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Double- Balloon Enteroscopy (Push and Pull Enteroscopy) of the Small Bowel: Comparison with Video Capsule Endoscopy and Magnetic Resonance Imaging
Abstracts
M1332 Role of Capsule Endoscopy in Inflammatory Disorders of the Small Intestine in Japanese Patients Presenting with Obscure Gastrointestinal Bleeding Nobuyuki Matsuhashi, Yasuyuki Kondo, Hiroki Endo, Tomohiko Ohya, Tomohiko Hasue, Katsuhiro Hanawa, Tomohiro Ito, Kantaro Hisatomi, Masako Asayama, Minoru Shibata, Yukihiro Sakurai Background: Vascular lesions including angiectasia are frequently detected in cases with obscure gastrointestinal bleeding (OGIB) in western countries. In Japan, however, inflammatory findings including erosions and ulcers are more prevalent than vascular abnormalities. Our knowledge about jejunal or ileal inflammation is limited, and capsule endoscopy (CE) may shed light on such conditions. Here, we have analyzed details of inflammatory findings in cases undergoing CE for OGIB in Japan. Methods: Study subjects were Japanese patients that underwent CE examination for OGIB in our Department in 2004 and 2005. Cases that presented inflammatory findings including ulcer or erosion in CE examinations were extracted. The strength of CE diagnosis was classified as definite/probable/ uncertain. Following points were analyzed for each case: 1) whether CE played the most important role in establishing diagnosis in the case, 2) whether therapeutic measures could be determined based on CE findings, 3) whether recurrence of bleeding or anemia could be prevented after CE examinations. Results: 68 cases underwent CE examination, and ulcers or erosions were detected in 40 cases, 25 males and 15 females (mean 59.2 y.o). Vascular lesions and tumors were detected in 8 and 6 cases, respectively. Among the 40 cases with ulcers or erosions, non-specific multiple small intestinal ulcers, NSAID-induced ulcers, Cohn’s disease corresponded to 21, 8, and 2 cases, respectively. Other disorders included radiation enteritis, Schoenlein-Hennoch syndrome, or cytomegalo virus infection. Diagnosis was difficult in the remaining 6. Thus, definitive, probable, and uncertain diagnosis was made in 17, 14, and 9 cases, respectively. 1) In 27 of the 40 cases, CE played the most important role in the diagnostic process. 2) Therapeutic measures could be determined based on CE findings in 17 of 17 cases with definitive, 10 of 14 cases with probable, and 4 of 9 cases with uncertain diagnosis. 3) Among 20 cases that could be followed up, recurrence of bleeding or anemia could be prevented after CE examinations in 16 cases. Especially, 4 of 6 cases with non-specific multiple small intestinal ulcers treated with 5-aminosalycylate responded to the therapy. Conclusion: Inflammatory disorders, especially non-specific multiple small intestinal ulcers and NSAID-induced ulcers are most prevalent in cases with OGIB in Japan. CE examinations are useful in diagnosis and determining therapeutic measures in such settings. 5-aminosalycylate may be effective in a certain subset of non-specific multiple small intestinal ulcers.
M1334 Triple Therapy Only for 7 Days Vs. Triple Therapy for 7 Days Plus Omeprazole for 21 Days in Treatment of Active Peptic Ulcer with Helicobacter Pylori Infection Hee Jung Oh, Ki-Nam Shim, Kum-Hei Ryu, Ji-Hyun Song, Hyun-Joo Song, Hye-Jung Yeom, Seong-Eun Kim, Tae-Hun Kim, Hye-Kyung Jung, Sung-Ae Jung, Sun-Young Yi, Kwon Yoo, Il-Hwan Moon, Kyu Won Chung Background/Aims: The current treatment for peptic ulcer disease is a 4-week course with triple therapy and antisecretory drugs in case of Helicobacter pylori (H. pylori) infection. But it is not clear whether the acid-suppressant therapy should be continued for symptomatic relief and ulcer healing before or after the eradication of H. pylori in patients with peptic ulcer disease. The aim of this study was to evaluate the effectiveness of additional acid-suppressant therapy before or after H. pylori eradication in peptic ulcer disease. Methods: Total 28 patients with active peptic ulcer (ulcer size O5 mm) with H. pylori infection were randomized in 3 groups: the first group of 8 patients treated with omeprazole (10 mg bid), amoxicillin (1 g bid), and clarithromycin (500 mg bid) (the standard triple therapy) for 7 days followed by omeprazole (10 mg qd) for 21 days (Group A), the second one of 10 patients with 7-day triple therapy only (Group B), and the third one of 10 patients treated with omeprazole for 21 days followed by 7-day triple therapy (Group C). Follow-up endoscopy with the rapid urease test and histology was performed 4~8 weeks after the completion of treatment. Statistical analyses for the eradication rate, symptom score, changes in the ulcer size, and endoscopic healing rate were performed. The symptoms before and after the treatments were scored by visual analog scale (0~3). Results: The frequencies of the endoscopic findings were: gastric ulcer 32.0%, duodenal ulcer 46.5%, and gastric ulcer plus duodenal ulcer 21.5%. Mean ulcer size was 7.6 G 4.1 mm (7.5 G 3.3 mm in Group A, 6.0 G 2.4 mm in Group B, 9.3 G 5.5 mm in Group C). The H. pylori eradication rates were 88% in Group A, 80% in Group B, and 90% in Group C. The peptic ulcer healing rates were 100% in Group A, 70% in Group B, and 90% in Group C. There was no difference in H. pylori eradication and ulcer healing rates among the 3 groups (p O 0.05). Symptom scores were significantly decreased after treatment in all groups (1.75 G 1.16 vs. 0.00 G 0.00 in Group A, 1.90 G 1.10 vs. 0.44 G 0.72 in Group B, 2.30 G 1.05 vs. 0.00 G 0.00 in Group C: (p ! 0.05), and the difference in symptomatic scores between before and after treatment in Group C was greater than those in other groups (p ! 0.05). Conclusions: The standard 7-day triple therapy only relieved symptoms remarkably, healed active peptic ulcer, and eradicated H. pylori infection in most patients. 21-day treatment extension with omeprazole, before or after triple therapy, was superior to the standard triple therapy in relieving the symptoms but did not modify ulcer healing and H. pylori eradication rates.
M1333 Double- Balloon Enteroscopy (Push and Pull Enteroscopy) of the Small Bowel: Comparison with Video Capsule Endoscopy and Magnetic Resonance Imaging Ulrich Damian, Dieter Schilling, Dirk Hartmann, Uwe Weickert, Axel Eickhoff, Ralf Jakobs, Valerie Kudis, Juergen F. Riemann Background and Study Aims: Double balloon endoscopy (DBE) and video capsule endoscopy (CE) are novel methods of enteroscopy. The values of CE, DBE and magnetic resonance imaging (MRI) in diagnosis of small intestinal diseases were compared in this study. Methods: Twenty-five patients with unclear bleeding, two patients with diarrhea and one patient with unclear weight loss were included and examined using MRI, CE and DBE. The mean age of the patients was 60 years. DBE procedure, using propofol sedation, was performed by a physician whereas capsule endoscopy and MRI findings were blinded. Results: Twenty-six patients were investigated only by oral route and two patients by both pathways (oral and rectal). In all DBE procedures there were no severe complications. One patient had an intermittend paralysis of nervus radialis due to wrong position during the examination. In CE and MRI examinations there were no complications. On average, 180 cm of the small bowel were examined by using the oral route. The average of 678 mg propofol was necessary and the mean radiation time lasted 4,9 minutes. In 50% of all DBE examination a pathologic finding was made. The most cases were angiodysplasia (11/14; 79%). In one case the possible diagnosis was a jejunal carcinoma. Compared with CE and MRI, CE identified positive findings in 19 patients (67%) and MRI in only 3 patients (11%) (table 1). Conclusion: In this study CE appears to be the superior examination in the diagnosis of small bowel injuries; however DBE points out the advantage in the possibility of therapeutic intervention. MRI is effective in the management of suspected tumorous diseases, but is deficient in the diagnosis of obscure gastrointestinal bleeding. In future CE and DBE could complement one another: Findings in CE could lead to the indication of DBE procedure and help to find the way of insertation (oral or rectal). Table 1. Positive or negative findings in small bowel imaging (n Z 28) DBE positive negative total (%)
CE positive
CE negative
MRI positive
MRI negative
Total (%)
13 6 67
1 8 33
2 1 11
12 13 89
50 50
AB174 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1335 Over Four Hundred Experiences of Double-Balloon Endoscopy for Small Intestinal Disorders Hiroto Kita, Hironori Yamamoto, Tomonori Yano, Tomohiko Miyata, Michiko Iwamoto, Keijiro Sunada, Toshiaki Omata, Yukio Tone, Taro Abe, Hakuei Shinhata, Shinji Fujieda, Hiroyuki Sato, Yoshikazu Hayashi, Kenichi Ido, Kentaro Sugano Background: Double-balloon endoscopy (DBE) is a novel system of endoscopy, developed by us in corporation with Fujinon, which allows the observation of the entire small intestine. DBE is based on a new insertion theory in which two balloons at the distal ends of both an endoscope and an overtube are operated in combination and the endoscope is inserted while shortening the intestine. DBE enables endoscopic scrutiny of the entire small bowel with intervention capabilities; targeted biopsy as well as endoscopic treatments including electrocoagulation, clip placement, balloon dilatation, and polypectomy are possible. Methods and Results: We have performed 411 enteroscopic examinations in 250 patients, including 225 oral approaches and 194 anal approach, using the Fujinon DBE system between September 2000 and October 2005. We used two types of dedicated endoscopes, one for general use (EN-450P5: Fujinon, Saitama, Japan) and one for treatment (EN-450T5: Fujinon, Saitama, Japan). Of 250 patients, inflammatory lesions were found in 49 cases and tumors/polyps were found in 49 cases. We also found 26 cases of angiodysplasia in the small intestine. Bleeding resource was detected in 82 of 123 cases (67%). Endoscopic treatments, including 35 hemostasis using either clipping devices or electrocoagulation, 25 cases of polypectomy, 6 cases of endoscopic mucosal resection, 35 cases of balloon dilation and 6 cases of stent placement were successfully carried out in the small intestine. Conclusions: DBE is both feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders. EN-450T5, therapeutic double-balloon endoscope with a larger accessory channel, further enhanced its therapeutic capabilities.
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M1332 Role of Capsule Endoscopy in Inflammatory Disorders of the Small Intestine in Japanese Patients Presenting with Obscure Gastrointestinal Bleeding Nobuyuki Matsuhashi, Yasuyuki Kondo, Hiroki Endo, Tomohiko Ohya, Tomohiko Hasue, Katsuhiro Hanawa, Tomohiro Ito, Kantaro Hisatomi, Masako Asayama, Minoru Shibata, Yukihiro Sakurai Background: Vascular lesions including angiectasia are frequently detected in cases with obscure gastrointestinal bleeding (OGIB) in western countries. In Japan, however, inflammatory findings including erosions and ulcers are more prevalent than vascular abnormalities. Our knowledge about jejunal or ileal inflammation is limited, and capsule endoscopy (CE) may shed light on such conditions. Here, we have analyzed details of inflammatory findings in cases undergoing CE for OGIB in Japan. Methods: Study subjects were Japanese patients that underwent CE examination for OGIB in our Department in 2004 and 2005. Cases that presented inflammatory findings including ulcer or erosion in CE examinations were extracted. The strength of CE diagnosis was classified as definite/probable/ uncertain. Following points were analyzed for each case: 1) whether CE played the most important role in establishing diagnosis in the case, 2) whether therapeutic measures could be determined based on CE findings, 3) whether recurrence of bleeding or anemia could be prevented after CE examinations. Results: 68 cases underwent CE examination, and ulcers or erosions were detected in 40 cases, 25 males and 15 females (mean 59.2 y.o). Vascular lesions and tumors were detected in 8 and 6 cases, respectively. Among the 40 cases with ulcers or erosions, non-specific multiple small intestinal ulcers, NSAID-induced ulcers, Cohn’s disease corresponded to 21, 8, and 2 cases, respectively. Other disorders included radiation enteritis, Schoenlein-Hennoch syndrome, or cytomegalo virus infection. Diagnosis was difficult in the remaining 6. Thus, definitive, probable, and uncertain diagnosis was made in 17, 14, and 9 cases, respectively. 1) In 27 of the 40 cases, CE played the most important role in the diagnostic process. 2) Therapeutic measures could be determined based on CE findings in 17 of 17 cases with definitive, 10 of 14 cases with probable, and 4 of 9 cases with uncertain diagnosis. 3) Among 20 cases that could be followed up, recurrence of bleeding or anemia could be prevented after CE examinations in 16 cases. Especially, 4 of 6 cases with non-specific multiple small intestinal ulcers treated with 5-aminosalycylate responded to the therapy. Conclusion: Inflammatory disorders, especially non-specific multiple small intestinal ulcers and NSAID-induced ulcers are most prevalent in cases with OGIB in Japan. CE examinations are useful in diagnosis and determining therapeutic measures in such settings. 5-aminosalycylate may be effective in a certain subset of non-specific multiple small intestinal ulcers.
M1334 Triple Therapy Only for 7 Days Vs. Triple Therapy for 7 Days Plus Omeprazole for 21 Days in Treatment of Active Peptic Ulcer with Helicobacter Pylori Infection Hee Jung Oh, Ki-Nam Shim, Kum-Hei Ryu, Ji-Hyun Song, Hyun-Joo Song, Hye-Jung Yeom, Seong-Eun Kim, Tae-Hun Kim, Hye-Kyung Jung, Sung-Ae Jung, Sun-Young Yi, Kwon Yoo, Il-Hwan Moon, Kyu Won Chung Background/Aims: The current treatment for peptic ulcer disease is a 4-week course with triple therapy and antisecretory drugs in case of Helicobacter pylori (H. pylori) infection. But it is not clear whether the acid-suppressant therapy should be continued for symptomatic relief and ulcer healing before or after the eradication of H. pylori in patients with peptic ulcer disease. The aim of this study was to evaluate the effectiveness of additional acid-suppressant therapy before or after H. pylori eradication in peptic ulcer disease. Methods: Total 28 patients with active peptic ulcer (ulcer size O5 mm) with H. pylori infection were randomized in 3 groups: the first group of 8 patients treated with omeprazole (10 mg bid), amoxicillin (1 g bid), and clarithromycin (500 mg bid) (the standard triple therapy) for 7 days followed by omeprazole (10 mg qd) for 21 days (Group A), the second one of 10 patients with 7-day triple therapy only (Group B), and the third one of 10 patients treated with omeprazole for 21 days followed by 7-day triple therapy (Group C). Follow-up endoscopy with the rapid urease test and histology was performed 4~8 weeks after the completion of treatment. Statistical analyses for the eradication rate, symptom score, changes in the ulcer size, and endoscopic healing rate were performed. The symptoms before and after the treatments were scored by visual analog scale (0~3). Results: The frequencies of the endoscopic findings were: gastric ulcer 32.0%, duodenal ulcer 46.5%, and gastric ulcer plus duodenal ulcer 21.5%. Mean ulcer size was 7.6 G 4.1 mm (7.5 G 3.3 mm in Group A, 6.0 G 2.4 mm in Group B, 9.3 G 5.5 mm in Group C). The H. pylori eradication rates were 88% in Group A, 80% in Group B, and 90% in Group C. The peptic ulcer healing rates were 100% in Group A, 70% in Group B, and 90% in Group C. There was no difference in H. pylori eradication and ulcer healing rates among the 3 groups (p O 0.05). Symptom scores were significantly decreased after treatment in all groups (1.75 G 1.16 vs. 0.00 G 0.00 in Group A, 1.90 G 1.10 vs. 0.44 G 0.72 in Group B, 2.30 G 1.05 vs. 0.00 G 0.00 in Group C: (p ! 0.05), and the difference in symptomatic scores between before and after treatment in Group C was greater than those in other groups (p ! 0.05). Conclusions: The standard 7-day triple therapy only relieved symptoms remarkably, healed active peptic ulcer, and eradicated H. pylori infection in most patients. 21-day treatment extension with omeprazole, before or after triple therapy, was superior to the standard triple therapy in relieving the symptoms but did not modify ulcer healing and H. pylori eradication rates.
M1333 Double- Balloon Enteroscopy (Push and Pull Enteroscopy) of the Small Bowel: Comparison with Video Capsule Endoscopy and Magnetic Resonance Imaging Ulrich Damian, Dieter Schilling, Dirk Hartmann, Uwe Weickert, Axel Eickhoff, Ralf Jakobs, Valerie Kudis, Juergen F. Riemann Background and Study Aims: Double balloon endoscopy (DBE) and video capsule endoscopy (CE) are novel methods of enteroscopy. The values of CE, DBE and magnetic resonance imaging (MRI) in diagnosis of small intestinal diseases were compared in this study. Methods: Twenty-five patients with unclear bleeding, two patients with diarrhea and one patient with unclear weight loss were included and examined using MRI, CE and DBE. The mean age of the patients was 60 years. DBE procedure, using propofol sedation, was performed by a physician whereas capsule endoscopy and MRI findings were blinded. Results: Twenty-six patients were investigated only by oral route and two patients by both pathways (oral and rectal). In all DBE procedures there were no severe complications. One patient had an intermittend paralysis of nervus radialis due to wrong position during the examination. In CE and MRI examinations there were no complications. On average, 180 cm of the small bowel were examined by using the oral route. The average of 678 mg propofol was necessary and the mean radiation time lasted 4,9 minutes. In 50% of all DBE examination a pathologic finding was made. The most cases were angiodysplasia (11/14; 79%). In one case the possible diagnosis was a jejunal carcinoma. Compared with CE and MRI, CE identified positive findings in 19 patients (67%) and MRI in only 3 patients (11%) (table 1). Conclusion: In this study CE appears to be the superior examination in the diagnosis of small bowel injuries; however DBE points out the advantage in the possibility of therapeutic intervention. MRI is effective in the management of suspected tumorous diseases, but is deficient in the diagnosis of obscure gastrointestinal bleeding. In future CE and DBE could complement one another: Findings in CE could lead to the indication of DBE procedure and help to find the way of insertation (oral or rectal). Table 1. Positive or negative findings in small bowel imaging (n Z 28) DBE positive negative total (%)
CE positive
CE negative
MRI positive
MRI negative
Total (%)
13 6 67
1 8 33
2 1 11
12 13 89
50 50
AB174 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1335 Over Four Hundred Experiences of Double-Balloon Endoscopy for Small Intestinal Disorders Hiroto Kita, Hironori Yamamoto, Tomonori Yano, Tomohiko Miyata, Michiko Iwamoto, Keijiro Sunada, Toshiaki Omata, Yukio Tone, Taro Abe, Hakuei Shinhata, Shinji Fujieda, Hiroyuki Sato, Yoshikazu Hayashi, Kenichi Ido, Kentaro Sugano Background: Double-balloon endoscopy (DBE) is a novel system of endoscopy, developed by us in corporation with Fujinon, which allows the observation of the entire small intestine. DBE is based on a new insertion theory in which two balloons at the distal ends of both an endoscope and an overtube are operated in combination and the endoscope is inserted while shortening the intestine. DBE enables endoscopic scrutiny of the entire small bowel with intervention capabilities; targeted biopsy as well as endoscopic treatments including electrocoagulation, clip placement, balloon dilatation, and polypectomy are possible. Methods and Results: We have performed 411 enteroscopic examinations in 250 patients, including 225 oral approaches and 194 anal approach, using the Fujinon DBE system between September 2000 and October 2005. We used two types of dedicated endoscopes, one for general use (EN-450P5: Fujinon, Saitama, Japan) and one for treatment (EN-450T5: Fujinon, Saitama, Japan). Of 250 patients, inflammatory lesions were found in 49 cases and tumors/polyps were found in 49 cases. We also found 26 cases of angiodysplasia in the small intestine. Bleeding resource was detected in 82 of 123 cases (67%). Endoscopic treatments, including 35 hemostasis using either clipping devices or electrocoagulation, 25 cases of polypectomy, 6 cases of endoscopic mucosal resection, 35 cases of balloon dilation and 6 cases of stent placement were successfully carried out in the small intestine. Conclusions: DBE is both feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders. EN-450T5, therapeutic double-balloon endoscope with a larger accessory channel, further enhanced its therapeutic capabilities.
www.giejournal.org