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Is double balloon enteroscopy the best initial imaging method for obscure gastrointestinal bleeding?

Nature Clinical Practice Gastroenterology & Hepatology volume 4, pages 120–121 (2007)Cite this article

Obscure gastrointestinal bleeding (OGIB) can be defined as bleeding from the gastrointestinal tract that persists or recurs without an obvious etiology after initial endoscopic and radiologic evaluation. Although a significant number of patients with OGIB have bleeding lesions in the esophagus, stomach, and colon that were overlooked during initial work-up, a considerable proportion of patients bleed from the small intestine. Endoscopic visualization or radiological imaging of the small intestine is difficult because of its length, tendency to loop freely in the peritoneal cavity, and its vigorous contractility. Many patients present with either iron deficiency anemia without any clinically evident bleeding, or intermittent discrete episodes of overt bleeding (this presentation limits the use of certain imaging studies such as bleeding scans and angiography), which makes an accurate clinical diagnosis of OGIB elusive. It has been reported that an average of 7.3 diagnostic tests, 5 hospitalizations and 46 units of blood are required per patient, over a median period of 2 years, to identify a potential source of bleeding.1,2 Even then, a definitive diagnosis is made only in ∼50% of patients with OGIB. The economic burden of OGIB is unknown, but given that most patients undergo extensive and often repeated diagnostic procedures over a prolonged period, it might be appropriate to describe it as staggering.

Before the advent of wireless capsule endoscopy (WCE) for small-bowel imaging, the sequence of diagnostic tests in patients with OGIB was well established. If initial endoscopic and radiological evaluation—which comprised upper endoscopy, colonoscopy and small intestine imaging—revealed nothing, the next test was push enteroscopy. The diagnostic yield and therapeutic value of push enteroscopy, however, were perceived to be limited because only 50–150 cm of the proximal bowel could be evaluated, and the addition of an overtube to the enteroscope did not increase the fairly low diagnostic yield of this test.3 Intraoperative endoscopy was the only other tool in the armamentarium of endoscopists. Although visualization of the entire small bowel could be accomplished in up to 90% of patients with intraoperative endoscopy, the procedure was always considered a last resort because of its significant cost, morbidity and even mortality. The emergence of WCE completely changed the diagnostic algorithm for patients with OGIB. Several well-conducted studies have shown the superiority of WCE over push enteroscopy and other imaging modalities for patients with OGIB. A meta-analysis showed that the diagnostic yields of WCE and push enteroscopy were 63% and 28%, respectively (with an incremental yield of 35% for WCE over push enteroscopy, 95% CI 26–43%; P <0.00001), and 56% and 26%, respectively for the detection of clinically significant findings.4 The excellent safety record and widespread availability of WCE made it easy for clinicians to agree that WCE should be the initial diagnostic test performed in patients with OGIB. Although a positive influence of WCE on patient outcome has been difficult to demonstrate convincingly (which is not surprising because this technique lacks therapeutic ability), the usefulness of WCE as an initial diagnostic test to direct further management in patients with OGIB has been validated by outcome data from prospective studies.5,6

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  1. Interim Chair of the Division of Gastroenterology & Hepatology, A Das is an Associate Professor of Medicine and Director of Endoscopic Research at the Mayo Clinic, and JA Leighton is an Associate Professor of Medicine, and Clinical Director of the Crohn's and Colitis Clinic at the Mayo Clinic, Arizona, AZ, USA.,

    Ananya Das & Jonathan A Leighton

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  1. Ananya Das
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Correspondence to Jonathan A Leighton.

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Competing interests

JA Leighton declared he has associations with the following companies: Fujinon, Olympus and Given Imaging. He has received research funding from Fujinon and Olympus, and he is a consultant for given imaging. A Das declared he has no competing interests.

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Das, A., Leighton, J. Is double balloon enteroscopy the best initial imaging method for obscure gastrointestinal bleeding?. Nat Rev Gastroenterol Hepatol 4, 120–121 (2007). https://doi.org/10.1038/ncpgasthep0744

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