Long-term Outcome of Patients With Obscure Gastrointestinal Bleeding Investigated by Double-Balloon Endoscopy

doi:10.1016/j.cgh.2009.10.023

Clinical Gastroenterology and Hepatology

Volume 8, Issue 2, February 2010, Pages 151-158

https://doi.org/10.1016/j.cgh.2009.10.023 Get rights and content

Background & Aims

It is often difficult to determine the cause of obscure gastrointestinal bleeding (OGIB). We evaluated the diagnostic yield and long-term outcome of patients with OGIB by using double-balloon endoscopy (DBE).

Methods

In this large, retrospective cohort study, DBE was performed in 200 consecutive patients with OGIB. Follow-up data were available from 151 patients for 29.7 months (range, 6–78 months), and clinical outcome was assessed.

Results

DBE detected bleeding sources in 155 of 200 patients (77.5%). The most frequent source detected was small intestine ulcers/erosions (64 patients). Patients who underwent DBE within 1 month after the last episode of overt bleeding had a better yield of positive findings than those who did not (84%, 107/128 patients vs 57%, 24/42; P = .002). The overall rate of control of OGIB was 64% (97/151 patients). Patients with vascular lesions of the small intestine had a significantly lower rate of control of OGIB than those with other small intestine lesions (40%, 12/30 patients vs 74%, 52/70; P = .001). A requirement for a large transfusion before DBE (P = .012), multiple lesions (P = .010), and suspicious (not definite) lesions (P = .038) each significantly increased the likelihood of overt rebleeding in patients with vascular lesions of the small intestine.

Conclusions

DBE is useful for the diagnosis of patients with OGIB and should be performed as soon as possible after overt OGIB. Patients with vascular lesions of the small intestine should be followed with particular care.

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Section snippets

Inclusion of Patients in the Study

We prospectively registered the medical history, endoscopic findings, and clinical findings of all patients who had undergone DBE at Jichi Medical University Hospital in a database. Consecutive patients whose indication for DBE was OGIB were selected for this study from a total of 552 patients (1042 procedures) who underwent DBE from September 2000 to March 2007. Of the 552 subjects, 200 patients underwent DBE for investigation of OGIB.

Methods of Obtaining Clinical Information

In addition to the information in the database, medical

Investigation of Obscure Gastrointestinal Bleeding by Using Double-Balloon Endoscopy

Demographic data for the patients undergoing DBE for OGIB are shown in Table 1. Despite the large range in age of patients, those in the fifth through seventh decades of age were predominant, and only 45 patients (23%) were younger than 40 years of age. Before DBE examination, hemoglobin level was increased by transfusion or iron replacement to stabilize vital signs. In total, 123 patients (62%) required transfusions, whereas 116 patients (58%) required iron replacement.

Diagnostic Usefulness of Double-Balloon Endoscopy in Patients With Obscure Gastrointestinal Bleeding

Details of DBE diagnosis

Discussion

We have reported here the findings of a large cohort study of DBE diagnosis and long-term outcome of patients with OGIB after DBE. The DBE diagnosis of 200 patients and long-term clinical outcomes of 151 patients who had been followed for 29.7 months on average were determined. To the best of our knowledge, both this length of follow-up and the number of patients followed are higher than in any previous reports on the clinical outcome of patients with OGIB after DBE.7, 10, 11 We found that the

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Singh et al. reported higher DY, rate of therapeutic intervention, and reduction in length of stay when SBCE was performed within 72 h of admission [20]. Studies have also demonstrated that the yield of SBCE and DAE in overt SBB is greater than in occult hemorrhage [18,21–23]. Evidence from a recent meta-analysis report a DY of 65.2% (95% CI 58.9–71.2%) for SBCE and 74.0% (95% CI 62.3–84.3%) for DAE, and a therapeutic yield of 55.9% (95% CI 44.3–67.1%) for SBCE and 35.8% (95% CI 30.6–41.2%) for DAE in overt midgut bleeding [24].
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A total of 33 statements were approved after three rounds of Delphi voting.
This Delphi consensus proposes clear definitions and a unifying strategy to standardize the management of small bowel bleeding. Furthermore, it provides a useful guide in daily practice for both clinical and technical issues of enteroscopy.
Diagnostic and therapeutic yields of early capsule endoscopy and device-assisted enteroscopy in the setting of overt GI bleeding: a systematic review with meta-analysis
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Citation Excerpt :
SBCE was performed in the first 72 hours in 3 studies,20-22 in the first 48 hours in 7,6,17,23-27 in the first 24 hours in 3,11,13,14 and during ongoing bleeding in 6.19,28-32. DAE was performed in the first 72 hours in 5 studies,33-37 in the first 24 hours in 9,35,36,38-44 and during ongoing bleeding in 3.29,45,46 Small-bowel studies were performed for OGIB (after negative bidirectional endoscopies) in all but 2 single-arm studies.
Small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) are essential in obscure GI bleeding (OGIB) management. However, the best timing for such procedures remains unknown. This meta-analysis aimed to compare, for the first time, diagnostic and therapeutic yields, detection of active bleeding and vascular lesions, recurrent bleeding, and mortality of “early” versus “nonearly” SBCE and DAE.
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: View this article's video abstract atwww.cghjournal.org.

: Conflicts of interest The authors disclose the following: Dr Yamamoto has applied for a patent in Japan for the double-balloon endoscopy technique described in this article. The remaining authors disclose no conflicts.

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Original article—alimentary tractLong-term Outcome of Patients With Obscure Gastrointestinal Bleeding Investigated by Double-Balloon Endoscopy

Background & Aims

Methods

Results

Conclusions

Section snippets

Inclusion of Patients in the Study

Methods of Obtaining Clinical Information

Investigation of Obscure Gastrointestinal Bleeding by Using Double-Balloon Endoscopy

Diagnostic Usefulness of Double-Balloon Endoscopy in Patients With Obscure Gastrointestinal Bleeding

Discussion

Gastroenterology

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Original article—alimentary tract
Long-term Outcome of Patients With Obscure Gastrointestinal Bleeding Investigated by Double-Balloon Endoscopy