title: Double-balloon enteroscopy following capsule endoscopy in the management of obscure gastrointestinal bleeding: outcome of a combined approach.
abstract: BACKGROUND
  There is no consensus on the relative accuracy of capsule endoscopy (CE) versus double-balloon enteroscopy (DBE) to investigate obscure gastrointestinal bleeding (GIB). CE is less invasive, but DBE more directly examines the small bowel, and allows tissue sampling plus therapeutic intervention.
  
  
  OBJECTIVE
  To evaluate the yield and outcome of DBE following CE in patients with obscure GIB.
  
  
  METHODS
  After DBE became readily available at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (St Michael's Hospital, Toronto, Ontario), all patients with obscure GIB seen from December 2002 to June 2007 were evaluated identically, first with CE, then with DBE (some with further interventions). Findings, adverse outcomes and interventions are reported.
  
  
  RESULTS
  Fifty-one patients (25 women) with a mean (range) age of 64.1 years (34 to 83 years) are reported. Eight patients underwent DBE twice, for a total of 59 DBEs. Fourteen patients had overt GIB and the median (range) number of red blood cell unit transfusions was 10 (0 to 100). The positive findings for each type of lesion were compared in these 51 patients: angiodysplasia (CE 64.7% and DBE 61%, P=0.3), ulcers (CE 19.6% and DBE 18.6%, P=0.5), bleeding lesions (CE 43.1% and DBE 15.3%, P=0.0004) and mass (CE 10.2% and DBE 8.5%, P=0.5). DBE provided the advantage of therapeutic intervention: argon plasma coagulation (33 of 59 DBEs), clipping (two of 59), both argon plasma coagulation and clipping (three of 59), polypectomy (two of 59), tattooing (52 of 59) and biopsies (11 of 59). DBE detected lesions not seen by CE in 21 patients; lesions were treated in 18 patients. However, CE detected 31 lesions not seen by DBE. No major complications occurred with either examination.
  
  
  CONCLUSIONS
  Overall detection rates for both techniques are similar. Each technique detected lesions not seen by the other. These data suggest that CE and DBE are complementary and that both evaluate obscure GIB more fully than either modality alone.
authors.affiliation: Centre for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. patarakamala@yahoo.com
authors.forename: Patarapong
authors.initials: P
authors.lastname: Kamalaporn
authors.forename: Sarah
authors.initials: S
authors.lastname: Cho
authors.forename: Nancy
authors.initials: N
authors.lastname: Basset
authors.forename: Maria
authors.initials: M
authors.lastname: Cirocco
authors.forename: Gary
authors.initials: G
authors.lastname: May
authors.forename: Paul
authors.initials: P
authors.lastname: Kortan
authors.forename: Gabor
authors.initials: G
authors.lastname: Kandel
authors.forename: Norman
authors.initials: N
authors.lastname: Marcon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D021721:Balloon Occlusion; D053704:Capsule Endoscopy; D015331:Cohort Studies; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000628:therapy*; D006801:Humans; D007410:Intestinal Diseases / Q000175:diagnosis* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D016896:Treatment Outcome