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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 43  |  Issue : 1  |  Page : 16-21

Push enteroscopy in the management of suspected small-bowel diseases: A 2-year retrospective study


Department of Internal Medicine, Gastroenterology and Hepatology Unit, Tanta University, Egypt

Date of Submission10-Jun-2014
Date of Acceptance26-Nov-2014
Date of Web Publication6-Apr-2015

Correspondence Address:
Mohamed Abd El-Raouf Tawfik
Lecturer of internal medicine, GI endoscopy and Hepatology Unit, Internal Medicine Department, Tanta University, Tanta
Egypt
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DOI: 10.4103/1110-1415.154560

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  Abstract 

Background and study aims
Small-intestinal lesions still represent a challenge with respect to their diagnosis and treatment. The detection of small bowel mass lesions (SBMLs) has been difficult due to the limited visualization of small-bowel esophagogastroduodenoscopy and colonoscopy. In this study, we aimed to assess the efficacy of push enteroscopy in diagnosis and therapy in the gastroenterology and endoscopy center of Tanta University hospital.
Patients and methods
In the period from January 2012 to December 2013, 14 patients with different indications, referred to the Tanta endoscopy center, a division of the internal medicine department and one of the most important centers in Delta Nile in Egypt, underwent examination by push enteroscope.
Results
The overall diagnostic yield for patients with suspected small-bowel disease was 57% and for patients with both occult and overt obscure bleeding 63%. Ectopic Jejunal varices was the most common diagnosis in patients with gastrointestinal blood loss. Patients with active overt gastrointestinal bleeding had a higher diagnostic yield. The procedure was tolerated well and no complications occurred.
Conclusion
Additional endoscopic evaluation of the proximal small bowel by push enteroscopy should be considered in all patients with negative or nonspecific findings on esophagogastroduodenoscopy and colonoscopy and with persistent bleeding, especially when a balloon-assisted enteroscopy is not readily available and capsule endoscopy (CE) is expensive.

Keywords: angiodysplasia, gastrointestinal hemorrhage, push enteroscopy, small-bowel disease


How to cite this article:
Tawfik MA, Allah Ahmed El-Sawy A. Push enteroscopy in the management of suspected small-bowel diseases: A 2-year retrospective study. Tanta Med J 2015;43:16-21

How to cite this URL:
Tawfik MA, Allah Ahmed El-Sawy A. Push enteroscopy in the management of suspected small-bowel diseases: A 2-year retrospective study. Tanta Med J [serial online] 2015 [cited 2019 Nov 17];43:16-21. Available from: http://www.tdj.eg.net/text.asp?2015/43/1/16/154560


  Introduction Top


Gastroscopy and colonoscopy have become the investigations of choice for gastrointestinal (GI) diseases. However, imaging of the small bowel is still limited. Small-bowel barium follow-through is the most commonly used investigation tool, but it has a low sensitivity and a specificity of only 10% for detecting the pathology [1] .

Thus, the quest for the inspection and the biopsy of the small intestine has been pursued enthusiastically for many years [2] . The detection of small-bowel lesions has been difficult due to limited visualization of the small bowel by esophagogastroduodenoscopy (EGD) and colonoscopy [3] .

The small bowel is the most difficult part of the GI tract to image due to its location, length, and tortuosity [4] . Enteroscopy, which is endoscopy of the small bowel, has been used for the investigation of small-bowel diseases, in which a push enteroscope (PE) is actively advanced under vision into the small bowel. The advantages of this method are that biopsy and endoscopic treatment of mucosal lesions can be performed [2] .

The most important clinical indication for the visualization of the small intestine is obscure GI bleeding or iron-deficiency anemia (IDA), when a source of blood loss cannot be found in the EGD or on colonoscopy. It is now recognized that small-intestinal lesions account for a significant proportion of patients with obscure GI bleeding and IDA [5] . In 20% of the patients with IDA, a routine upper and lower GI endoscopy may not ascertain the GI cause during hospital admission [6] . Many studies have concluded that on evaluation of the GI tract for IDA, most of the lesions were in the lower GI tract, and have recommended that the evaluation for IDA should be started with lower GI examination [7],[8] .

Small-bowel bleedings with the origin located between the papilla and the ileocecal valve are defined as mid-GI bleeding. The diagnostic yield of push enteroscopy was reported to be in the range of 20 ± 80% [9] .

PE can be considered as the first diagnostic step in patients with suspected small-bowel stenosis because capsule endoscopy should be avoided in these cases due to the risk of capsule retention [10] .

The present study examines the usefulness of push enteroscopy at the GI endoscopy unit in Tanta University in Egypt for the investigation of either GI bleeding or suspected small-bowel disease.


  Patients Top


A total of 14 patients underwent push enteroscopy procedures over a 24-month period. The procedures were carried out from January 2012 to December 2013. Clinical indications of push enteroscopy were as follows: IDA/occult GI bleeding (seven patients), overt GI bleeding (four patients), abnormal small-bowel radiology (one patient), and persistent vomiting and chronic diarrhea (one patient).

Inclusion criteria

All patients who needed PE examination and underwent initial assessment by both EGD and colonoscopy, which revealed negative findings.

Exclusion criteria

There are no absolute contraindications to push-and-pull enteroscopy. Suspected or already known stenoses are, in fact, a very good indication for push enteroscopy (PE), which is useful for their further diagnostic assessment. Postprocedural observation of the patients is also important for the timely detection of potential complications, particularly after endoscopic therapeutic interventions [11] .

Confidentiality of data was guaranteed. Verbal witnessed consents were taken from patients for data collection. The research includes data collection only without any interference with the patient treatment.


  Methods Top


The Pentax VSB-3440 (Pentax Company, Tokyo, Japan) was used for all examinations. This instrument is a video push-type enteroscope, with a total length of 2528 cm and a working length of 2200 cm. The distal diameter was 11.5 mm and the instrument channel was 3.5 mm. After intubation of the pylorus and passage of the instrument to the distal duodenum, the enteroscope was advanced through the duodeno-jejunal flexure and the instrument was progressed by the rotation of the shaft, with shortening and straightening of the scope to facilitate advancement. The small-intestinal intubation length was calculated by straightening the instrument to remove the gastric loop, and subtracting 60 cm from the depth inserted: 60 cm was the average distance from the incisors to the pylorus (range 40-80 cm). All enteroscopic examinations were performed by the author of this study.


  Results Top


This study included 14 patients, six male (43%) and eight female (57%), and their ages ranged from 17 to 67 years, with a mean age of 48.6 years.

[Table 1] shows that IDA was the main indication for enteroscopic examination, which represented 7/14 cases (50%), whereas four cases presented with recurrent episodes of melena (28.6%), and finally, there was only one case each of abnormal computed tomography findings (dilated loops with air fluid levels), persistent vomiting and chronic diarrhea ([Figure 1], [Figure 2]).
Figure 1: Indications of PE. PE, push enteroscope.

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Figure 2: The PE diagnostic ability in all patients. PE, push enteroscope.

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Table 1: Indications, fi ndings, and outcomes of PE among the studied patients

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In contrast, enteroscopic examination of these cases achieved diagnosis in 8/14 patients (57%), with a distribution pattern as follows: varices, 3/8 (37%); arteriovenous malformations (AVMs), 2/8 (25%); ischemia, 1/8 (12.5%); infestations, 1 (12.5%); and nonspecific inflammation, 1 (12.5%) ([Figure 3]).
Figure 3: Distribution of the PE-detected lesions among positive cases. PE, push enteroscope.

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Diagnosis was achieved only in three out of seven patients who presented with IDA, whereas all the studied patients who presented with overt bleeding were diagnosed; in contrast, only one out of three patients who presented with other complaints was diagnosed ([Figure 4]).
Figure 4: Comparison between the achieved diagnosis in occult (1), overt bleeding (2), and other indications (3).

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Only two patients (14.3%) in this study were treated by enteroscopy (one injected and the other by argon plasma coagulation (APC)), whereas medical treatment succeeded in controlling the main indication in four cases (28.5%). Recurrence happened in five cases (35.7%): all were of negative on enteroscopic examination; and finally, death occurred in two cases after being referred to surgery ([Figure 5]). The mean Hb among the studided patients were 9.05 gm/dl, however the mean prothrombin activity were 87.8% [Table 2].
Figure 5: Outcome of the studied patients.

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Table 2: U/S and laboratory tests of all studied patients who underwent PE

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  Discussion Top


Push enteroscopy could not be considered as a new tool in the investigation of the small intestine, because it was established during the 1980s, but due to excessive loop formation, it allows only limited visualization of the small intestine [10] ; however, we established the diagnosis in eight out of the 14 studied patients with suspected [Photo 1]

[Photo 2]

[Photo 3]

[Photo 4]

[Photo 5]

small-bowel lesion, achieving a diagnostic yield of 57%; this result is very close to that of Pennazio et al. (60%) [12] ; however, it is higher than that of Barkin and Ross (39%) [13] and Chen et al. (33%) [14] .

Both occult and overt bleeding were the most important indications for performing push enteroscopy and achieving diagnosis in 7/11 patients (63.6%); this was compatible with Chak et al. (70%) [15] Chong et al. (64%) [16] , and Schmit et al. (57%) [17] and in contrast to Chen et al. (47%) [14] and Landi et al. (27%) [18] .

The presence of active GI bleeding increased the diagnostic yield of the present study (four of four patients). This is consistent with the published series [13],[19] . It stresses the importance of performing the procedure when patients have had an evidence of active bleeding.

Since the introduction of wireless capsule endoscopy into clinical practice, the ability to diagnose small-bowel diseases has improved significantly [20] . However, CE is limited by the fact that biopsies cannot be taken and interventional endoscopic procedures cannot be performed [3],[21] . Moreover, their economic cost is still a burden in our country for it to be used as a diagnostic tool alone.

Previous studies have revealed an overall CE 'miss rate' of 10% and a miss rate of 18.6% for SMBLs, especially if the lesion is smaller than 3 cm [3],[22],[23] . There are several possible reasons as to why SBMLs are missed by CE. First, unlike vascular lesions, SBMLs are typically unifocal. At the current image capture rate of two frames per second, focal lesions are more likely to be missed than those that are diffuse [3] . Second, as the capsule passes along the duodenal sweep, it may increase in speed. Therefore, SBMLs located in the proximal small bowel are more likely to be missed by CE. Lastly, incomplete small-bowel transit and blood in the lumen may obscure the visualization of underlying SBMLs [3],[23] .

Double balloon enetroscopy (DBE) is a novel technique that was described in 2003 [20] . DBE has resulted in the improved diagnosis of small-bowel lesions by allowing deep access into the small bowel with diagnostic and therapeutic capacity [21] . However, DBE is actually more time-consuming than other endoscopic procedures, which typically takes about 2 h. A longer duration often means patient intolerance and an increased risk of complications including but not limited to bowel perforation and pancreatitis [20] . Moreover, DBE requires special endoscopic training and is not readily available in many institutions.

PE permits visualization and therapeutic intervention in the proximal small bowel, ~80-120 cm beyond the ligament of Treitz [20],[24] . PE is safe, relatively quick, and a readily available modality. However, push enteroscopy is not a risk-free procedure. PE cannot reach the distal small intestine, and push enteroscopy has a similar profile of complications as a conventional upper endoscopy [25] .

CE, push enteroscopy, DBE, computed tomography scan, and magnetic resonance enterography have facilitated the diagnosis, the monitoring, and the management of patients with small-bowel lesions [26] .

The outcome of these patients after 3 months of follow-up was recorded. Six patients were improved clinically; however, recurrence occurred in five cases: all of them were negative on push enteroscopic examination; and unfortunately, two patients died after being referred to surgery.

Although this study was carried out on cases referred to the gastroenterology and endoscopy center of Tanta university hospital, over 24 months, the number of patients was relatively small (14 patients), which reflects the lack of expectancy to small-intestinal lesions; however, this expectancy is growing steadily.


  Conclusion Top


We conclude that PE plays an important and useful role in our center, and it is the most suitable tool to begin with in the investigation of patients in whom a small-bowel lesion is suspected as it is cheap, easily available, partially time saving, and tolerable, with a significant diagnostic yield of 57% in this study. Other endoscopic and nonendoscopic modalities will be useful in patients with PE-negative findings, especially if they are unavailable and/or relatively highly expensive.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Chen RY, Taylor AC, Desmond PV. Push enteroscopy: a single centre experience and review of published series. ANZ J Surg 2002; 72:215-218.  Back to cited text no. 2
    
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Park DI, Ryu SH, Oh SJ, Yoo TW, Kim HJ, Cho YK, et al. Significance of endoscopy in asymptomatic premenopausal women with iron deficiency anemia. Dig Dis Sci 2006; 51:2372-2376.  Back to cited text no. 7
    
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Chen RY, Taylor AC, Desmond PV. Push enteroscopy: a single centre experience and review of published series. ANZ J Surg 2002; 72:215-218.  Back to cited text no. 14
    
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Chak A, Koehler MK, Sundaram SN, Cooper GS, Canto MI, SivakMVJr. Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings. Gastrointest Endosc 1998; 47:18-22.  Back to cited text no. 15
    
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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; 89:2143-2146.  Back to cited text no. 16
    
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Schmit A, Gay F, Adler M, Cremer M, Van Gossum A. Diagnostic efficacy of push-enteroscopy and long-term follow-up of patients with small bowel angiodysplasias. Dig Dis Sci 1996; 41:2348-2352.  Back to cited text no. 17
    
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Landi B, Tkoub M, Gaudric M, Guimbaud R, Cervoni JP, Chaussade S, et al. Diagnostic yield of push-type enteroscopy in relation to indication. Gut 1998; 42:421-425.  Back to cited text no. 18
    
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Kaffes AJ, Koo JH, Meredith C. Double-balloon enteroscopy in the diagnosis and the management of small-bowel diseases: an initial experience in 40 patients. Gastrointest Endosc 2006; 63:81-86.  Back to cited text no. 20
    
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Ross A, Mehdizadeh S, Tokar J, Leighton JA, Kamal A, Chen A, et al. Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy. Dig Dis Sci 2008; 53:2140-2143.  Back to cited text no. 21
    
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Postgate A, Despott E, Burling D, Gupta A, Phillips R, O'Beirne J, et al. Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy. Gastrointest Endosc 2008; 68:1209-1214.  Back to cited text no. 23
    
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25.
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; 52:1122-1126.  Back to cited text no. 25
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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