Small Bowel Enteroscopy-A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups

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). Usage and dis ibu ion o comme cial pu poses as well as any dis- ibu ion o modi ied ma e ial equi es w i en pe mission. 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 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. 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;27:324–335 326 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. 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 Small Bowel En e oscopy – Guideline 327 GE Po J Gas oen e ol 2020;27:324–335 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]. 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;27:324–335 328 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]. 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 Small Bowel En e oscopy – Guideline 329 GE Po J Gas oen e ol 2020;27:324–335 DOI: 10.1159/000507375 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- 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;27:324–335 330 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) 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 Small Bowel En e oscopy – Guideline 331 GE Po J Gas oen e ol 2020;27:324–335 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. 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