Clinical Practicality Of Double-ballon Enteroscopy In Obscure Gastrointestinal Bleeding

Background and ObjectiveDigestive tract hemorrhage is a common symptom, but about 3%-5% located in intestine which can not be deteted with gastroscope or colonscope. The intestine is the longest, tortuous, and far away from both ends of the gastrointestinal tract, which restricts the deep intubation of endoscopy, confines the diagnosing ability of X-ray small bowel series and influences the localization of scintigraphy and angiography. Therefore, the diagnosis of small intestinal bleeding is far behind the other parts of gastrointestinal tract. And the occurrence of double-ballon enteroscopy(DBE) brings the first light of morning to the diagnosis of small intestinal disorders. Patients of suspected small intestinal bleeding were performed by DBE and barium swallow or computer tomography (CT) or mesenteric agiography(MA) in our study. Demographic, clinical, procedural, therapeutic, and follow-up data were collected for analysis. The primary aims of this retrospective study were to estimate the clinical practicality of DBE in obscure gastrointestinal bleeding in different aspects.MethodsWe studied 158 patients who underwent DBE during June 2005 to October 2008 in the XiangYa hospital. All of the patients were performed by DBE, without an obvious etiology after gastroscopy, colonoscopy, and radiologic evaluation of the small bowel. According to bleeding type and clinical cue, selected cases were divided into three groups: overt-ongoing bleeding (58 cases), overt-previous bleeding (78 cases) and occult bleeding(22 cases). Analyze pathological type, detective yield and diagnostic yield totally and in different groups. Compare the detective yield and diagnostic yield with barium swallow, CT and MA. Observe the coincidence of etiological diagnosis in DBE and pathological diagnosis. Compute the etiological diagnostic accuracy and positive or negative predict value of DBE. Estimate the safety of DBE. Observe the patients' tolerance and prognosis. Statistical analysis was performed using the X~2 test, significance was accepted at a value of P<0.05.Result1. 158 patients underwent 93 anterograde and 104 retrograde procedures, the success rate was 98.9% and 98.1%.2. The total detective yield of DBE was 94.9% (150/158) . Most common lesions detected were vascular diseases, tumors or polyps, ulcers or erosions and diverticulum. Lesions were more frequently located in jejunum.3. The detective yield of DBE in positive lesions varied according to the type of bleeding(P<0.05). In patients with overt-ongoing bleeding the positive lesion detective yield was significantly higher than in patients with over-previous bleeding or occult bleeding(P<0.01), whereas there's no difference between other two groups(P>0.05). Constitution of positive lesions detected is different in groups.4. The diagnostic yield of barium swallow was 15.1%(14/93), while DBE was 90.3%(84/93), was superior than the former(P<0.05).The diagnostic yield of DBE was also superior than combination of CT and MA, the diagnostic yield was 86.7% (26/30) to 60.0% (18/30) (P<0.05).5. The coincidence rate of etiological diagnosis in DBE and pathological diagnosis was 84.7% (63/75) . Location rate was 97.3%.6. The etiological diagnostic accuracy of DBE was 89.7%(105/117) totally, positive predict value was 90.8%(99/109),negative predict value was 75%(6/8).In groups of different bleeding types, the etiological diagnostic accuracy was 94.1%(48/51),86.3%(44/51) and 86.7%(13/15), respectively, without obvious difference.(P>0.05)7. According to the diagnosis of DBE, 94 patients received specific treatments, while other 64 patients only received symptomatic treatments or clinical observation. In 125 patients whose follow-up data were available, the ratio of symptom relieved was 83.2%, especially high in the patients underwent specific treatment. The vascular malformations were more prone to rebleeding.8. Most of the patients could endure the examination, a part of the patients could feel nausea, slight abdominal pain and abdominal distention. We encountered 1 case of perforation digestive tract.Conclusions1. DBE is a reliable and effective examination of obscure gastrointestinal bleeding, the detective yield for positive lesions is high, especially in the overt-ongoing bleeding group. Findings detected are vascular malformation, tumor, diverticulum and Crohn's disease in order.2. DBE is superior to barium swallow, combination of CT and MA in detective yield and diagnostic yield in obscure gastrointestinal bleeding, especially sensitive in tiny vascular diseases or superficial ulceration;3. The etiological diagnostic accuracy of DBE is 89.7%.4. The results of DBE had a substantial impact on subsequent management decisions and patients' prognosis.5. DBE is a relatively safe examination. The incidence rate of complications was low.