Combined use of capsule endoscopy and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding.

Background: Most of the sources of bleeding in patients with obscure gastrointestinal bleeding are located in the small bowel. Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are innovative modalities to examine the small intestine. This study evaluated the combined use of CE and DBE in patients with obscure gastrointestinal bleeding.

Methods: From October 2005 to November 2006, ten patients with obscure gastrointestinal bleeding who underwent CE followed by DBE were included in this study. The insertion route for DBE was determined according to the site of obscure gastrointestinal bleeding detected by CE in nine patients. The anterograde route was selected when the estimated location of the lesion was in the proximal two-thirds of the small bowel and the retrograde route was chosen when the estimated location was after the proximal two-thirds. In one patient without a definite lesion detected by CE, the route of insertion was determined according to clinical judgment.

Results: Eleven capsule endoscopies were performed in ten patients. Significant or suspicious small bowel lesions were discovered by CE in nine (90%; 9/10) patients, including angiodysplasia (n=3), active bleeding (n=3), a polypoid lesion (n=1), suspected enteritis (n=1) and gastric antral vascular ectasia with small bowel bleeding (n=1). Eleven DBE were performed in ten patients. Significant small bowel lesions were detected by DBE in eight patients (80%), including angiodysplasias (n=3), lymphangioectasias (n= 2), varices (n=1), polypoid lesion (n=1) and Dieulafoy's lesion (n=1). Endoscopic treatments were performed successfully in 7 patients, including argon plasma coagulation in four, heat probe coagulation in one, endoscopic mucosal resection in one and sclerotherapy in one.

Conclusions: CE can provide useful information on the indications for DBE and the selection of the route of DBE. DBE can verify the findings of CE and provide therapeutic intervention. Combined use of CE and DBE is effective in the diagnosis and management of patients with obscure gastrointestinal bleeding.