Guidelines
GE Po J Gas oen e ol 2020;27:324–335
Small Bowel En e oscopy – A Join Clinical
Guideline om he Spanish and Po uguese
Small Bowel S udy G oups
En ique Pé ez-Cuad ado-Robles a Rolando Pinho b Begoña Gonzalez c Susana Mão de Fe o d
C is ina Chagas e Pila Es eban Delgado C is ina Ca e e o g Ped o Figuei edo h, i
B uno Rosa j, k Ja ie Ga cía Lledó l Ósca Nogales l Ana Pon e b Pa ícia And ade m
Jose F ancisco Juanma iñena-Fe nández n Mileidis San-Juan-Acos a o Sand a Lopes h, i
Césa P ie o-F ías g Juan Egea-Valenzuela p Noemí Caballe o q
Edua do Valdi ieso-Co aza Hélde Ca doso m Consuelo Gál ez s Nuno Almeida h, i
Pila Bo que Ba e a o Blas José Gómez-Rod íguez F ancisco Sánchez Ceballos u
Ca los Be na des Ped o Alonso Fede ico A güelles-A ias Miguel Masca enhas Sa ai a w
En ique Pé ez-Cuad ado-Ma ínez Capsule Endoscopy and En e oscopy G oup o he Spanish
Socie y o Gas oin es inal Endoscopy (SEED) Po uguese Small Bowel S udy G oup (GEPID)
a Depa men o Gas oen e ology, Hôpi al Eu opéen Geo ges-Pompidou, Pa is, F ance; b Depa men o Gas oen e ology, Cen o
Hospi ala de Vila No a de Gaia e Espinho, Vila No a de Gaia, Po ugal; c Depa men o Gas oen e ology. Endoscopy Uni , ICMDiM,
Hospi al Clínic, Ba celona, Spain; d Depa men o Gas oen e ology, Ins i u o Po uguês de Oncologia de Lisboa F ancisco Gen il EPE,
Lisbon, Po ugal; e Depa men o Gas oen e ology, Hospi al de Egas Moniz, Cen o Hospi ala de Lisboa Ociden al, Lisbon, Po ugal;
Small Bowel Uni , Hospi al Uni e si a io Mo ales Mesegue , Mu cia, Spain; g Depa men o Gas oen e ology, Uni e si y o Na a a Clinic,
Pamplona, Spain; h Gas oen e ology Uni , Cen o Hospi ala e Uni e si á io de Coimb a, Coimb a, Po ugal; i Facul y o Medicine, Uni e si y
o Coimb a, Coimb a, Po ugal; j Depa men o Gas oen e ology, Hospi al da Senho a da Oli ei a, Guima ães, Po ugal; k Li e and Heal h
Sciences Resea ch Ins i u e, School o Medicine, Uni e si y o Minho, ICVS/3B’s, PT Go e nmen Associa e Labo a o y, B aga/Guima ães,
Po ugal; l Depa men o Gas oen e ology, Endoscopy Uni , Hospi al Gene al Uni e si a io G ego io Ma añón, Mad id, Spain; m Depa men
o Gas oen e ology, Cen o Hospi ala São João, Po o, Po ugal; n Depa men o Gas oen e ology, Complejo Hospi ala io de Na a a,
Na a a, Spain; o Depa men o Gas oen e ology, Gas oin es inal Endoscopy Uni , Hospi al Uni e si a io Nues a Seño a de Candela ia,
Candela ia, Tene i e, Spain; p Uni o Gas oin es inal Endoscopy, Depa men o Diges i e Disease, Hospi al Clínico Uni e si a io Vi gen
de la A ixaca, Mu cia, Spain; q Depa men o Gas oin es inal Endoscopy, Hospi al Uni e si a io Ge mans T ias i Pujol, Badalona, Spain;
Depa men o Gas oen e ology, Complejo Hospi ala io Uni e si a io de A Co uña, A Co uña, Spain; s Depa men o Gas oen e ology.
Hospi al Clínico Uni e si a io de Valencia, Valencia, Spain; Depa men o Gas oen e ology, Hospi al Uni e si a io Vi gen Maca ena,
Uni e sidad de Se illa, Se illa, Spain; u Depa men o Gas oen e ology, Hospi al Clínico San Ca los, Mad id, Spain; Depa men
o Gas oen e ology, Hospi al de San o An ónio dos Capuchos, Cen o Hospi ala Uni e si á io de Lisboa Cen al, Lisbon, Po ugal;
w Labo a ó io de endoscopia e mo ilidade diges i a, ManopH, Po o, Po ugal
Recei ed: Ma ch 1, 2020
Accep ed: Ma ch 19, 2020
Published online: Ap il 21, 2020
En ique Pé ez-Cuad ado-Robles
Depa men o Gas oen e ology, Geo ges-Pompidou Eu opean Hospi al
20 Rue Leblanc
FR–75015 Pa is (F ance)
kikemu cia @ gmail.com
© 2020 Sociedade Po uguesa de Gas en e ologia
Published by S. Ka ge AG, Basel
ka ge @ka ge .com
www.ka ge .com/pjg
En ique Pé ez-Cuad ado-Robles and Rolando Pinho a e i s co-au ho s and con ibu ed equally o he p esen guidelines. No e: This a icle is
published simul aneously in GE – Po uguese Jou nal o Gas oen e ology, DOI: 10.1159/000507375, and The Spanish Jou nal o Gas oen e ol-
ogy, DOI: 10.17235/ eed.2020.7020/2020, wi h he consen o he au ho s and edi o s.
DOI: 10.1159/000507375
This a icle is licensed unde he C ea i e Commons A ibu ion-
NonComme cial-NoDe i a i es 4.0 In e na ional License (CC BY-
NC-ND) (h p://www.ka ge .com/Se ices/OpenAccessLicense).
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Small Bowel En e oscopy – Guideline
325
GE Po J Gas oen e ol 2020;27:324–335
DOI: 10.1159/000507375
Keywo ds
Small bowel · En e oscopy · Angioec asia · Guidelines ·
Capsule endoscopy · De ice-assis ed en e oscopy
Abs ac
The p esen e idence-based guidelines a e ocused on he
use o de ice-assis ed en e oscopy in he managemen o
small-bowel diseases. A panel o expe s selec ed by he
Spanish and Po uguese small bowel s udy g oups e iewed
he a ailable e idence ocusing on he main indica ions o
his echnique, i s ole in he managemen algo i hm o each
indica ion and on i s diagnos ic and he apeu ic yields. A se
o ecommenda ions we e issued acco dingly.
© 2020 Sociedade Po uguesa de Gas en e ologia
Published by S. Ka ge AG, Basel
En e oscopia lexí el – Guideline conjun a dos
G upos de es udos Espanhol e Po uguês de
In es ino Delgado
Pala as Cha e
In es ino delgado · En e oscopia · Angiec asia ·
Guidelines · Endoscopia po cápsula · En e oscopia
assis ida po disposi i o
Resumo
Es as ecomendações baseadas na e idência de alham o
uso da en e oscopia assis ida po disposi i o no manejo
clínico das doenças do in es ino delgado. Um conjun o de
Gas en e ologis as di e enciados em pa ologia do in es-
ino delgado oi selecionado pelos g upos de es udos Es-
panhol e Po uguês de in es ino delgado pa a e e a e -
idência disponí el sob e as p incipais indicações des a
écnica, o seu papel nos algo i mos de manejo de cada
indicação e sob e o seu endimen o diagnós ico e e -
apêu ico. Foi ge ado um conjun o de ecomendações pe-
los au o es. © 2020 Sociedade Po uguesa de Gas en e ologia
Publicado po S. Ka ge AG, Basel
In oduc ion
De ice-assis ed en e oscopy (DAE) has shown high di-
agnos ic yields in small bowel (SB) diseases [1]. Fu he -
mo e, his echnique is he i s -line he apeu ic p ocedu e
o se e al small bowel pa hologies. Howe e , i s ole, place
in he managemen algo i hm and yields a e dependen on
nume ous ac o s namely he indica ion and p e ious ex-
amina ions such as capsule endoscopy (CE). The aim o he
p esen guidelines is o p o ide e idence-based ecommen-
da ions on he clinical indica ions and diagnos ic and he -
apeu ic yields o DAE in SB diseases.
Me hods
The p esen guidelines we e p omo ed and suppo ed
by he Capsule Endoscopy and En e oscopy G oup o he
Spanish Socie y o Gas oin es inal Endoscopy (SEED)
and he Po uguese Small Bowel S udy G oup (GEPID)
– a sec ion o he Po uguese Gas oen e ology Socie y
(SPG). Two guideline coo dina o s (EPCR, RP) we e des-
igna ed, who in i ed membe s om bo h socie ies and
selec ed expe s in he ield om Spain and Po ugal.
Se en ask o ce g oups comp ising 3–5 pe sons coo -
dina ed by a g oup leade we e c ea ed o he ollowing
subjec s: o e SB bleeding, occul SB bleeding, C ohn’s
disease (CD), umo s, polyposis synd omes, celiac dis-
ease and miscellaneous indica ions. Each g oup con-
ained membe s om bo h socie ies, wi h a iable le els
o expe ise and om di e en ins i u ions (Table 1).
The key ques ions o be add essed we e decided by each
g oup coo dina o bu included indica ions, diagnos ic
Table 1. G oup membe dis ibu ion on di e en a eas
O e OGIB C is ina Ca e e o*, Edua do Valdi ielso, Ana
Pon e, Sand a Lopes, Noemí Caballe o
Occul OGIB C is ina Chagas*, Pila Bo que Ba e a, Ped o
Alonso, Ca los Be na des, Consuelo Gál ez
C ohn’s disease Begoña González*, Fede ico A güelles-A ias,
B uno Rosa, Juan Egea-Valenzuela
Tumo s Susana Mão de Fe o*, Nuno Almeida, Milei-
dis San Juan-Acos a, Osca Nogales
Polyposis Pila Es eban Delgado*, Miguel Masca enhas
Sa ai a, Ja ie Ga cía Lledó, F ancisco Sán-
chez Ceballos
Celiac disease Ped o Figuei edo*, Pa ícia And ade, José
F ancisco Juanma iñena-Fe nández, Blas
José Gómez-Rod iguez
Miscellanea En ique Pé ez-Cuad ado Ma ínez*, Helde
Ca doso, Césa P ie o-F ías
*G oup leade . OGIB, obscu e gas oin es inal bleeding.
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Pé ez-Cuad ado-Robles e al.
GE Po J Gas oen e ol 2020;27:324–335
326
DOI: 10.1159/000507375
yield, and he apeu ic yield o impac in he pa ien clinical
cou se. Technical aspec s and he use o DAE in speci ic se -
ings ou side he SB, such as di icul colonoscopy and en-
e oscopy-assis ed endoscopic e og ade cholangiopan-
c ea og aphy, we e no included in his guideline.
A sys ema ic e iew o he li e a u e was pe o med.
The li e a u e sea ch was ca ied ou in PubMed, he Co-
ch ane Lib a y and Scopus un il No embe 2019 combin-
ing he ollowing common and speci ic e ms:
− Common e ms o all ask o ces: en e oscopy OR
double-balloon OR DBE OR single-balloon OR SBE.
− Speci ic e ms depending on he opic: obscu e gas o-
in es inal bleeding OR OGIB OR small-bowel bleed-
ing OR anemia OR anaemia; C ohn OR in lamma o y
bowel disease OR IBD; umo OR umo s OR umou
OR umou s OR neoplasia OR cance ; polyp OR pol-
yps OR polyposis OR Peu z-Jeghe s OR Familial ade-
noma ous polyposis; celiac disease OR coeliac disease.
The G ading o Recommenda ions Assessmen , De el-
opmen , and E alua ion (GRADE) was used o assessing
e idence le els and ecommenda ion s eng hs (Table 2).
The guideline de elopmen p ocess included online dis-
cussions and one mee ing du ing he Ibe ian Mee ing o
En e oscopy in Janua y 2020 o discuss d a p oposals
and he main ecommenda ions o all opics. Finally, a
panel o expe s was decided by he Edi o ial Commi ee
o he Re is a Española de En e medades Diges i as
(REED) o pe o m an ex e nal e iew o he manusc ip .
The p esen documen is in ended o be an e idence-
based s a e o he a guide o endoscopis s dedica ed o
SB diseases. This Guideline will be conside ed o e iew
in 2025, bu an upda e will be added soone i ele an
e idence becomes a ailable meanwhile.
Small Bowel Bleeding
Obscu e gas oin es inal bleeding (OGIB) accoun s o
app oxima ely 5% o all cases o gas oin es inal bleeding
and is usually due o a SB lesion p esen ing wi h SB bleed-
ing (SBB) [1]. Se e al me a-analyses ha e shown compa-
able diagnos ic yields o CE and DAE [2]. CE is ecom-
mended as he i s line examina ion due o i s non-in a-
si eness and a o able sa e y p o ile. DAE should be
pe o med a e he de ec ion o he bleeding sou ce o in
he eme gency se ing in pa ien s wi h massi e bleeding [1,
3]. The diagnos ic yield o DAE anges om 47% o 75% [2,
4–8], depending on he ype o lesion and indica ion [9, 10].
Xin e al showed a pooled o e all diagnos ic yield o double
balloon en e oscopy (DBE) o 68% in a me a-analysis [11].
In addi ion, his a e is signi ican ly highe when DAE is
pe o med ollowing a posi i e-CE (75% s. 27.5%) [2].
Table 2. GRADE sco e acco ding o bene i s and isks
GRADE Bene i s. isk Quali y o e idence
1 A Bene i s clea ly ou weigh isks,
o ice e sa; ecommenda ion
can apply o mos pa ien s in
mos ci cums ances
RCTs wi h no impo an limi a ions, o excep ionally s ong e idence om
obse a ional s udies; u he esea ch is unlikely o change ou con idence in he
es ima e o e ec
1 B RCTs wi h impo an limi a ions o s ong e idence om obse a ional s udies;
u he highe -quali y esea ch may ha e an impo an impac
1 C A leas one c i ical ou come om RCTs wi h se ious laws, obse a ional s udies, case
se ies, o indi ec e idence; u he highe -quali y esea ch is likely o ha e an
impo an impac
2 A Bene i s balanced wi h isks;
bes ac ion may di e depending
on ci cums ances o pa ien /
socie y alues
RCTs wi h no impo an limi a ions, o excep ionally s ong e idence om
obse a ional s udies; u he esea ch is unlikely o change ou con idence in he
es ima e o e ec
2 B RCTs wi h impo an limi a ions o s ong e idence om obse a ional s udies;
u he highe -quali y esea ch may ha e an impo an impac
2 C Bene i s balanced wi h isks;
o he al e na i es may be equally
easonable
A leas one c i ical ou come om RCTs wi h se ious laws, obse a ional s udies, case
se ies, o indi ec e idence; u he highe -quali y esea ch is likely o ha e an
impo an impac
RCT, andomized con olled ial.
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DOI: 10.1159/000507375
O e Small Bowel Bleeding
Da a on he diagnos ic yield o DAE ocused in o e -
OGIB is limi ed o small case se ies. In his se ing, DAE
p o ed o ha e a highe diagnos ic yield when pe o med
in he u gen se ing (< 72 h), a e aging 70–90% [12]. This
compa es a o ably wi h he diagnos ic yield o DAE in
he non-u gen se ing, which a e ages 30–50% [13–15].
The he apeu ic yield o DAE pe o med in he o e -
OGIB se ing anges om 41.4 o 88.9% [14, 16–21].
The apeu ic p ocedu es a y acco ding o he e iology
and include clipping, a gon plasma coagula ion, epi-
neph ine injec ion, hea e p obe coagula ion and polyp-
ec omy [14, 18, 21–24]. Addi ionally, endoscopic a oo-
ing can be pe o med o a subsequen su gical app oach
[20]. The iming in which DAE is pe o med can also
in luence he he apeu ic yields. Recen s udies epo ed
ha eme gen DAE (< 24–72 h) esul ed in endoscopic
he apy in 28.6–57.5%, while non-eme gen DAE esul -
ed in endoscopic he apy in 13–50% [14, 24–26]. Con-
ce ning ebleeding, epea ing DAE he apy a e an ini-
ial he apeu ic DAE may dec ease he numbe o epi-
sodes o o e ebleeding in pa ien s wi h ecu en OGIB
[27]. Mo eo e , Aniwan S, e al concluded ha he e-
bleeding a e was lowe a e eme gen DBE compa ed o
non-eme gen DBE, al hough no signi ican (10% s.
29%, p = 0.08) [26].
The o al ou e is usually selec ed i s [12, 14, 16, 28,
29]. P e ious indings om imaging s udies o CE ha e a
majo ole guiding u he app oach [5, 12, 14, 28, 30–33].
I a lesion de ec ed on CE is wi hin he i s 75% o SB
ansi ime, an an e og ade app oach should be chosen
[14, 17, 20, 22, 24, 25, 34]. Pé ez-Cuad ado Robles E e al.
concluded ha eal- ime CE indings can also be use ul o
decide he ini ial ou e on eme gen SBB [17]. When a
p io s udy hasn’ e ealed a po en ial bleeding sou ce,
he o al app oach should be chosen o he inse ion ou e
should be selec ed acco ding o he ype o bleeding [5, 12,
16, 19, 22, 25–28, 30, 31, 33–37]. The p esence o melena
p omp s o an e og ade DAE and hema ochezia o e o-
g ade DAE [16, 26, 36]. In ac , Zhu CN e al. showed ha
he p esence o melena doubles he odds o inding a
bleeding si e wi hin he p oximal SB (OR 1.97, 95% CI
1.17–3.33, p = 0.01), p omp ing o o al DAE in hese pa-
ien s [38]. I he clinical suspicion o bleeding is high de-
spi e nega i e indings on he ini ial inse ion ou e, he
limi o inse ion should be ma ked by clipping o a oo-
ing, and DAE using he opposi e ou e o inse ion should
be pe o med [12, 14, 19–22, 25, 26, 28, 33, 35–37]. When
a bleeding sou ce is iden i ied, o al en e oscopy is no
equi ed [27, 30, 35].
Majo ad e se e en s associa ed wi h DAE p ocedu es
in o e -OGIB (such as pe o a ion o panc ea i is) a e
e y a e and occu in abou 0.5% o cases [8, 16, 20, 29,
31, 37, 39]. Mino complica ions occu in abou 11% o
pa ien s, and include abdominal discom o , abdominal
pain o < 48 h, so e h oa and minimal SB mucosal au-
ma. Pa ien s can usually be discha ged on he same day o
he p ocedu e [19, 31, 34, 37, 40]. Mo ali y ela ed o
DAE o endoscopic he apy is ex emely a e [41].
Occul Small Bowel Bleeding and I on De iciency
Anemia
DAE has a high diagnos ic yield in he se ing o oc-
cul -OGIB o i on de iciency anemia (IDA) anging om
52.4% o 75.6% [2, 25, 36, 40, 42–46], which inc eases
when DAE is pe o med a e a posi i e CE [20]. The
mos equen ly iden i ied lesions a e angiodysplasias,
e osions, ulce s and umo s [1, 2, 44]. The yields and ind-
ings appea o be simila o hose achie ed wi h CE, espe-
cially when a comple e DAE is achie ed [47–49]. CE p i-
o DAE is use ul o iden i y po en ial lesions and o selec
he mos con enien ou e o he p ocedu e, as desc ibed
abo e o o e -OGIB [2, 47].
The e a e no andomized con olled ials e alua ing
he e icacy o DAE in pa ien s wi h occul -OGIB/IDA.
Mo eo e , mos coho s don’ di ide hei he apeu ic e-
sul s be ween pa ien s wi h o e and occul -OGIB/IDA.
Howe e , se e al e ospec i e and p ospec i e obse a-
ional s udies epo ed a high he apeu ic yield – usually
de ined as he abili y o success ully pe o m he apeu ic
endoscopic p ocedu es o imp o emen in hemoglobin
le els/dec ease in ans usion equi emen s [19, 20, 39,
50–55]. In spi e o achie ing a high endoscopic he apeu-
ic success and a educ ion in he need o ans usion
suppo , wo sys ema ic e iews concluded ha he a e
o ecu ence/ ebleeding is subs an ial [56, 57]. Gi en he
ac ha he majo cause o occul -OGIB/IDA a e SB an-
giodysplasias, which end o be mul iple, addi ional s ud-
ies o e i y he ole o pe iodic en e oscopic in e en-
ions and/o i s associa ion wi h medical ea men in he
p e en ion o ebleeding a e needed.
The ou comes o occul -OGIB/IDA a e DAE he apy
e alua ed in di e en publica ions a e nume ous: esolu-
ion o anemia (o imp o emen in hemoglobin le els),
need o endoscopic p ocedu es, numbe o hospi al ad-
missions, hospi aliza ion ime, ans usion equi emen s,
mo ali y e c. Mos e ospec i e s udies and case se ies
epo high diagnos ic and he apeu ic yields, esul ing in
educed ans usion equi emen s, i on supplemen a ion
o he need o subsequen endoscopic ea men [58].
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DOI: 10.1159/000507375
Rebleeding a e an ini ial DAE hemos asis anges om
20% o 52.6% [18, 19, 21, 23, 27, 55, 59–61]. Female sex
[OR: 1.96, 95% CI: 1.1–3.3], Osle -Webe synd ome [OR:
4.35, 95% CI: 1.2–15.4] and ca diac disease [OR: 1.89,
95% CI: 1.1–2.9] we e associa ed wi h ebleeding in a e-
cen me a-analysis [62]. Williamson e al demons a ed a
signi ican dec ease in blood ans usion equi emen s,
need o i on supplemen a ion and addi ional p ocedu es
a e a i s he apeu ic DAE [55]. Repea ing he apeu ic
DAE has p o en o be use ul in ebleeding pa ien s [53].
Fu he mo e, pa ien s wi h ea able lesions ha e be -
e clinical ou comes [26, 35, 63]. When mul iple SB as-
cula lesions a e iden i ied, ea men e icacy can be lim-
i ed, bu a educ ion in he numbe o ans usions may
be achie ed. In he case o e osions o ulce s, pa ien s wi h
po en ially ea able lesions, such as NSAIDs use, o in-
lamma o y bowel disease (IBD), ha e be e long- e m
ou comes han hose in which he cause emains un-
known [35].
C ohn’s Disease
DAE has a limi ed ole in he ini ial e alua ion o pa-
ien s wi h suspec ed IBD. Howe e , when SB lesions a e
iden i ied by c oss-sec ional imaging modali ies o CE,
his ologic e alua ion may be necessa y o ule ou o he
diseases [64, 65]. I he loca ion o hese lesions lies ou -
side he each o s anda d endoscopy, DAE is he p e-
e ed echnique. In his se ing, i has a highe diagnos ic
yield han adiologic echniques (SB ba ium con as , CT
en e og aphy and magne ic esonance en e og aphy,
MRE) [66].
Rega ding es ablished CD, DAE may be use ul in pa-
ien s wi h unclea symp oms and o he apy o SB s ic-
u es o bleeding lesions [67–70]. This echnique can con-
i m suspec ed CD wi h a diagnos ic yield o 22–80% [65,
71–73], and can also change he ini ial diagnosis in up o
12% o cases when he lesions ha a e obse ed o he
his ological indings a e di e en om hose epo ed by
CE o adiology [73–75].
The apeu ic DAE in CD is mainly indica ed o pe -
o m balloon dila ion o SB s ic u es o p e en o delay
su gical in e en ions. In expe ienced hands he echnical
easibili y is o e 90%, which is equi alen o con en ion-
al endoscopic balloon dila ion o colon and ileocolonic
anas omoses [69]. Dila ion o anas omo ic o p ima y
s ic u es, sho e han 5 cm, non-angula ed and wi hou
signi ican in lamma o y ac i i y namely deep ulce s o
is ulae, p o ed o be sa e and associa ed wi h be e long-
e m ou comes [69, 70, 76–78]. Da a on adjunc i e he a-
pies o e ac o y s ic u es, such as iamcinolone o in-
liximab injec ion, s en placemen o cu ing echniques
a e sca ce and mixed, cu en ly no suppo ing hei ou-
ine use. App oxima ely 80% o CD pa ien s submi ed o
DAE balloon dila ion emain symp om- ee a e 3 yea s,
al hough nea ly hal o hese cases will equi e a leas one
e-dila ion p ocedu e. The mean diame e o dila ion e-
po ed is 12–15 mm, wi h an o e all complica ion a e o
4.8% pe pa ien and 2.6% pe dila ion [76, 77]. The p es-
ence o la ge and deep ulce s, is ulas and/o abdominal
o pel ic abscesses a e con aindica ions o balloon dila-
ion.
Small Bowel Tumo s
SB umo s (SBT) comp ise less han 5% o gas oin es-
inal cance s. The incidence o p ima y SBT is inc easing,
mainly due o he ise o neu oendoc ine umo s (NETs).
The mos common SBTs a e gas oin es inal s omal u-
mo (GIST), adenoca cinoma, NET, and lymphoma [79].
O e all, SBTs a e mo e equen in he jejunum, ollowed
by he duodenum and ileum, and mos p esen wi h SBB
[80–83].
CE and DAE a e complemen a y, wi h high diagnos ic
conco dance o he de ec ion o SBT and polyps [84].
Howe e , DAE may ha e a highe diagnos ic yield han
CE [85]. Bo h endoscopic echniques pe o med be e in
SBT de ec ion han con as -enhanced compu ed omog-
aphy [85–87]. DBE is an use ul p ocedu e o de e mine
he ex en , loca ion and endoscopic cha ac e is ics o
SBT, allowing biopsy examina ion and a oo injec ion o
guide a possible su ge y. I also p o ides addi ional in o -
ma ion o o he p ocedu es, ha may be decisi e in he
clinical cou se o hese pa ien s [81–83, 87–90].
I he e a e no doub s abou he diagnosis o SBT a CE,
di ec su ge y is accep able i c oss-sec ional imaging ex-
cludes inope abili y [1]. In all o he cases, his ological
con i ma ion is c ucial o make ea men decisions [83,
90, 91]. Biopsies ha e a high diagnos ic alue, especially
o adenoca cinoma and lymphoma (71.4 and 60%, e-
spec i ely) [87].The need o his ology o GISTs mus be
ho oughly balanced, since he a e o a posi i e his o-
logical diagnosis by DAE does no exceed 46.7% and he
isk o bleeding is no negligible [92, 93].
Conce ning NETs, a e ospec i e s udy demons a ed
ha bidi ec ional DAE pe o med in pa ien s wi h p e i-
ously known umo s, o exclude mul i ocali y, e ealed
addi ional neu oendoc ine umo s in 51.1% [94].
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DAE can modi y he clinical cou se in 25–65% o pa-
ien s by delaying o a oiding eme gen su ge y o by
modi ying he su gical app oach [83, 86].
DAE allows he apeu ic in e en ions, p ima ily he-
mos asis o bleeding SBT (using a gon plasma coagula-
ion, hemos a ic powde , clipping, and epineph ine o
scle osan injec ions). Some case se ies p oposed DAE o
s en ing in SB obs uc ion seconda y o SBT (as eme -
gency ea men and in pallia i e pa ien s) [95–98]. The
e idence is sca ce gi en he limi ed wo king channel o
he en e oscope and he high deg ee o echnical skills e-
qui ed.
A e su gical esec ion o SBT in pa ien s wi hou pol-
yposis o o he inhe i ed synd omes he e a e no clea
ecommenda ions o ollow-up. Howe e , some au ho s
ecommend DAE [99].
Small Bowel Polyposis
Small bowel polyps occu in 90% o Peu z-Jeghe s syn-
d ome (PJS) pa ien s and in mo e han 75% o hose wi h
amilial adenoma ous polyposis, being dis al small bowel
polyps mo e equen in pa ien s who also ha e duodenal
polyps [100]. A e ospec i e s udy showed ha CE iden-
i ied he numbe , loca ion and size o polyps and could
indica e he ou e (o al o anal) o DAE and p edic he
di icul y o polypec omy du ing deep en e oscopy [101].
Howe e , DAE was be e han CE o de ine he size and
loca ion o polyps.
A p ospec i e s udy showed ha MRE and DAE ha e
simila diagnos ic yield o de ec ing clinically ele an
SB polyps (≥ 15 mm in diame e ) in pa ien s wi h PJS
[102], bu he mos impo an ad an age o DAE com-
pa ed wi h MRE is i s abili y o immedia e polypec omy,
a ooing and biopsy.
An ini ial CE/MRE may be p e e ed o selec o en-
e oscopy only hose pa ien s needing he apy [1] al-
hough he diagnos ic a e is simila o DAE [103]. Polyp
size is he mos impo an isk ac o o SB in ussuscep-
ion, being in ussuscep ion gene ally due o polyps ≥15
mm in diame e . Consequen ly, la ge polyps (10–15 mm)
o symp oma ic o apidly g owing polyps should be e-
mo ed in PJS [104, 105]. DAE p o ed o be use ul in he
esec ion o SB polyps esul ing in a dec ease in he a e -
age numbe and size o lesions in pe iodic en e oscopies
[106–108]. Addi ionally, absence o in ussuscep ion o
complica ions equi ing su ge y a e a ollow-up o up o
56.5 mon hs [107] and an adequa e sa e y p o ile was also
e i ied. The e a e se ies in which complica ions a e no
epo ed [109], bu o he s udies epo complica ions be-
ween 4–6% including bleeding, panc ea i is, pe o a ion
and pos -polypec omy abscesses, ea ed wi h conse a-
i e managemen in mos cases [106–108, 110]. The e ec
on cance educ ion a e en e oscopy esec ions emains
unknown.
The e is li le e idence in de e mining he indica ion
o DAE in amilial adenoma ous polyposis pa ien s.
Sc eening and su eillance wi h DAE o SB adenomas
could be use ul in pa ien s wi h Spigelman sco es III o
IV [111], e en hough he malignan po en ial o hese le-
sions is unknown [112–114].
Celiac Disease
The e is a li le ole o DAE in he diagnosis o celiac
disease (CeD) as mos pa ien s a e diagnosed based on
endoscopic and his ologic indings o uppe GI endos-
copy. Some s udies epo ed a pa chy dis ibu ion o his-
ologic abno mali ies [115], hus DAE may be indica ed
in cases o s ong clinical suspicion wi h posi i e speci ic
se ology and nega i e duodenal biopsies a uppe -GI en-
doscopy.
The ole o DAE is mainly o he diagnosis o CeD
complica ions [116]. Pa ien s uncomplian o un espon-
si e o a glu en- ee die , wi h ala m symp oms o i on
de iciency anemia, ha e an inc eased isk o de eloping
SB malignancies [117]; in his case, SB e alua ion by CE,
uppe endoscopy and imaging es s ollowed by DAE in
o de o ob ain mucosal samples o his ological and/o
molecula analysis is ecommended. Cu en ly, i is di -
icul o know he diagnos ic yield o DAE as only a ew
e ospec i e pape s and a single me a-analysis [117] can
be ound. Among hese s udies, he o e all diagnos ic
yield app oaches up o 20%, al hough his alue dec eases
when e alua ing SB malignan and p emalignan lesions
sepa a ely. The diagnos ic yield o malignan lesions
anges be ween 16.7–24%, whe eas o p emalignan le-
sions i anges om 9 o 16% [118, 119].
Miscelaneous
The e a e o he clinical condi ions in which DAE is
use ul. Due o i s abili y o pe o m biopsies o he en i e
SB, DAE has been epo ed in he diagnosis o malabso p-
ion synd omes and SB ch onic in ec ions, mainly ube -
culosis and Whipple’s disease [120, 121]. I also enables
he cha ac e iza ion o o he diseases such as NSAID en-
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330
DOI: 10.1159/000507375
e opa hy [122], ischemic en e i is and adia ion-induced
en e i is, g a e sus hos disease wi h SB in ol emen ,
and o he lesions such as in lamma o y ib oid polyps
and SB di e icula, including Meckel’s di e iculum
[123]. In al e ed ana omy, such as Roux-en-Y anas omo-
sis and gas ojejunos omy, DAE enables he s udy o in-
es inal segmen s ha a e inaccessible o egula endo-
scopes, including CE [124]. Endoscopic en e oclysis can
be use ul in selec ed cases such as s enosis. DAE has also
been used o he apy: e ie al o po en ially ha m ul o -
eign bodies, especially e ained CE [125], bu also bezoa s
[126], needles [127], coins [128], gas ic bands [129], den-
u es [130] and mig a ed s en s [131]. Many SB s ic u es
seconda ies o NSAIDs, adia ion, su gical anas omosis,
o malignancy ha e been ea ed wi h balloon dila ion
[76, 132, 133] o s en ing, using bo h o e - he-wi e o
h ough- he-scope echniques [134–136]. DAE can also
be used o pe cu aneous endoscopic jejunos omy [137]
and SB in ussuscep ion [138].
Conclusions
Since i s in oduc ion in ou ine clinical p ac ice al-
mos wo decades ago, he diagnos ic and he apeu ic ca-
pabili ies o DAE ha e con inuously e ol ed [139]. The
e idence published in he las yea s helped o be e de-
ine he ole o DAE in i s a ious indica ions, as well as
i s ad an ages and disad an ages o e o he endoscopic
and adiologic p ocedu es. As he echnology con inues
o e ol e and ma u e, u he e inemen s in i s capabili-
ies and use a e an icipa ed.
Disclosu e S a emen
The au ho s ha e no hing o disclose.
Appendix: S a emen s
Small bowel bleeding
• In OGIB, he ou e o inse ion o DAE should be
based on p e-DAE in es iga ions, such as CE. GRADE 2B
(weak ecommenda ion, mode a e-quali y e idence)
• DAE should be he i s -line he apeu ic p ocedu e
ollowing CE in bo h pa ien s wi h o e and occul OGIB.
GRADE 2A (weak ecommenda ion, high-quali y e i-
dence)
• The e a e no se ious complica ions ega ding he ex-
amina ion, o he endoscopic ea men . The p ocedu e
is gene ally well ole a ed. GRADE 2B (weak ecommen-
da ion, mode a e-quali y e idence)
1. O e OGIB
• DAE has a high he apeu ic yield in o e -OGIB. The
he apeu ic echnique should be selec ed acco ding o he
bleeding sou ce. GRADE 1B (s ong ecommenda ion,
mode a e-quali y e idence)
• In pa ien s wi h ecu en o e -OGIB, a second he -
apeu ic DAE is ecommended. GRADE 2C (weak ecom-
menda ion, low-quali y e idence)
• In o e -OGIB, DAE should be pe o med whene e
possible in he i s 72h, as his leads o highe diagnos ic
and he apeu ic yields and lowe ebleeding a es.
GRADE 2C (weak ecommenda ion, low-quali y e i-
dence)
2. Occul OGIB
• DAE has a high he apeu ic yield in occul -OGIB.
The ecommended ea men op ions a e: a gon plas-
ma coagula ion o angioec asia coagula ion; hemos a -
ic clipping o Dieula oy lesions o bleeding ulce s; pol-
ypec omy o bleeding small bowel polyps; and/o a -
ooing lesions o u he su eillance o ea men .
GRADE 2B (weak ecommenda ion, mode a e-quali y
e idence)
• Follow-up o pa ien s wi h ascula lesions is ecom-
mended due o hei high ebleeding a e. Repea ed ea -
men wi h DAE migh imp o e managemen o e ac-
o y OGIB. G ade 1C (s ong ecommenda ion, low-
quali y e idence)
C ohn’s disease
• DAE is indica ed in suspec ed CD in pa ien s wi h SB
lesions iden i ied by o he non-in asi e echniques (CE
o CT/MR en e og aphy) and non-accessible o con en-
ional endoscopy. In hese cases, his ological diagnosis is
ecommended. GRADE 1B (s ong ecommenda ion,
mode a e-quali y e idence)
• In es ablished CD, DAE can be use ul o diagnosis
and he apy in selec ed cases (dila a ion o s ic u es and
e ie al o impac ed capsules). GRADE 1B (s ong ec-
ommenda ion, mode a e-quali y e idence)
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DOI: 10.1159/000507375
• DAE dila a ion o p ima y o anas omo ic s ic u es
which a e sho e han 5cm, non-angula ed and wi hou
signi ican in lamma o y ac i i y, is sa e and e ec i e,
wi h a low a e o complica ions. GRADE 1B (s ong ec-
ommenda ion, mode a e-quali y e idence)
Tumo s
• DAE should be used in a combined app oach wi h CE
and adiological examina ions o he diagnosis o SB u-
mo s. GRADE 1C (s ong ecommenda ion, low-quali y
e idence)
• DAE should be conside ed in pa ien s wi h a high clin-
ical suspicion o SB umo s despi e nega i e CE and c oss-
sec ional s udies. GRADE 2C (weak ecommenda ion,
low-quali y e idence)
• In pa ien s wi h suspec ed SB umo s, i he e is no un-
deniable indica ion o su ge y, DAE should be pe -
o med o con i m diagnosis, ob ain biopsies o his o-
logical documen a ion, es ablish he p ecise loca ion o
he lesion and ma k i o u he su gical ea men .
GRADE 1C (s ong ecommenda ion, low-quali y e i-
dence)
Polyposis
• DAE he apy is ecommended o polyps > 10-15mm
o p e en polyp- ela ed complica ions GRADE 1B
(s ong ecommenda ion, mode a e-quali y e idence)
• DAE may also be used in symp oma ic pa ien s wi h
polyps causing in ussuscep ion symp oms and hemo -
hage / anemia in in es inal polyposis synd omes (FAP
and PJS) GRADE 1C (s ong ecommenda ion, low-qual-
i y e idence)
• DAE may be used in FAP pa ien s wi h Spigelman
s ages III/IV o sc eening and su eillance o in es inal
adenomas and endoscopic ea men . GRADE 2C (weak
ecommenda ion, low-quali y e idence)
Celiac disease
• The e is a li le ole o en e oscopy in he diagnosis o
celiac disease. En e oscopy may be indica ed in cases o
s ong clinical suspicion wi h posi i e speci ic se ology
and nega i e duodenal biopsies a uppe GI endoscopy.
GRADE 2C (weak ecommenda ion, low-quali y e i-
dence)
• The ole o en e oscopy is mainly o he diagnosis o
celiac disease complica ions. In pa ien s uncomplian o
un esponsi e o glu en- ee die , wi h ala m symp oms o
i on de iciency anemia, en e oscopy is ecommended a -
e SB e alua ion by CE, uppe -GI endoscopy and imag-
ing es s, in o de o ob ain mucosal samples o his o-
logic and/o molecula analysis. GRADE 2B (weak ec-
ommenda ion, mode a e-quali y e idence)
Re e ences
1 Pennazio M, Spada C, Eliakim R, Keuchel M,
May A, Mulde CJ, e al. Small-bowel capsule
endoscopy and de ice-assis ed en e oscopy
o diagnosis and ea men o small-bowel
diso de s: Eu opean Socie y o Gas oin es i-
nal Endoscopy (ESGE) Clinical Guideline.
Endoscopy. 2015 Ap ; 47(4): 352–76.
2 Teshima CW, Kuipe s EJ, an Zan en SV,
Mensink PB. Double balloon en e oscopy
and capsule endoscopy o obscu e gas oin-
es inal bleeding: an upda ed me a-analysis. J
Gas oen e ol Hepa ol. 2011 May; 26(5): 796–
801.
3 Pé ez-Cuad ado-Robles E, Pé ez-Cuad a-
do-Ma ínez E. The Role o Eme gency En-
doscopy in Small Bowel Bleeding: A Re iew.
GE Po J Gas oen e ol. 2015 Dec; 23(2):
84–90.
4 Pa ni V, Ta e DJ, Te le ich A, Ma den P,
Hughes S. De ice-assis ed en e oscopy in he
UK: desc ip ion o a la ge e ia y case se ies
unde conscious seda ion. F on line Gas o-
en e ol. 2018 Ap ; 9(2): 122–8.
5 Hashimo o R, Ma suda T, Nakaho i M. False-
nega i e double-balloon en e oscopy in o e
small bowel bleeding: long- e m ollow-up a -
e nega i e esul s. Su g Endosc. 2019 Aug;
33(8): 2635–41.
6 Aka su M, Akkaya Özdinç S, Cel ik A,
Akpına H. Diagnos ic and he apeu ic e i-
cacy o double-balloon endoscopy in pa ien s
wi h small in es inal diseases: single-cen e
expe ience in 513 p ocedu es. Tu k J Gas o-
en e ol. 2014 Aug; 25(4): 374–80.
7 Khashab MA, Lennon AM, Dunba KB, Singh
VK, Chand asekha a V, Giday S, e al. A com-
pa a i e e alua ion o single-balloon en e os-
copy and spi al en e oscopy o pa ien s wi h
mid-gu diso de s. Gas oin es Endosc. 2010
Oc ; 72(4): 766–72.
8 A akawa D, Ohmiya N, Nakamu a M, Honda
W, Shi ai O, I oh A, e al. Ou come a e en e -
oscopy o pa ien s wi h obscu e GI bleeding:
diagnos ic compa ison be ween double-bal-
loon endoscopy and ideocapsule endoscopy.
Gas oin es Endosc. 2009 Ap ; 69(4): 866–74.
9 Pe ez-Cuad ado-Robles E, Es eban-Delgado
P, Ma inez-And es B e al. [Diagnosis ag ee-
men be ween capsule endoscopy and double-
balloon en e oscopy in obscu e gas oin es i-
nal bleeding a a e e al cen e ]. Re Esp En-
e m Dig. 2015; 107: 495–500.
10 Ohmiya N, Yano T, Yamamo o H, A akawa
D, Nakamu a M, Honda W, e al. Diagnosis
and ea men o obscu e GI bleeding a dou-
ble balloon endoscopy. Gas oin es Endosc.
2007 Sep; 66(3 Suppl):S72–7.
11 Xin L, Liao Z, Jiang YP, Li ZS. Indica ions,
de ec abili y, posi i e indings, o al en e -
oscopy, and complica ions o diagnos ic
double-balloon endoscopy: a sys ema ic e-
iew o da a o e he i s decade o use.
Gas oin es Endosc. 2011 Sep; 74(3): 563–
70.
12 Liu Y, Jiang W, Chen G, Li Y. Diagnos ic Val-
ue and Sa e y o Eme gency Single-Balloon
En e oscopy o Obscu e Gas oin es inal
Bleeding. Gas oen e ol Res P ac . 2019 Aug;
2019: 9026278.
Downloaded om h p://ka ge .com/pjg/a icle-pd /27/5/324/3439228/000507375.pd by Biblio eca Se illa use on 17 May 2023
Pé ez-Cuad ado-Robles e al.
GE Po J Gas oen e ol 2020;27:324–335
332
DOI: 10.1159/000507375
13 Mönkemülle K, Neumann H, Meye F, Kuhn
R, Mal e heine P, F y LC. A e ospec i e
analysis o eme gency double-balloon en e -
oscopy o small-bowel bleeding. Endoscopy.
2009 Aug; 41(8): 715–7.
14 Rod igues JP, Pinho R, Rod igues A, Sousa M,
Sil a JC, Gomes C, e al. Diagnos ic and he -
apeu ic yields o u gen balloon-assis ed en-
e oscopy in o e obscu e gas oin es inal
bleeding. Eu J Gas oen e ol Hepa ol. 2018
No ; 30(11): 1304–8.
15 Aniwan S, Vi iyau sahakul V, Re knimi R,
Angsuwa cha akon P, Kongkam P, T ee-
p ase suk S, e al. U gen double balloon en-
doscopy p o ides highe yields han non-u -
gen double balloon endoscopy in o e ob-
scu e gas oin es inal bleeding. Endosc In
Open. 2014 Jun; 2(2):E90–5.
16 Tu CH, Kao JY, Tseng PH, Lee YC, Chiang
TH, Chen CC, e al. Ea ly iming o single bal-
loon en e oscopy is associa ed wi h inc eased
diagnos ic yield in pa ien s wi h o e small
bowel bleeding. J Fo mos Med Assoc. 2019
Dec; 118(12): 1644–51.
17 Pe ez-Cuad ado Robles E, Bebia Conesa P,
Es eban Delgado P e al. Eme gency double-
balloon en e oscopy combined wi h eal-
ime iewing o capsule endoscopy: a easible
combined app oach in acu e o e -obscu e
gas oin es inal bleeding? Dig Endosc. 2015;
27: 338–44. h ps://doi.o g/10.1111/den.
12384.
18 Edwa ds AL, Mönkemülle K, Pamboukian
SV, Geo ge JF, Wilcox CM, Pe e S. U ili y o
double-balloon en e oscopy in pa ien s wi h
le en icula assis de ices and obscu e
o e gas oin es inal bleeding. Endoscopy.
2014 No ; 46(11): 986–91.
19 Lin WP, Chiu CT, Su MY, Hsu CM, Sung CM,
Chen PC. T ea men decision o po en ial
bleede s in obscu e gas oin es inal bleeding
du ing double-balloon en e oscopy. Dig Dis
Sci. 2009 Oc ; 54(10): 2192–7.
20 Ka es AJ, Siah C, Koo JH. Clinical ou comes
a e double-balloon en e oscopy in pa ien s
wi h obscu e GI bleeding and a posi i e cap-
sule endoscopy. Gas oin es Endosc. 2007
Aug; 66(2): 304–9.
21 Hsu CM, Chiu CT, Su MY, Lin WP, Chen PC,
Chen CH. The ou come assessmen o dou-
ble-balloon en e oscopy o diagnosing and
managing pa ien s wi h obscu e gas oin es i-
nal bleeding. Dig Dis Sci. 2007 Jan; 52(1): 162–
6.
22 Lipka S, Rabbani a d R, Kuma A, B ady P. A
single-cen e Uni ed S a es expe ience wi h
bleeding Dieula oy lesions o he small bowel:
diagnosis and ea men wi h single-balloon
en e oscopy. Endosc In Open. 2015 Aug;
3(4):E339–45.
23 Chen YY, Chiu CT, Hsu CM, Chen TH, Chiu
YC, Chu YC, e al. En e oscopic Diagnosis
and Managemen o Small Bowel Di e icula
Hemo hage: A Mul icen e Repo om he
Taiwan Associa ion o he S udy o Small In-
es inal Diseases. Gas oen e ol Res P ac .
2015; 2015: 564536.
24 Pin o-Pais T, Pinho R, Rod igues A, Fe -
nandes C, Ribei o I, F aga J, e al. Eme gency
single-balloon en e oscopy in o e obscu e
gas oin es inal bleeding: e icacy and sa e y.
Uni ed Eu opean Gas oen e ol J. 2014 Dec;
2(6): 490–6.
25 Nelson KK, Lipka S, Da is-Yadley AH, Rod i-
guez AC, Do aiswamy V, Rabbani a d R, e al.
Timing o single balloon en e oscopy: signi i-
can o no ? Endosc In Open. 2016 Jul;
4(7):E761–6.
26 Aniwan S, Vi iyau sahakul V, Angsu-
wa cha akon P, Kongkam P, T eep ase suk
S, Re knimi R, e al. Compa ison o u gen
ideo capsule endoscopy and u gen double-
balloon endoscopy in massi e obscu e gas o-
in es inal bleeding. Hepa ogas oen e ology.
2014 Oc ; 61(135): 1990–4.
27 Shinozaki S, Yamamo o H, Yano T, Sunada K,
Hayashi Y, Shinha a H, e al. Fa o able long-
e m ou comes o epea endo he apy o
small-in es ine ascula lesions by double-
balloon endoscopy. Gas oin es Endosc.
2014 Jul; 80(1): 112–7.
28 Madisch A, Schmolde s J, B ückne S, Aus D,
Miehlke S. Less a o able clinical ou come a -
e diagnos ic and in e en ional double bal-
loon en e oscopy in pa ien s wi h suspec ed
small-bowel bleeding? Endoscopy. 2008 Sep;
40(9): 731–4.
29 Tanaka S, Mi sui K, Ta suguchi A, Kobayashi
T, Eha a A, Gudis K, e al. Cu en s a us o
double balloon endoscopy—indica ions, in-
se ion ou e, seda ion, complica ions, ech-
nical ma e s. Gas oin es Endosc. 2007 Sep;
66(3 Suppl):S30–3.
30 Hashimo o R, Nakaho i M, Ma suda T. Im-
pac o U gen Double-Balloon En e oscopy
on he Sho -Te m and Long-Te m Ou -
comes in O e Small Bowel Bleeding. Dig Dis
Sci. 2019 Oc ; 64(10): 2933–8.
31 He mans C, S onkho s A, Tjhie-Wensing
A, Kamphuis J, Balkom BV, Dahlmans R, e
al. Double-Balloon Endoscopy in O e and
Occul Small Bowel Bleeding: Resul s, Com-
plica ions, and Co ela ion wi h P io Video-
capsule Endoscopy in a Te ia y Re e al Cen-
e . Clin Endosc. 2017 Jan; 50(1): 69–75.
32 Nakamu a M, Ohmiya N, Shi ai O, Takenaka
H, Mo ishima K, Miyaha a R, e al. Rou e se-
lec ion o double-balloon endoscopy, based
on capsule ansi ime, in obscu e gas oin-
es inal bleeding. J Gas oen e ol. 2010 Jun;
45(6): 592–9.
33 Ge son LB, Ba enic MA, Newsom SL e al.
Long- e m ou comes a e double-balloon
en e oscopy o obscu e gas oin es inal
bleeding. Clin Gas oen e ol Hepa ol. 2009; 7:
664–9. h ps://doi.o g/10.1016/j.
cgh.2009.01.021.
34 Mo an RA, Ba ola S, Law JK, Ama eau SK,
Rolshud D, Co less E, e al. A Randomized
Con olled T ial Compa ing he Dep h o
Maximal Inse ion Be ween An e og ade Sin-
gle-Balloon Ve sus Spi al En e oscopy. Clin
Med Insigh s Gas oen e ol. 2018 Jan; 11:
1179552218754881.
35 Shinozaki S, Yano T, Sakamo o H, Sunada K,
Hayashi Y, Sa o H, e al. Long-Te m Ou -
comes in Pa ien s wi h O e Obscu e Gas o-
in es inal Bleeding A e Nega i e Double-
Balloon Endoscopy. Dig Dis Sci. 2015 Dec;
60(12): 3691–6.
36 Sun B, Rajan E, Cheng S, Shen R, Zhang C,
Zhang S, e al. Diagnos ic yield and he apeu-
ic impac o double-balloon en e oscopy in a
la ge coho o pa ien s wi h obscu e gas o-
in es inal bleeding. Am J Gas oen e ol. 2006
Sep; 101(9): 2011–5.
37 Ka es AJ, Koo JH, Me edi h C. Double-bal-
loon en e oscopy in he diagnosis and he
managemen o small-bowel diseases: an ini-
ial expe ience in 40 pa ien s. Gas oin es En-
dosc. 2006 Jan; 63(1): 81–6.
38 Zhu CN, F iedland J, Yan B, Wilson A, G ego
J, Jai a h V, e al. P esence o Melena in Ob-
scu e Gas oin es inal Bleeding P edic s
Bleeding in he P oximal Small In es ine. Dig
Dis Sci. 2018 May; 63(5): 1280–5.
39 Shelnu DJ, Sims OT, Zaibaq JN, Oh H, Ven-
ka a KV, Pe e S. P edic o s o ou comes and
eadmission a es ollowing double balloon
en e oscopy: a e ia y ca e expe ience. En-
dosc In Open. 2018 Jun; 6(6):E751–7.
40 P achayakul V, Deesomsak M, Aswakul P,
Leelakusol ong S. The u ili y o single-bal-
loon en e oscopy o he diagnosis and man-
agemen o small bowel diso de s acco ding
o hei clinical mani es a ions: a e ospec-
i e e iew. BMC Gas oen e ol. 2013 Jun;
13(1): 103.
41 Pinho R, Pon e A, Rod igues A, Pin o-Pais T,
Fe nandes C, Ribei o I, e al. Long- e m e-
bleeding isk ollowing endoscopic he apy o
small-bowel ascula lesions wi h de ice-as-
sis ed en e oscopy. Eu J Gas oen e ol Hepa-
ol. 2016 Ap ; 28(4): 479–85.
42 San hakuma C, Liu K. E alua ion and ou -
comes o pa ien s wi h obscu e gas oin es i-
nal bleeding. Wo ld J Gas oin es Pa ho-
physiol. 2014 No ; 5(4): 479–86.
43 Sidhu R, McAlindon ME, D ew K, Ha dcas le
S, Came on IC, Sande s DS. E alua ing he ole
o small-bowel endoscopy in clinical p ac ice:
he la ges single-cen e expe ience. Eu J Gas-
oen e ol Hepa ol. 2012 May; 24(5): 513–9.
44 Möschle O, May A, Mülle MK, Ell C; Ge -
man DBE S udy G oup. Complica ions in and
pe o mance o double-balloon en e oscopy
(DBE): esul s om a la ge p ospec i e DBE
da abase in Ge many. Endoscopy. 2011 Jun;
43(6): 484–9.
45 Ba e o-Zuñiga R, Tellez-A ila FI, Cha ez-
Tapia NC, Rami ez-Luna MA, Sanchez-Co -
es E, Valdo inos-And aca F, e al. Diagnos ic
yield, he apeu ic impac , and complica ions
o double-balloon en e oscopy in pa ien s
wi h small-bowel pa hology. Su g Endosc.
2008 May; 22(5): 1223–6.
46 Manabe N, Tanaka S, Fukumo o A, Nakao M,
Kamino D, Chayama K. Double-balloon en-
e oscopy in pa ien s wi h GI bleeding o ob-
scu e o igin. Gas oin es Endosc. 2006 Jul;
64(1): 135–40.
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