Review Article

The Diagnosis and Investigation of Obscure Gastrointestinal Bleeding

K. Liu; A. J. Kaffes

Disclosures

Aliment Pharmacol Ther. 2011;34(14):416-423. 

In This Article

Device Assisted Enteroscopy (Balloon Assisted, Spiral and Push)

Several new device assisted enteroscopes (DAE) have been released and studied. The first of these was the double balloon enteroscope (Fijinon) described in 2001 and made available for clinical use in 2004. This was followed by the release of a single balloon system (Olympus optical) and more recently spiral enteroscopy (Spirus medical). These devices enable endoscopic inspection of the entire small bowel through the use of a 200 cm enteroscope and an overtube. The single and double balloon systems utilise inflatable balloons to grip the intestine to facilitate deep enteroscopy whereas the spiral system consists of a specialised overtube with a compliant spiral located at the distal tip. The majority of clinical evidence is with DBE but emerging literature shows similar benefits with the other modalities. Comparative studies between all of these techniques show technical differences (e.g. procedure time, depth of insertion, rates of total enteroscopy) but few if any show diagnostic or therapeutic benefit for one over the other.[21–24] The literature on this is in its infancy and further evaluation will be needed before one modality could be recommended over the other.

Double balloon enteroscopy and CE have comparable diagnostic yields in patients with OGIB.[25–30] A meta-analysis of 11 studies (397 patients) demonstrated the pooled overall yield for CE and DBE was 60% and 57% respectively.[31] The yields of each study for vascular malformations, inflammatory lesions and polyps or tumours were also found to be similar. The main advantage of DBE is its ability to perform therapeutic interventions and obtain biopsies, not possible on CE. Endoscopic therapies and biopsies are performed in 27–57% and 27% of patients undergoing DBE respectively.[5,26,29,32]

One shortfall of DAE is its inability to achieve total enteroscopy in all patients. Rates of achieving total enteroscopy with DBE vary widely from 0% to 86%. Raju et al. pooled data from 12 studies on 723 patients and found that total enteroscopy was performed in only 29% of patients.[33] Other limitations include its limited availability, time and sedation requirements and failure to perform adequate retrograde examinations because of poor colon preparation or adhesions from prior surgery. Double balloon enteroscopy is a safe procedure with major complications reported in fewer than 1% of patients. The most commonly reported complications include intestinal perforation (0.4%), pancreatitis (0.3%) and ileus.[34,35] Complication rates are higher after a therapeutic procedure and significantly more perforations occur in patients with altered surgical anatomy. Surprisingly, increased age (>75) is not a predictor of having a complication from DBE.[5]

Push enteroscopy (PE), despite having a lower diagnostic yield compared with CE, is still widely used in diagnosis and management of OGIB. PE can obtain biopsies and provide therapeutic interventions for lesions within 50–150 cm of the proximal small bowel. A prospective comparison between PE and DBE demonstrated that although the diagnostic yield was superior for DBE, PE still had high diagnostic yields and therapeutic rates. Therefore very proximal lesions should be targeted with PE, especially if DBE is not available.[36]

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