Use of the Enteroscope for Colo-Ileoscopy: Low Yield in Unexplained Lower Gastrointestinal Bleeding

Background and Study Aims: The small intestine is a potential origin of bleeding in patients with unexplained gastrointestinal tract hemorrhage or iron-deficiency anemia. Most reports on the investigation of these patients describe the use of upper tract enteroscopy. The diagnostic yield of combined upper and lower enteroscopy has not been widely assessed and remains to be clarified. The aim of this study was to assess the benefit of lower gastrointestinal tract enteroscopy in occult digestive bleeding.

Patients and Methods: Between 1 December 1995 and 15 January 1998, 54 patients with gastrointestinal bleeding of unknown origin were prospectively studied using upper and lower video push enteroscopy (44 for chronic iron-deficiency anemia and 10 for unexplained gastrointestinal tract hemorrhage with no potential site having been identified by other investigations). Examinations were done using a Olympus video enteroscope (SIF-100) under general anesthesia in a one-day clinic. An upper tract examination was done first, directly followed by the lower tract investigation.

Results: The upper tract enteroscopy was successful in 53 patients (98 %) and retrograde ileoscopy in 21 patients (39 %). In 18 (38 %) cases the technical failure re-sulted from the impossibility of intubating the ileocecal valve. A potential source of upper gastrointestinal bleeding was detected in 35 % of patients with chronic iron-deficiency anemia and in 20 % of those with unexplained gastrointestinal tract hemorrhage. The most common lesion in the small bowel was angiodysplasia (25 %). The lower tract video push enteroscopy disclosed 11 lesions in patients with chronic anemia. However the lesions, including two ileocecal valve cancers, were mainly located in the colon and had been missed by previous colonoscopy. No case of ileal lesion was detected in this group of patients. In patients with unexplained gastrointestinal tract hemorrhage, three lesions were detected but only one of these was in the ileum. Associated colonic and jejunal lesions were observed in three patients (5.5 %). Overall, the diagnostic yield of lower video push enteroscopy was less than 2 %.

Conclusion: This prospective study has shown that using an enteroscope as a colonoscope in the management of patients with gastrointestinal bleeding of unknown origin is of little help. It might actually be more appropriate to perform a second colonoscopy. This however remains controversial and a prospective study is needed to answer that question.

References

• 1 Lewis BS, Waye JD. Chronic gastrointestinal bleeding of obscure origin: role of small bowel enteroscopy.  Gastroenterology. 1988;  94 1117-20
• 2 Gostout CJ, Schroeder KW, Burton DD. Small bowel enteroscopy: an early experience in gastrointestinal bleeding of unknown origin.  Gastrointest Endosc. 1991;  37 5-8
• 3 Morris AJ, Wasson LA, MacKenzie JF. Small bowel enteroscopy in undiagnosed gastrointestinal blood loss.  Gut. 1992;  33 887-9
• 4 Van Gossum A, El Nawar A, Adler M, Cremer M. L'entéroscopie: méthode et résultats.  Acta Gastroenterol Belg. 1992;  55 169-75
• 5 Foutch GP, Sawyer R, Sanowski RA. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin.  Gastrointest Endosc. 1990;  36 337-41
• 6 Barkin JS, Lewis BS, Reiner DK, et al. Diagnostic and therapeutic jejunoscopy with a new longer enteroscope.  Gastrointest Endosc. 1992;  38 55-8
• 7 Chong J, Tagle M, Barkin JS, Reiner DK. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology.  Am J Gastroenterol. 1994;  89 2143-6
• 8 Davies GR, Benson MJ, Gertner DJ, et al. Diagnostic and therapeutic push type enteroscopy in clinical use.  Gut. 1995;  37 346-52
• 9 Pennazio M, Arrigoni A, Risio M, et al. Clinical evaluation of push-type enteroscopy.  Endoscopy. 1995;  27 164-70
• 10 Schmit A, Gay F, Adler M, et al. Diagnostic efficacy of push-enteroscopy and long-term follow-up of patients with small bowel angiodysplasias.  Dig Dis Sci. 1996;  41 2348-52
• 11 Askin MP, Lewis BS. Push enteroscopic cauterization: long term follow-up of 83 patients with bleeding small intestinal angiodysplasia.  Gastrointest Endosc. 1996;  43 580-3
• 12 Rossini FP, Arrigoni A, Pennazio M. Clinical enteroscopy.  J Clin Gastroenterol. 1996;  22 213-6
• 13 Vakil N, Huilgol V, Khan I. Effect of push enteroscopy on transfusion requirements and quality of life in patients with unexplained gastrointestinal bleeding.  Am J Gastroenterol. 1997;  92 425-8
• 14 O'Mahony S, Morris AJ, Straiton M, et al. Push enteroscopy in the investigation of small-intestinal disease.  Q J Med. 1996;  89 685-90
• 15 Chak A, Koehler S, Sundaram SN, et al. Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings.  Gastrointest Endoscopy. 1998;  4 18-20
• 16 Bouhnik Y, Bitoun A. L'entéroscopie: technique, indications, résultats. In: Colombel JF, Dupas JL, editors. Pathologie du grêle. Paris; Doin éditeurs 1997: 63-71
• 17 Landi B, Tkoub M, Gaudric M, et al. Diagnostic yield of push-type enteroscopy in relation to indication.  Gut. 1998;  42 421-5
• 18 Croguenec B, Canard JM, Houcke Ph, et al. Video enteroscopie poussée par double voie (V.E.P.) premier bilan (269 cas). (abstract).  Gastroenterol Clin Biol. 1995;  19 2-17
• 19 Chollet R, Benhamou Y, Luciani F, et al. L'entéroscopie pulsée: une nouvelle technique endoscopique pour l'intestin grêle (abstract).  Gastroenterol Clin Biol. 1996;  20 2-137
• 20 Rolachon A, Bohn B, Gueddah N, Fournet J. L'entéroscopie poussée par double voie présente-t-elle un intérêt pour le diagnostic des lésions de l'intestin grêle? A propos d'une étude prospective (abstract).  Gastroenterol Clin Biol. 1998;  22 2-68
• 21 Jakobs R, Benz C, Maier M, et al. Transvalvular enteroscopy using a mother-baby endoscope system: a new approach to the distal ileum.  Gastrointest Endosc. 1997;  45 298-300
• 22 Lau WY, Yuen WK, Chu KW, et al. Obscure bleeding in the gastrointestinal tract originating in the small intestine.  Surg Gynecol Obstet. 1992;  174 119-24