Diagnostic Yield and Effect on Clinical Outcomes of Push Enteroscopy in Suspected Small-Bowel Bleeding

Background and Study Aims: Endoscopic examination of the small bowel (enteroscopy) has become an important modality in the investigation of patients with obscure gastrointestinal bleeding/anaemia. The aim of this study was to look at our clinical experience and also to determine the clinical outcomes following push enteroscopy (PE) in patients with suspected small intestinal bleeding.

Patients and Methods: The indications for PE were iron-deficiency anaemia/occult or obscure gastrointestinal bleeding (50 patients) and overt gastrointestinal bleeding (28 patients). Out of these 78 patients, a subgroup of 21 unselected patients with suspected small intestinal bleeding (six men, 15 women; mean age 59, range 26 - 85) was recruited to determine the clinical outcomes following PE. The principal outcome measures in this study were a) whether the procedure led to a change in the management of the patients referred for PE and b) whether it saved them from having further investigations.

Results: In those patients with undiagnosed gastrointestinal bleeding/anaemia, small-bowel arteriovenous malformations (AVMs) were detected in 24/78 (31 %). Heater probe ablation therapy was performed in 23 patients with small-bowel and gastric AVMs. In total, seven of these 23 patients (30 %) re-bled or required transfusion; these seven had repeat enteroscopy and heater probe ablation therapy. Three of these seven re-bled and required further enteroscopy and therapy. PE resulted in a change in management and treatment plans in eight of 20 patients (40 %). The certainty of diagnosis increased in seven of 20 patients (35 %). It increased from a mean value of 1.35 before PE to 2.40 following PE ( P = 0.01). The test was assigned a median „usefulness score” of 3 by the requesting physicians on an integer scale from 1 (not helpful) to 5 (very helpful).

Conclusions: We conclude that (i) PE can establish a diagnosis in a high proportion of patients with undiagnosed gastrointestinal bleeding/anaemia; (ii) heater probe ablation therapy of vascular lesions can be performed routinely at the time of PE; (iii) a significant proportion of patients (42 %) referred for enteroscopy have lesions in the stomach/proximal duodenum that are missed at diagnostic endoscopy; (iv) PE provides helpful information in routine clinical practice and is perceived as a helpful test by requesting physicians; (v) PE improves certainty of diagnosis as perceived by requesting physicians, and plays an important role in altering management plans.

References

• 1 Huilgol V, Harris M S, Vakil N. Enteroscopy: outcomes.  Gastrointest Endosc Clin N Am. 1996;  6 811-818
• 2 Mujica V R, Barkin J S. Occult gastrointestinal bleeding: general overview and approach.  Gastrointest Endosc Clin N Am. 1996;  6 833-846
• 3 Myers R T. Diagnosis and management of occult gastrointestinal bleeding: visualisation of the small bowel lumen by fibreoptic colonoscope.  Am J Surg. 1976;  42 92-95
• 4 Netterville R, Hardy J, Martin R. Small bowel haemorrhage.  Ann Surg. 1968;  167 949-957
• 5 Lau W, Wong S, Ngan H. Intra-operative localization of bleeding small intestinal lesions.  Br J Surg. 1988;  75 249-251
• 6 Foutch P G. Angiodysplasia of the gastrointestinal tract.  Am J Gastroenterol. 1993;  55 807-818
• 7 Barthel J S. Diagnostic and therapeutic push type enteroscopy in clinical use.  Gastrointest Endosc. 1996;  44 103-105
• 8 Messer J, Romeu J, Waye J, et al. The value of proximal jejunoscopy in unexplained gastrointestinal bleeding (abstract).  Gastrointest Endosc. 1984;  30 151
• 9 Foutch P G, Sawyer R, Sanowski R A. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin.  Gastrointest Endosc. 1990;  36 337-341
• 10 Yang R, Laine L. Mucosal stripping: a complication of push enteroscopy.  Gastrointest Endosc. 1995;  41 156-158
• 11 Davies G R, Benson M J, Gertner D J, et al. Diagnostic and therapeutic push-type enteroscopy in clinical use.  Gut. 1995;  37 346-352
• 12 Chong J, Tagle M, Barkin J S, Reiner D K. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology.  Am J Gastroenterol. 1994;  89 2143-2146
• 13 Berner J S, Mauer K, Lewis B S. Push and sonde enteroscopy for the diagnosis of obscure gastrointestinal bleeding.  Am J Gastroenterol. 1994;  89 2139-2142
• 14 Shike M, Wallach C, Likier H. Direct percutaneous endoscopic jejunostomies.  Gastrointest Endosc. 1991;  37 62-65
• 15 Gostout C J, Bender C E. Cholangiopancreatography, sphincterotomy, and common duct stone removal via Roux-en-Y limb enteroscopy.  Gastroenterology. 1988;  95 156-163