showed actively inflamed mucosa with fibrin thrombi, vascular ectasia in the lamina propria, and perivascular hyalinization, suggestive of PHE. His hospital course was complicated by recurrent hematochezia, decompensated cirrhosis, hepatorenal syndrome, and respiratory failure from pneumonia. A repeat RSBE, together with epinephrine injections and argon plasma cauterization, was subsequently performed with successful endoscopic hemostasis. After a 3-week wait without further bleeding, he underwent a liver transplant. A segmental ileal resection was also performed during the transplant surgery. Pathology confirmed congested mucosa and scattered polypoid lesions with focal hyalinization and diffuse vascular ectasia, diagnostic of PHE. He recovered well with no bleeding episodes at the 4-month post-transplant follow-up. This case highlighted a unique aspect of PHE as a bleeding polypoid lesion in the ileum. It also underscores the fact that portal hypertension can involve any part of the gastrointestinal tract. High Child-Pugh score and gastric varices are associated with PHE, as seen in our case, and suggested by previous studies. While portal hypertensive gastropathy and colopathy have been well described, portal hypertensive ileopathy has been underdiagnosed and should be considered as a potential source of occult gastrointestinal hemorrhage. A video capsule endoscopy and a deep enteroscopy are important diagnostic and therapeutic tools for this rare condition. Liver transplantation and small bowel resection can be considered for definitive diagnosis and treatment.