Gastrointestinal Endoscopy
Volume 69, Issue 4 , Pages 875-876, April 2009

Video capsule endoscopy or double-balloon enteroscopy: are they equivalent?

Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Israel

Article Outline

Abbreviations: DBE, double-balloon enteroscopy, OGIB, obscure GI bleeding, VCE, video capsule endoscopy

 

Double-balloon endoscopy, even though it enables visualization of the small bowel in most patients, is not yet the definitive examination for the entire small bowel in all patients.

Until few years ago, most of the small bowel was out of the range of endoscopic examination. The only standard available technique at that time was push enteroscopy, which allowed visualization as far as the proximal jejunum only. At the beginning of the 21st century, endoscopic examination of the small bowel became possible by the development of video capsule endoscopy (VCE)1 and double-balloon enteroscopy (DBE).2 VCE allows painless endoscopic imaging of the entire small bowel, but it lacks the ability to obtain biopsy specimens and perform therapeutic procedures such as polypectomy and electrocauterization. DBE, on the other hand, is more labor intensive and, in most patients, does not allow examination of the whole small bowel during one examination. The proper route, oral or anal, should therefore be carefully selected. VCE is helpful in selecting the proper route for DBE, so therefore these two examinations are considered complementary to each other. With regard to obscure GI bleeding (OGIB), a group of international experts came up with a consensus statement that says that VCE should be performed before DBE.3

In the current issue of Gastrointestinal Endoscopy, Arakawa et al4 confirmed what has been previously reported, that VCE has a decreased yield in the detection of lesions in the proximal jejunum. Among the 11 patients in whom DBE detected lesions not seen by VCE, 9 were in the proximal small intestine. Fukumoto et al5 also reported a large jejunal leiomyosarcoma that was missed by VCE. In their discussion they quote 3 previous studies where small-bowel masses had been missed, most of them in the proximal small intestine as well. In this issue, Arakawa et al concluded that VCE and DBE are complementary to each other, so therefore in case of OGIB, both tests should be done. However, the growing evidence as to the decreased yield of VCE in the proximal small intestine tends to contradict this conclusion, at least in some of the patients in whom the site of bleeding is most probably in the proximal small intestine (ie, patients who vomited blood or in whom blood was present in the stomach on endosopy). In these patients, VCE does not add to the management, and DBE should thus be the only examination performed both for diagnostic and therapeutic purposes. This is because VCE may either miss the lesion or detect a lesion that in any case requires DBE for biopsy and therapy. VCE should be saved for those patients in whom the site of bleeding is not clear. Another study6 supports this approach because of economic considerations as well and, even further, recommends VCE to be done only in those in whom visual identification is sufficient.

VCE misses lesions that can either be detected by DBE or by a second VCE study. We reported on patients with significant iron deficiency anemia and hemoglobin of less than 10 g/dL (normal 12-16 g/dL) in whom the first VCE study was negative and the second VCE revealed definite lesions in 20% of the patients.7 The explanation for this diagnostic difference may be related to a different direction that the camera takes (caudal or cephalad) while traveling through the small bowel. Obviously this problem does not exist with DBE.

In this issue of Gastrointestinal Endoscopy, Arakawa et al and Fukumoto et al compared the yield of VCE to DBE, and both authors concluded that VCE and DBE are of similar sensitivity in detecting small-bowel lesions, in the range of 55% to 60%. Their results are in agreement with a recent meta-analysis that showed a similar yield for both techniques.8 The meta- analysis by Pasha et al8 included 11 studies on 397 patients; the pooled overall yield for VCE and DBE was 60% and 57%, respectively. The meta-analysis was also done for subgroups of lesions in the small bowel. It was found that the pooled yield for vascular malformations was 24% for both VCE and DBE. The yield for inflammatory findings for VCE and DBE was 18% and 16%, respectively. In polyps/tumors the yield for both techniques was also similar: 11%. Vascular malformations are therefore the lesion with the highest probability to be detected by either of the two techniques.

The sensitivity of VCE is higher than that of most of the other imaging modalities used in the diagnosis of small-bowel conditions.9 In their meta-analysis, Triester et al9 showed VCE to be superior to small-bowel barium radiography, CT enterography/enteroclysis, magnetic resonance imaging of the small bowel, and push enteroscopy. It is for this reason that it seems justified to start the workup of a patient with suspected small-bowel condition with VCE rather than with other procedures. DBE is of equal yield and should be used as the first procedure in patients where the route by which the DBE should be performed is clear or when a biopsy or endoscopic therapy is needed.6 CT/magnetic resonance enterography still has a role in that it is better for localization of the lesion within the small bowel.

The optimal timing for VCE in patients with GI bleeding is as close to the time of bleeding as possible. Pennazio et al10 used VCE in patients with OGIB. Patients were divided into 3 groups: those with continuing overt bleeding, those with previous overt bleeding, and those who were guaiac positive. They found a yield of 92%, 12.9%, and 44.2%, respectively.

In the study of Fukumoto et al,5 of 11 of the patients who had recurrent bleeding after electrocoagulation, the bleeding was the result of vascular malformations. Rebleeding was associated with comorbidities and with more severe anemia. The authors concluded that the combination of vascular malformations and other comorbidites is a poor prognostic factor for rebleeding. In this group of patients, the option of increasing the amount of energy during argon plasma therapy is tempting because the amount used in this study was less than that used in other parts of the GI tract. This is done to avoid perforation of the small-bowel wall that is one third of the width of the colonic wall. Yet it is not clear whether in such patients we can use higher energy levels similar to those used in the rest of the GI tract. The proper energy level for argon plasma coagulation in such patients is not yet clear.

In the study by Fukumoto et al, examination of the entire small bowel was accomplished in only 2 of the 33 patients. Even by using the combined (oral and anal) route, in 30% of the patients it was impossible to examine the entire small bowel. These results are compatible with the experience in the Western world but different from previous reports from Japan. In a recent publication from the United States,11 DBE performed by an experienced endoscopist could only visualize the entire small bowel with both routes in 63%. Thus, it should be kept in mind that DBE, although it enables visualization of the small bowel in most patients, is not yet the definitive examination for the entire small bowel in all patients. VCE is thus a complementary examination. We have gone a long way in the endoscopic diagnosis of the small bowel, but we are still striving for a better tool that will be both diagnostic and therapeutic.

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Disclosure 

The author disclosed no financial relationships relevant to this publication.

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References 

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PII: S0016-5107(08)02352-3

doi:10.1016/j.gie.2008.07.051

Gastrointestinal Endoscopy
Volume 69, Issue 4 , Pages 875-876, April 2009

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