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Clinical Significance of Double-Balloon Enteroscopy for Small Intestinal Bleeding
Abstracts
M1353 Double Balloon Enteroscopy in the Diagnosis of Small Bowel Diseases. The Mexican Experience Oscar V. Hernandez, Juan M. Blancas Valencia, Victor M. Paz Flores, Maria L. Hernandez Reyes Background: The current methods used to explore the entire intestine lack of the ability to take biopsies or perform therapeutic maneuvers, including the wireless capsule endoscopy. Recently, double balloon enteroscopy (DBE) has been introduced in this field. It allows high resolution visualization, biopsy samples and therapeutic interventions. The aim of this study was to analyze the use of this new method in the diagnosis and treatment of small bowel diseases in Mexican population. Methods: This is a retrospective study conducted in one tertiary medical center by 4 experienced endoscopists between February 2004 and October 2005. 90 patients were studied for suspected or confirmed small bowel disease by imaging studies. Upper and lower endoscopies were normal. We document the characteristics of the procedures. Results: 90 patients (52 men; 38 women mean age 53.1 G 37 years), 102 DBE were done, 50 by an oral, 28 anal and 12 in a combined approach. Completely enteroscopy was done in 10 patients (11%) (8 by combined and 2 by oral approach). The mean time of procedure was 68 G 25 min and 85 G 36 min by oral and anal routes respectively. Mean length in oral approach was 280 G 150 cm beyond ligament of treitz and 130 G 105 cm beyond the ileocecal valve by anal route. Complications were mild and occurred in 20 patients (22%) Final diagnosis and treatments are showed in table 1. Conclusions: Besides the difficulty to perform a complete enteroscopy and the long time of the procedure. DBE is a safe and relative easy method that can explore and treat effectively lesions in patients with suspected or documented lesions in the small bowel. Table 1. Diagnosis, type of approach and treatment with DBE in the evaluation of small bowel diseases Diagnosis Angiodysplasia Vascular ectasia Small bowel ulcers Jejunoileitis Diverticulum Lipoma Polips Yeyunal Hemangioma Intestinal varices Malignant tumor Duodenal Xanthoma Benign stenosis Intestinal lymphangiectasia Normal Total
No Oral and patients Oral Anal anal Treatment 8 10 4 14 3 3 5 1 1 9 3 4 3 22 90
5 6 2 6 2 2 1 0 1 8 3 1 1 12 50
2 3 2 7 0 1 4 0 0 1 0 2 0 6 28
1 1 0 1 1 0 0 1 0 0 0 1 2 4 12
Endoscopic APC Endoscopic APC Medical treatment Medical treatment Medical Treatment None Endoscopic resection Sclerotherapy Sclerotherapy Surgery None Surgery None Symptomatic treatment
intestinal bleeding, DBE is a very useful procedure in the diagnosis and also effective in the treatment in some cases such as angiodysplasia.
M1355 Regular Or Half-Dose, Not High-Dose Histamine-H2 Receptor Antagonists Can Prevent NSAID-Associated Peptic Ulcers in Japanese Patients with Rheumatoid Arthritis Kazumasa Miyake, Masafumi Kusunoki, Tomotaka Shindo, Tatsuhiko Hamamoto, Nobue Ueki, Kenji Suzuki, Yoko Shinji, Tetsuro Hiratsuka, Hitoshi Nishigaki, Seiji Futagami, Ken Wada, Katya Gudis, Taku Tsukui, Atsuo Nakajima, Choitsu Sakamoto Background/Aim: It has been established in Europe and USA that proton pump inhibitors (PPIs), prostaglandin E1 analog (PG), and high-dose histamine H2 receptor antagonists (H2RA) effectively prevent NSAID-caused peptic ulcer. However, strategies to prevent NSAID-related ulcer have yet to be elucidated in Japan where the elderly have a lower gastric acidity and the dosage of NSAID is relatively low. That raises a possibility that a minimum effective dose of anti-ulcer agents might be much lower than those required in Europe and USA. Especially, it is expected that not only high-dose but also regular or half-dose H2RA shows the preventive effect. Therefore we investigated the relationship between anti-ulcer medications and NSAID-related peptic ulcer in Japanese patients with rheumatoid arthritis (RA) receiving long-term NSAID treatment. Methods: One hundred and seventy-nine patients with RA treated over a long-term with NSAID were enrolled. Their demographic data were recorded and laboratory data were measured. Endoscopy was performed to assess the prevalence of peptic ulcer. To verify the ulcer-preventive efficacy of anti-ulcer agents in patients with PU induced by longterm use of NSAID, the demographic factors and prevalence of PU were compared according to the use of anti-ulcer agents in this survey. For anti-ulcer agents, the remaining 179 patients were divided into those not taking anti-ulcer agents (non-medication group); those taking mucosal protective agents (mucosal protectant group), regular or half-dose H2RA (H2RA group), PPI or PG (PPI/PG group). Multiple comparisons were analyzed by one-way analysis of variance followed by the Fisher’s projected least significant difference (PLSD) test. Results: No significant difference was seen between any two groups when comparing age, sex, PU history, PSL usage, NSAID using condition (variety and dosage) and H. pylori infection rate. Thirty-eight (21.2%) of 179 RA patients had peptic ulcer, including 31 with gastric ulcer, 6 with duodenal ulcer and 1 with gastro-duodenal ulcer. The prevalence of PU in the H2RA group or PPI /PG group was significantly low compared to the mucosal protectant group (p ! 0.05, respectively). On the other hand, No significant difference was seen between any other groups (Table) Conclusions: In Japan, regular or half-dose of H2RA might be effective for preventing gastroduodenal injuries induced by long-term NSAID treatment. Table None
Mucosal
H2RA
PPI/PG
(n Z 10) 2 (20.0)
protectant (n Z 111) 30 (27.0)
(n Z 41) 5 (12.2)
(n Z 17) 17 (5.9)
APC Z Argon Plasma Coagulation. Peptic ulcer (%)
M1354 Clinical Significance of Double-Balloon Enteroscopy for Small Intestinal Bleeding Takayoshi Suzuki, Masashi Matsushima, Takayuki Shirai, Tetsuya Mine Background and Aim: It had been extremely difficult to observe the entire small intestine by endoscopy until the emergence of wireless capsule endoscopy (CE) or double-balloon enteroscopy (DBE). To assess the usefulness of DBE in patients with suspected small intestinal bleeding, the cases before and after the introduction of DBE to our hospital were compared retrospectively in their diagnoses and treatments. Methods: Twenty consecutive patients with suspected small intestinal bleeding underwent enteroscopy using double-balloon technique between September 2003 and November 2005 in Tokai University Hospital (Group A). Two patients were subsequently excluded owing to being diagnosed as bleeding from a diverticulum or an angiodysplasia in the ascending colon. For comparison, inpatients with colonoscopy and gastroscopy negative gastrointestinal bleeding in Tokai University Hospital from May 1998 to August 2003 were reviewed and 27 consecutive cases without DBE were selected as a control group (Group B). All patients selected in this study had undergone more than one colonoscopy and gastroscopy that was negative for a source of bleeding. Results: There were no significant differences between the 2 groups in terms of age, gender, history of blood transfusion, blood hemoglobin value on admission, or symptom. The diagnostic yields of DBE in identifying the source of bleeding were 83.3% including 6 cases of angiodysplasia, 6 of small intestinal ulcers, 1 of arteriovenous(A-V) malformation and 2 of submucosal tumor (SMT). Besides, 3 of the 6 angiodysplasia cases were successfully treated by argon plasma coagulation using DBE. As for the control group, conventional approaches including enteroclysis, angiography, Meckel scan, scintigraphy with technetium labeled red blood cells, and/or push enteroscopy were performed in 88.9%, 29.6%, 29.6%, 55.6%, 25.9% of the cases, respectively. The overall diagnostic yields of the conventional approaches were only 11.1% (p ! 0.01) including a Meckel’s diverticulum, a polyp or an angiodysplasia. There were no severe complications attributed to the examinations in either of the groups during the procedures. Conclusion: For the patients with suspected small
AB180 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1356 The Diagnostic Value of Push-Enteroscopy, Capsule Endoscopy, Ileoscopy and Enteroclysis (Sellink) for Small Bowel Evaluation in Patients with Familial Adenomatous Polyposis (FAP): A Comparative Prospective Trial Nicola Plum, Andrea May, Christian Ell Background: Patients with familial adenomatous polyposis (FAP) have a significantly increased lifetime risk to develop neoplastic polyps and malignancies along the entire length of the small bowel. The aim of this study was to compare the diagnostic yields of Push-enteroscopy (PE), Ileoscopy (IC), Capsule Endoscopy (CE) and Enteroclysis (EC) for the detection of small-bowel polyps. Methods: In a total of 18 FAP-patients with known duodenal adenomas PE, IC, CE and EC were performed and compared. Results: Based on the findings of Push-Enteroscopy all of the 18 patients had duodenal adenomas. In seven patients (39%) duodenal adenomas had to be removed because of their size (O10 mm). In six cases endoscopic treatment was performed. One patient was transmitted to surgery due to a duodenal carcinoma. Additional jejunal and ileal polyps were detected in 16 patients (89%). Ten (62%) of these 16 patients showed jejunal and ileal adenomas that could only be seenby CE. However, only in 2 patients adenomas with a diameter of O10 mm were seen. EC identified small bowel adenomas (size over 20 mm) in only two patients (11%). In six patients with adenomas ranging between 10 mm and 30 mm the results of EC were negative. Discussion: Our data confirm that jejunal and ileal adenomas are frequent in patients with duodenal polyposis. In sixty-two percent of our patients CE was able to detect adenomas that could not be reached by PE and IL. Therefore CE seems to be indicated in FAP-patients with duodenal polyposis. Pushenteroscopy as well as push-and-pull enteroscopy offer a save and gentle way of endoscopic treatment of adenomas in the small bowel. In comparison to the other diagnostic modalities, the diagnostic value of EC is low. It can therefore not be recommended for adenoma evaluation in the small bowel.
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M1353 Double Balloon Enteroscopy in the Diagnosis of Small Bowel Diseases. The Mexican Experience Oscar V. Hernandez, Juan M. Blancas Valencia, Victor M. Paz Flores, Maria L. Hernandez Reyes Background: The current methods used to explore the entire intestine lack of the ability to take biopsies or perform therapeutic maneuvers, including the wireless capsule endoscopy. Recently, double balloon enteroscopy (DBE) has been introduced in this field. It allows high resolution visualization, biopsy samples and therapeutic interventions. The aim of this study was to analyze the use of this new method in the diagnosis and treatment of small bowel diseases in Mexican population. Methods: This is a retrospective study conducted in one tertiary medical center by 4 experienced endoscopists between February 2004 and October 2005. 90 patients were studied for suspected or confirmed small bowel disease by imaging studies. Upper and lower endoscopies were normal. We document the characteristics of the procedures. Results: 90 patients (52 men; 38 women mean age 53.1 G 37 years), 102 DBE were done, 50 by an oral, 28 anal and 12 in a combined approach. Completely enteroscopy was done in 10 patients (11%) (8 by combined and 2 by oral approach). The mean time of procedure was 68 G 25 min and 85 G 36 min by oral and anal routes respectively. Mean length in oral approach was 280 G 150 cm beyond ligament of treitz and 130 G 105 cm beyond the ileocecal valve by anal route. Complications were mild and occurred in 20 patients (22%) Final diagnosis and treatments are showed in table 1. Conclusions: Besides the difficulty to perform a complete enteroscopy and the long time of the procedure. DBE is a safe and relative easy method that can explore and treat effectively lesions in patients with suspected or documented lesions in the small bowel. Table 1. Diagnosis, type of approach and treatment with DBE in the evaluation of small bowel diseases Diagnosis Angiodysplasia Vascular ectasia Small bowel ulcers Jejunoileitis Diverticulum Lipoma Polips Yeyunal Hemangioma Intestinal varices Malignant tumor Duodenal Xanthoma Benign stenosis Intestinal lymphangiectasia Normal Total
No Oral and patients Oral Anal anal Treatment 8 10 4 14 3 3 5 1 1 9 3 4 3 22 90
5 6 2 6 2 2 1 0 1 8 3 1 1 12 50
2 3 2 7 0 1 4 0 0 1 0 2 0 6 28
1 1 0 1 1 0 0 1 0 0 0 1 2 4 12
Endoscopic APC Endoscopic APC Medical treatment Medical treatment Medical Treatment None Endoscopic resection Sclerotherapy Sclerotherapy Surgery None Surgery None Symptomatic treatment
intestinal bleeding, DBE is a very useful procedure in the diagnosis and also effective in the treatment in some cases such as angiodysplasia.
M1355 Regular Or Half-Dose, Not High-Dose Histamine-H2 Receptor Antagonists Can Prevent NSAID-Associated Peptic Ulcers in Japanese Patients with Rheumatoid Arthritis Kazumasa Miyake, Masafumi Kusunoki, Tomotaka Shindo, Tatsuhiko Hamamoto, Nobue Ueki, Kenji Suzuki, Yoko Shinji, Tetsuro Hiratsuka, Hitoshi Nishigaki, Seiji Futagami, Ken Wada, Katya Gudis, Taku Tsukui, Atsuo Nakajima, Choitsu Sakamoto Background/Aim: It has been established in Europe and USA that proton pump inhibitors (PPIs), prostaglandin E1 analog (PG), and high-dose histamine H2 receptor antagonists (H2RA) effectively prevent NSAID-caused peptic ulcer. However, strategies to prevent NSAID-related ulcer have yet to be elucidated in Japan where the elderly have a lower gastric acidity and the dosage of NSAID is relatively low. That raises a possibility that a minimum effective dose of anti-ulcer agents might be much lower than those required in Europe and USA. Especially, it is expected that not only high-dose but also regular or half-dose H2RA shows the preventive effect. Therefore we investigated the relationship between anti-ulcer medications and NSAID-related peptic ulcer in Japanese patients with rheumatoid arthritis (RA) receiving long-term NSAID treatment. Methods: One hundred and seventy-nine patients with RA treated over a long-term with NSAID were enrolled. Their demographic data were recorded and laboratory data were measured. Endoscopy was performed to assess the prevalence of peptic ulcer. To verify the ulcer-preventive efficacy of anti-ulcer agents in patients with PU induced by longterm use of NSAID, the demographic factors and prevalence of PU were compared according to the use of anti-ulcer agents in this survey. For anti-ulcer agents, the remaining 179 patients were divided into those not taking anti-ulcer agents (non-medication group); those taking mucosal protective agents (mucosal protectant group), regular or half-dose H2RA (H2RA group), PPI or PG (PPI/PG group). Multiple comparisons were analyzed by one-way analysis of variance followed by the Fisher’s projected least significant difference (PLSD) test. Results: No significant difference was seen between any two groups when comparing age, sex, PU history, PSL usage, NSAID using condition (variety and dosage) and H. pylori infection rate. Thirty-eight (21.2%) of 179 RA patients had peptic ulcer, including 31 with gastric ulcer, 6 with duodenal ulcer and 1 with gastro-duodenal ulcer. The prevalence of PU in the H2RA group or PPI /PG group was significantly low compared to the mucosal protectant group (p ! 0.05, respectively). On the other hand, No significant difference was seen between any other groups (Table) Conclusions: In Japan, regular or half-dose of H2RA might be effective for preventing gastroduodenal injuries induced by long-term NSAID treatment. Table None
Mucosal
H2RA
PPI/PG
(n Z 10) 2 (20.0)
protectant (n Z 111) 30 (27.0)
(n Z 41) 5 (12.2)
(n Z 17) 17 (5.9)
APC Z Argon Plasma Coagulation. Peptic ulcer (%)
M1354 Clinical Significance of Double-Balloon Enteroscopy for Small Intestinal Bleeding Takayoshi Suzuki, Masashi Matsushima, Takayuki Shirai, Tetsuya Mine Background and Aim: It had been extremely difficult to observe the entire small intestine by endoscopy until the emergence of wireless capsule endoscopy (CE) or double-balloon enteroscopy (DBE). To assess the usefulness of DBE in patients with suspected small intestinal bleeding, the cases before and after the introduction of DBE to our hospital were compared retrospectively in their diagnoses and treatments. Methods: Twenty consecutive patients with suspected small intestinal bleeding underwent enteroscopy using double-balloon technique between September 2003 and November 2005 in Tokai University Hospital (Group A). Two patients were subsequently excluded owing to being diagnosed as bleeding from a diverticulum or an angiodysplasia in the ascending colon. For comparison, inpatients with colonoscopy and gastroscopy negative gastrointestinal bleeding in Tokai University Hospital from May 1998 to August 2003 were reviewed and 27 consecutive cases without DBE were selected as a control group (Group B). All patients selected in this study had undergone more than one colonoscopy and gastroscopy that was negative for a source of bleeding. Results: There were no significant differences between the 2 groups in terms of age, gender, history of blood transfusion, blood hemoglobin value on admission, or symptom. The diagnostic yields of DBE in identifying the source of bleeding were 83.3% including 6 cases of angiodysplasia, 6 of small intestinal ulcers, 1 of arteriovenous(A-V) malformation and 2 of submucosal tumor (SMT). Besides, 3 of the 6 angiodysplasia cases were successfully treated by argon plasma coagulation using DBE. As for the control group, conventional approaches including enteroclysis, angiography, Meckel scan, scintigraphy with technetium labeled red blood cells, and/or push enteroscopy were performed in 88.9%, 29.6%, 29.6%, 55.6%, 25.9% of the cases, respectively. The overall diagnostic yields of the conventional approaches were only 11.1% (p ! 0.01) including a Meckel’s diverticulum, a polyp or an angiodysplasia. There were no severe complications attributed to the examinations in either of the groups during the procedures. Conclusion: For the patients with suspected small
AB180 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1356 The Diagnostic Value of Push-Enteroscopy, Capsule Endoscopy, Ileoscopy and Enteroclysis (Sellink) for Small Bowel Evaluation in Patients with Familial Adenomatous Polyposis (FAP): A Comparative Prospective Trial Nicola Plum, Andrea May, Christian Ell Background: Patients with familial adenomatous polyposis (FAP) have a significantly increased lifetime risk to develop neoplastic polyps and malignancies along the entire length of the small bowel. The aim of this study was to compare the diagnostic yields of Push-enteroscopy (PE), Ileoscopy (IC), Capsule Endoscopy (CE) and Enteroclysis (EC) for the detection of small-bowel polyps. Methods: In a total of 18 FAP-patients with known duodenal adenomas PE, IC, CE and EC were performed and compared. Results: Based on the findings of Push-Enteroscopy all of the 18 patients had duodenal adenomas. In seven patients (39%) duodenal adenomas had to be removed because of their size (O10 mm). In six cases endoscopic treatment was performed. One patient was transmitted to surgery due to a duodenal carcinoma. Additional jejunal and ileal polyps were detected in 16 patients (89%). Ten (62%) of these 16 patients showed jejunal and ileal adenomas that could only be seenby CE. However, only in 2 patients adenomas with a diameter of O10 mm were seen. EC identified small bowel adenomas (size over 20 mm) in only two patients (11%). In six patients with adenomas ranging between 10 mm and 30 mm the results of EC were negative. Discussion: Our data confirm that jejunal and ileal adenomas are frequent in patients with duodenal polyposis. In sixty-two percent of our patients CE was able to detect adenomas that could not be reached by PE and IL. Therefore CE seems to be indicated in FAP-patients with duodenal polyposis. Pushenteroscopy as well as push-and-pull enteroscopy offer a save and gentle way of endoscopic treatment of adenomas in the small bowel. In comparison to the other diagnostic modalities, the diagnostic value of EC is low. It can therefore not be recommended for adenoma evaluation in the small bowel.
www.giejournal.org