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Obscure GI bleeding in the world of capsule endoscopy, push, and double balloon enteroscopies
Obscure GI bleeding in the world of capsule endoscopy, push, and double balloon enteroscopies Blair S. Lewis, MD, FACP, FACG, FASGE New York, New York, USA
Worldwide experience suggests that capsule endoscopy is the preferred method of small bowel evaluation due to the length of small bowel it can examine, the quality of the examination, and the noninvasive nature of the test.1 The International Conference on Capsule Endoscopy (ICCE) produced a consensus statement on obscure GI bleeding.2 They concluded, ‘‘capsule endoscopy is currently the preferred test for mucosal imaging of the entire small intestine and should be part of the initial investigation in patients with obscure bleeding.’’ A pooled data analysis of manufacturer-sponsored trials showed capsule endoscopy to have a significantly increased pathology detection capability for suspected disease of the small intestine compared to push enteroscopy, small bowel series, and colonoscopy with ileal intubation.3 Capsule endoscopy identified pathology in approximately 70% of the examinations in the pooled data analysis of 530 capsule examinations. This is double the yield of other methods. Approximately 90% of 1349 pathologies were not identified by any method other than capsule endoscopy. A meta-analysis of both published trials and abstracts also attests to this increased yield.4 A review of 14 studies comparing capsule endoscopy to push enteroscopy revealed a combined yield of 63% for capsule endoscopy and 28% for push enteroscopy. Long-term follow-up studies have allowed calculation of sensitivity and specificity for capsule endoscopy by obtaining a final diagnosis during the follow-up period. Pennazio et al5 reported 1-year follow-up of 100 patients with obscure bleeding. Sensitivity, specificity, and positive predictive values, and negative predictive values of capsule endoscopy were 88.9%, 95%, 97%, and 82.6%, respectively, in the 56 patients in whom a definite confirmed diagnosis was obtained. Delvaux et al6 reported 1-year follow-up experience in 44 patients. The positive predictive value of capsule endoscopy was 94.4% in those with findings at capsule endoscopy, and the negative predictive value was 100 % in patients with normal capsule examination findings. Double balloon enteroscopy fills 3 major roles in the world where capsule endoscopy is the third test to diagnose obscure GI bleeding: (1) as a therapeutic tool to treat lesions identified by capsule endoscopy; (2) as a diagnostic tool if capsule endoscopy is negative and the patient continues to bleed; and (3) as a tool for removal in Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.01.015
cases of capsule retention. It can also be used for capsule findings that are not interpretable. Double balloon enteroscopy’s major role is a therapeutic one, providing endoscopic cautery of bleeding sites within the small bowel. Angioectasias constitute the major cause of obscure GI bleeding, accounting for approximately 80% of cases. Endoscopic therapy has been shown to be effective in controlling bleeding from intestinal angioectasias, but depth of intubation has previously been limited.7 Before the development of double balloon enteroscopy, when faced with a patient with a bleeding site in the mid to distal small bowel, the only option was surgery guided by intraoperative enteroscopy. Currently, double balloon enteroscopy replaces intraoperative enteroscopy to identify causes of bleeding seen on capsule endoscopy and to provide therapy. Another therapeutic use of double balloon enteroscopy is to tattoo mass lesions seen on capsule endoscopy when the lesions are thought to be too small to allow laparoscopic identification and resection. There are numerous advantages of double balloon enteroscopy over intraoperative enteroscopy, including a less invasive procedure, a shorter procedure time, improved visibility, and the ability to repeat the examination. Double balloon enteroscopy can also be performed in patients in whom surgery is contraindicated due to severe medical conditions, such as heart disease. Another advantage to this targeted approach is that it limits the time taken to perform the double balloon examination, a major factor that has limited the adoption of this new technology. The findings at capsule endoscopy are reliable, and this has been confirmed by a prospective study comparing capsule endoscopy to intraoperative endoscopy in 47 patients.8 The overall yield for capsule endoscopy was 74%, and the overall yield for both procedures was 76.6%. Bleeding sites were identified by both techniques in 36 patients, by capsule only in 2 patients, and by intraoperative enteroscopy only in 1 patient. Both examinations showed negative results in 11 patients. The calculated sensitivity for capsule endoscopy was 95%, specificity 75%, and positive and negative predictive values of 95% and 86%. With the use of double balloon enteroscopy, the therapeutic impact of capsule endoscopy will continue to grow. Kraus et al9 reported that in 33% of cases, capsule examination findings guided additional diagnostic and therapeutic steps. Ben Soussan et al10 reported that in 37% of examinations, new steps in management were undertaken including endoscopic management in 10 patients, surgery in 2 patients, and medical therapy in 1 patient. Mylonaki et al11
S66 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
www.giejournal.org
Lewis
Obscure GI bleeding
reported that capsule endoscopy led to an alteration of therapy in 66% of patients with positive findings. Pennazio et al5 reported that in 20 of 23 patients (86.9%) in whom capsule endoscopy was performed for ongoing overt bleeding, directed treatments led to resolution of bleeding. Overall, follow-up data of 91 patients during a mean follow-up period of 18 months showed that subsequent management dictated by capsule endoscopy led to the resolution of the bleeding in 59 patients (65%). An area of ongoing investigation has been localizing a bleeding site seen on capsule endoscopy to determine whether the finding is within reach of push enteroscopy, double balloon enteroscopy from an oral approach, or double balloon from a transrectal approach. Initial attempts to use capsule-passage time from the pylorus to the lesion proved inaccurate because total small-bowel– passage times vary due to varied peristalsis among individuals. Mark Appleyard has advocated using percentage of passage times to determine where a finding is located (personal communication, May 24, 2006). The time required for the capsule to pass from the pylorus to the lesion is divided by the total small bowel passage time. Appleyard has suggested that passage percentages less than 10% are within reach of a push enteroscope; lesions within 70% can be reached from an oral approach; and those longer than 70% can only be reached by transrectal passage. Though both national and international guidelines advocate capsule endoscopy in patients with obscure GI bleeding after a negative colonoscopy and upper endoscopy, it is not clear how to manage these patients if the capsule examination is negative. As stated previously, yields of capsule endoscopy in obscure bleeding average 70%. The pooled data analysis suggest that the overall miss rate for capsule endoscopy is 20%, with approximately 10% of cases having bleeding not in the small intestine but elsewhere in the GI tract.3 Data suggest that most patients have no further bleeding if capsule endoscopy is negative.12 However, some patients do continue to bleed, and it is unclear how to manage them. Two approaches have been suggested. One option is to repeat the capsule examination. The other is to pursue double balloon enteroscopy. Jones repeated capsule studies for a variety of indications in 24 patients.13 In 75%, repeat capsule endoscopy revealed additional findings, which led to a change in management in 62%. There are limited data available for the use of double balloon enteroscopy in cases of negative capsule examinations. Chong et al14 reported on 4 patients who underwent enteroscopy after negative capsule studies; a diagnosis was made in 3. The final role for double balloon enteroscopy is to remove a retained capsule. Having a capsule retained in the small bowel remains a major concern for physicians performing capsule endoscopy because it could lead to surgery in a patient who may otherwise have been treated medically. This is thought to be especially true for patients with Crohn’s disease or nonsteroidal anti-inflammatory disease (NSAID) enteropathy. The ICCE consensus statement
on capsule retention reported a 1.5% risk of retention when capsule endoscopy is performed in the setting of obscure bleeding.15 The consensus statement defined capsule retention as having a capsule endoscope remain in the digestive tract for a minimum of 2 weeks. Retention was also defined as the capsule permanently remaining in the bowel lumen unless extracted by endoscopic or surgical methods or passed as a result of medical therapy. There are no data on the success of medial therapies such as initiating a course of steroids or infliximab, stopping NSAIDs, or using prokinetics or cathartics to aid in the passage of a retained capsule. There is no time limit to institute management for capsule removal, and the physician and patient together can decide on the best management choice. The choice of surgical or endoscopic management once capsule retention has been diagnosed depends on the cause of the retention and the indication for the examination in the first place. If retention occurs behind a tumor or mass, surgical intervention is typically pursued quickly. If retention occurs behind a Crohn’s or NSAID stricture and the patient has had pronounced bleeding, surgical intervention may prove the most efficacious method of not only removing the capsule but also dealing with the cause of hemorrhage. This is equally true for retention in a patient with known Crohn’s disease, recurrent symptoms, and failure to respond to medical therapy before the capsule examination but without documented disease by any other method. Finally, for the patient in whom bleeding is not pronounced or in whom prior disease was only suspected but not treated, capsule retention behind an NSAID or Crohn’s stricture can be managed with double balloon enteroscopy.16 This technique for capsule retrieval allows the patient to subsequently be treated medically for the underlying illness. In summary, capsule endoscopy will remain the third test to be used in cases of obscure GI bleeding. Double balloon enteroscopy does not replace capsule endoscopy but does replace intraoperative enteroscopy for the majority of cases of obscure bleeding, except when double balloon enteroscopy is limited by the presence of adhesions or other anatomic factors. Lo and Mehdizadeh17 stated that ‘‘unlike other common endoscopies, double balloon enteroscopy is an expensive procedure. It requires fluoroscopy, extended anesthesia support, long procedure time, significant capital investment, and a team of three or four people (endoscopist, anesthesiologist, nurse).’’ It is not surprising that, for these reasons, capsule endoscopy will remain the major investigational tool for these patients. Capsule endoscopy is less invasive and can reliably guide a subsequent double balloon exam, thereby shorting examination time. While double balloon enteroscopy does not allow visualization of the entire small bowel in 1 examination, it has the capability to detect lesions missed by capsule endoscopy and offers the advantages of therapeutic treatment and capsule retrieval.
www.giejournal.org
Volume 66, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY S67
Obscure GI bleeding
DISCLOSURE Dr Lewis is a consultant for Given Imaging, Ltd.
REFERENCES 1. American Society for Gastrointestinal Endoscopy. ASGE technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc 2006;63:539-45. 2. Pennazio M, Eisen G, Goldfarb N. ICCE consensus for obscure gastrointestinal bleeding. Endoscopy 2005;37:1046-50. 3. Lewis B, Eisen G, Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy 2005;37:960-5. 4. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100:2407-18. 5. Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126:643-53. 6. Delvaux M, Fassler I, Gay G. Clinical usefulness of the endoscopic video capsule as the initial intestinal investigation in patients with obscure digestive bleeding: validation of a diagnostic strategy based on the patient outcome after 12 months. Endoscopy 2004;36:1067-73. 7. Askin M, Lewis B. Push enteroscopic cauterization: long-term followup of 83 patients with bleeding small intestinal angiodysplasia. Gastrointest Endosc 1996;43:580-3. 8. Hartmann D, Schmidt H, Bolz G, et al. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2005;61:826-32.
S68 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
Lewis 9. Kraus K, Hollerbach S, Pox C, et al. Diagnostic utility of capsule endoscopy in occult gastrointestinal bleeding [German]. Dtsch Med Wochenschr 2004;129:1369-74. 10. Ben Soussan E, Antonietti M, Herve S, et al. Diagnostic yield and therapeutic implications of capsule endoscopy in obscure gastrointestinal bleeding. Gastroenterol Clin Biol 2004;28:1068-73. 11. Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Gut 2003;52:1122-6. 12. Lai LH, Wong GL, Chow DK, et al. Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. Am J Gastroenterol 2006;101:1224-8. 13. Jones BH, Fleischer DE, Sharma VK, et al. Yield of repeat wireless video capsule endoscopy in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100:1058-64. 14. Chong AK, Chin BW, Meredith CG. Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy. Gastrointest Endosc 2006;64:445-9. 15. Cave D, Legnani P, deFranchis R, et al. ICCE consensus for capsule retention. Endoscopy 2005;37:1065-7. 16. Tanaka S, Mitsui K, Shirakawa K, et al. Successful retrieval of video capsule endoscopy retained at ileal stenosis of Crohn’s disease using double-balloon endoscopy. J Gastroenterol Hepatol 2006;21:922-3. 17. Lo SK, Mehdizadeh S. Therapeutic uses of double-balloon enteroscopy. Gastrointest Endosc Clin N Am 2006;16:363-76.
Current affiliation: Mount Sinai School of Medicine, New York, New York, USA. Reprint requests: Blair Lewis, MD, 1067 5th Avenue, New York, NY 10128.
www.giejournal.org
Worldwide experience suggests that capsule endoscopy is the preferred method of small bowel evaluation due to the length of small bowel it can examine, the quality of the examination, and the noninvasive nature of the test.1 The International Conference on Capsule Endoscopy (ICCE) produced a consensus statement on obscure GI bleeding.2 They concluded, ‘‘capsule endoscopy is currently the preferred test for mucosal imaging of the entire small intestine and should be part of the initial investigation in patients with obscure bleeding.’’ A pooled data analysis of manufacturer-sponsored trials showed capsule endoscopy to have a significantly increased pathology detection capability for suspected disease of the small intestine compared to push enteroscopy, small bowel series, and colonoscopy with ileal intubation.3 Capsule endoscopy identified pathology in approximately 70% of the examinations in the pooled data analysis of 530 capsule examinations. This is double the yield of other methods. Approximately 90% of 1349 pathologies were not identified by any method other than capsule endoscopy. A meta-analysis of both published trials and abstracts also attests to this increased yield.4 A review of 14 studies comparing capsule endoscopy to push enteroscopy revealed a combined yield of 63% for capsule endoscopy and 28% for push enteroscopy. Long-term follow-up studies have allowed calculation of sensitivity and specificity for capsule endoscopy by obtaining a final diagnosis during the follow-up period. Pennazio et al5 reported 1-year follow-up of 100 patients with obscure bleeding. Sensitivity, specificity, and positive predictive values, and negative predictive values of capsule endoscopy were 88.9%, 95%, 97%, and 82.6%, respectively, in the 56 patients in whom a definite confirmed diagnosis was obtained. Delvaux et al6 reported 1-year follow-up experience in 44 patients. The positive predictive value of capsule endoscopy was 94.4% in those with findings at capsule endoscopy, and the negative predictive value was 100 % in patients with normal capsule examination findings. Double balloon enteroscopy fills 3 major roles in the world where capsule endoscopy is the third test to diagnose obscure GI bleeding: (1) as a therapeutic tool to treat lesions identified by capsule endoscopy; (2) as a diagnostic tool if capsule endoscopy is negative and the patient continues to bleed; and (3) as a tool for removal in Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.01.015
cases of capsule retention. It can also be used for capsule findings that are not interpretable. Double balloon enteroscopy’s major role is a therapeutic one, providing endoscopic cautery of bleeding sites within the small bowel. Angioectasias constitute the major cause of obscure GI bleeding, accounting for approximately 80% of cases. Endoscopic therapy has been shown to be effective in controlling bleeding from intestinal angioectasias, but depth of intubation has previously been limited.7 Before the development of double balloon enteroscopy, when faced with a patient with a bleeding site in the mid to distal small bowel, the only option was surgery guided by intraoperative enteroscopy. Currently, double balloon enteroscopy replaces intraoperative enteroscopy to identify causes of bleeding seen on capsule endoscopy and to provide therapy. Another therapeutic use of double balloon enteroscopy is to tattoo mass lesions seen on capsule endoscopy when the lesions are thought to be too small to allow laparoscopic identification and resection. There are numerous advantages of double balloon enteroscopy over intraoperative enteroscopy, including a less invasive procedure, a shorter procedure time, improved visibility, and the ability to repeat the examination. Double balloon enteroscopy can also be performed in patients in whom surgery is contraindicated due to severe medical conditions, such as heart disease. Another advantage to this targeted approach is that it limits the time taken to perform the double balloon examination, a major factor that has limited the adoption of this new technology. The findings at capsule endoscopy are reliable, and this has been confirmed by a prospective study comparing capsule endoscopy to intraoperative endoscopy in 47 patients.8 The overall yield for capsule endoscopy was 74%, and the overall yield for both procedures was 76.6%. Bleeding sites were identified by both techniques in 36 patients, by capsule only in 2 patients, and by intraoperative enteroscopy only in 1 patient. Both examinations showed negative results in 11 patients. The calculated sensitivity for capsule endoscopy was 95%, specificity 75%, and positive and negative predictive values of 95% and 86%. With the use of double balloon enteroscopy, the therapeutic impact of capsule endoscopy will continue to grow. Kraus et al9 reported that in 33% of cases, capsule examination findings guided additional diagnostic and therapeutic steps. Ben Soussan et al10 reported that in 37% of examinations, new steps in management were undertaken including endoscopic management in 10 patients, surgery in 2 patients, and medical therapy in 1 patient. Mylonaki et al11
S66 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
www.giejournal.org
Lewis
Obscure GI bleeding
reported that capsule endoscopy led to an alteration of therapy in 66% of patients with positive findings. Pennazio et al5 reported that in 20 of 23 patients (86.9%) in whom capsule endoscopy was performed for ongoing overt bleeding, directed treatments led to resolution of bleeding. Overall, follow-up data of 91 patients during a mean follow-up period of 18 months showed that subsequent management dictated by capsule endoscopy led to the resolution of the bleeding in 59 patients (65%). An area of ongoing investigation has been localizing a bleeding site seen on capsule endoscopy to determine whether the finding is within reach of push enteroscopy, double balloon enteroscopy from an oral approach, or double balloon from a transrectal approach. Initial attempts to use capsule-passage time from the pylorus to the lesion proved inaccurate because total small-bowel– passage times vary due to varied peristalsis among individuals. Mark Appleyard has advocated using percentage of passage times to determine where a finding is located (personal communication, May 24, 2006). The time required for the capsule to pass from the pylorus to the lesion is divided by the total small bowel passage time. Appleyard has suggested that passage percentages less than 10% are within reach of a push enteroscope; lesions within 70% can be reached from an oral approach; and those longer than 70% can only be reached by transrectal passage. Though both national and international guidelines advocate capsule endoscopy in patients with obscure GI bleeding after a negative colonoscopy and upper endoscopy, it is not clear how to manage these patients if the capsule examination is negative. As stated previously, yields of capsule endoscopy in obscure bleeding average 70%. The pooled data analysis suggest that the overall miss rate for capsule endoscopy is 20%, with approximately 10% of cases having bleeding not in the small intestine but elsewhere in the GI tract.3 Data suggest that most patients have no further bleeding if capsule endoscopy is negative.12 However, some patients do continue to bleed, and it is unclear how to manage them. Two approaches have been suggested. One option is to repeat the capsule examination. The other is to pursue double balloon enteroscopy. Jones repeated capsule studies for a variety of indications in 24 patients.13 In 75%, repeat capsule endoscopy revealed additional findings, which led to a change in management in 62%. There are limited data available for the use of double balloon enteroscopy in cases of negative capsule examinations. Chong et al14 reported on 4 patients who underwent enteroscopy after negative capsule studies; a diagnosis was made in 3. The final role for double balloon enteroscopy is to remove a retained capsule. Having a capsule retained in the small bowel remains a major concern for physicians performing capsule endoscopy because it could lead to surgery in a patient who may otherwise have been treated medically. This is thought to be especially true for patients with Crohn’s disease or nonsteroidal anti-inflammatory disease (NSAID) enteropathy. The ICCE consensus statement
on capsule retention reported a 1.5% risk of retention when capsule endoscopy is performed in the setting of obscure bleeding.15 The consensus statement defined capsule retention as having a capsule endoscope remain in the digestive tract for a minimum of 2 weeks. Retention was also defined as the capsule permanently remaining in the bowel lumen unless extracted by endoscopic or surgical methods or passed as a result of medical therapy. There are no data on the success of medial therapies such as initiating a course of steroids or infliximab, stopping NSAIDs, or using prokinetics or cathartics to aid in the passage of a retained capsule. There is no time limit to institute management for capsule removal, and the physician and patient together can decide on the best management choice. The choice of surgical or endoscopic management once capsule retention has been diagnosed depends on the cause of the retention and the indication for the examination in the first place. If retention occurs behind a tumor or mass, surgical intervention is typically pursued quickly. If retention occurs behind a Crohn’s or NSAID stricture and the patient has had pronounced bleeding, surgical intervention may prove the most efficacious method of not only removing the capsule but also dealing with the cause of hemorrhage. This is equally true for retention in a patient with known Crohn’s disease, recurrent symptoms, and failure to respond to medical therapy before the capsule examination but without documented disease by any other method. Finally, for the patient in whom bleeding is not pronounced or in whom prior disease was only suspected but not treated, capsule retention behind an NSAID or Crohn’s stricture can be managed with double balloon enteroscopy.16 This technique for capsule retrieval allows the patient to subsequently be treated medically for the underlying illness. In summary, capsule endoscopy will remain the third test to be used in cases of obscure GI bleeding. Double balloon enteroscopy does not replace capsule endoscopy but does replace intraoperative enteroscopy for the majority of cases of obscure bleeding, except when double balloon enteroscopy is limited by the presence of adhesions or other anatomic factors. Lo and Mehdizadeh17 stated that ‘‘unlike other common endoscopies, double balloon enteroscopy is an expensive procedure. It requires fluoroscopy, extended anesthesia support, long procedure time, significant capital investment, and a team of three or four people (endoscopist, anesthesiologist, nurse).’’ It is not surprising that, for these reasons, capsule endoscopy will remain the major investigational tool for these patients. Capsule endoscopy is less invasive and can reliably guide a subsequent double balloon exam, thereby shorting examination time. While double balloon enteroscopy does not allow visualization of the entire small bowel in 1 examination, it has the capability to detect lesions missed by capsule endoscopy and offers the advantages of therapeutic treatment and capsule retrieval.
www.giejournal.org
Volume 66, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY S67
Obscure GI bleeding
DISCLOSURE Dr Lewis is a consultant for Given Imaging, Ltd.
REFERENCES 1. American Society for Gastrointestinal Endoscopy. ASGE technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc 2006;63:539-45. 2. Pennazio M, Eisen G, Goldfarb N. ICCE consensus for obscure gastrointestinal bleeding. Endoscopy 2005;37:1046-50. 3. Lewis B, Eisen G, Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy 2005;37:960-5. 4. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100:2407-18. 5. Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126:643-53. 6. Delvaux M, Fassler I, Gay G. Clinical usefulness of the endoscopic video capsule as the initial intestinal investigation in patients with obscure digestive bleeding: validation of a diagnostic strategy based on the patient outcome after 12 months. Endoscopy 2004;36:1067-73. 7. Askin M, Lewis B. Push enteroscopic cauterization: long-term followup of 83 patients with bleeding small intestinal angiodysplasia. Gastrointest Endosc 1996;43:580-3. 8. Hartmann D, Schmidt H, Bolz G, et al. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2005;61:826-32.
S68 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
Lewis 9. Kraus K, Hollerbach S, Pox C, et al. Diagnostic utility of capsule endoscopy in occult gastrointestinal bleeding [German]. Dtsch Med Wochenschr 2004;129:1369-74. 10. Ben Soussan E, Antonietti M, Herve S, et al. Diagnostic yield and therapeutic implications of capsule endoscopy in obscure gastrointestinal bleeding. Gastroenterol Clin Biol 2004;28:1068-73. 11. Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Gut 2003;52:1122-6. 12. Lai LH, Wong GL, Chow DK, et al. Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. Am J Gastroenterol 2006;101:1224-8. 13. Jones BH, Fleischer DE, Sharma VK, et al. Yield of repeat wireless video capsule endoscopy in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100:1058-64. 14. Chong AK, Chin BW, Meredith CG. Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy. Gastrointest Endosc 2006;64:445-9. 15. Cave D, Legnani P, deFranchis R, et al. ICCE consensus for capsule retention. Endoscopy 2005;37:1065-7. 16. Tanaka S, Mitsui K, Shirakawa K, et al. Successful retrieval of video capsule endoscopy retained at ileal stenosis of Crohn’s disease using double-balloon endoscopy. J Gastroenterol Hepatol 2006;21:922-3. 17. Lo SK, Mehdizadeh S. Therapeutic uses of double-balloon enteroscopy. Gastrointest Endosc Clin N Am 2006;16:363-76.
Current affiliation: Mount Sinai School of Medicine, New York, New York, USA. Reprint requests: Blair Lewis, MD, 1067 5th Avenue, New York, NY 10128.
www.giejournal.org