Roshanak Rabbanifard

Single versus double balloon enteroscopy for small bowel diagnostics: a systematic review and meta-analysis.

Introduction: Double balloon enteroscopy (DBE) and single balloon enteroscopy (SBE) are 2 types of commonly used balloon-assisted enteroscopic techniques for “deep enteroscopy.” Although there are several randomized controlled trials assessing the superiority of DBE compared with SBE, the results from individual randomized controlled trials seem conflicting. We performed a systematic review and meta-analysis to assess the efficacy of DBE compared with SBE. Methods: Primary outcomes were diagnostic and therapeutic yield. Secondary outcomes were failure rates, adverse events, complete enteroscopy, anterograde/retrograde insertion depths, and procedure times. We searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception until February 28, 2014, as well as other databases. For quality assurance purposes throughout the systematic review process, dual extraction was performed. The systematic review was performed as per the standards of Cochrane collaboration. Results: Four trials enrolling a total of 375 patients were included. DBE did not offer an advantage over SBE in therapeutic yield [risk ratio (RR), 1.11; 95% confidence interval (CI): 0.90, 1.37; P=0.33)] or diagnostic yield (RR=1.08; 95% CI: 0.89, 1.32; P=0.42), failure rates (RR=0.68; 95% CI: 0.23, 2.05; P=0.5), overall adverse events (RR=1.41; 95% CI: 0.32, 6.3; P=0.65), or complete enteroscopy rates (RR=1.73; 95% CI: 0.86, 3.48; P=0.12). No evidence existed for an advantage of anterograde or retrograde procedure time between these 2 modalities [mean difference (MD), 3.78; 95% CI, −30.76, 38.32; P=0.83; and MD, −0.53; 95% CI: −7.66, 6.59; P=0.88, respectively]. Neither anterograde nor retrograde insertion depths appeared to differ between the 2 studies analyzed (MD, −7.36; 95% CI: −40.36, 25.64; P=0.66 and MD, 7.86; 95% CI: −12.68, 28.40; P=0.45, respectively). Conclusions: Performance of SBE and DBE appears to be similar in terms of diagnostic/therapeutic yield, insertion depths, procedure time, complete enteroscopy, failure rates, or adverse events.

A single-center United States experience with bleeding Dieulafoy lesions of the small bowel: diagnosis and treatment with single-balloon enteroscopy.

Introduction: A Dieulafoy lesion (DL) of the small bowel can cause severe gastrointestinal bleeding, and presents a difficult clinical setting for endoscopists. Limited data exists on the therapeutic yield of treating DLs of the small bowel using single-balloon enteroscopy (SBE). Methods: Data were collected from Tampa General Hospital a 1 018-bed teaching hospital affiliated with University of South Florida in Tampa, Florida. Patients were selected from a database of patients that underwent SBE from January 2010 – August 2013. Results: Eight patients were found to have DL an incidence of 2.6 % of 309 SBE performed for obscure gastrointestinal bleeding. 7/8 were identified in the jejunum, with one found in the duodenum. The mean age of patients with DL was 71.5 years old. 6/8 patients were on some form of anticoagulant/antiplatelet agent. The primary modality of therapy employed was electrocautery, multipolar electrocoagulation in seven patients and APC (argon plasma coagulation) in one patient. In three patients, electrocoagulation was unsuccessful and hemostasis was achieved with clip placement. Three patients required repeat SBE with one found to have rebleeding from a failed clip with hemostasis achieved upon reapplication of one clip. Conclusion: In our United States’ experience, SBE offers a reasonable therapeutic approach to treat DL of the small bowel with low rates of rebleeding, no adverse events, and no patient requiring surgery.

The safety and efficacy of single balloon enteroscopy in the elderly.

Background: Single balloon enteroscopy (SBE) is an important tool in the management of small bowel disease with limited data available on its performance in the elderly. We aimed to evaluate the safety, efficacy, diagnostic and therapeutic outcomes of SBE in the elderly. Methods: A retrospective review was performed on 366 patients undergoing 428 SBEs from 2010 to 2014. Patients were divided into different age groups: control <55, 55–64, 65–74 and ⩾75 years. Data on comorbidities, complications, findings, diagnostic and therapeutic yield were compared between groups. Results: Anterograde and retrograde SBE were performed in 340 and 49 patients, respectively, with 63 patients requiring more than 1 procedure. Diagnostic yield was significantly higher for age ⩾75 years compared with <55, 66.3% versus 50%, odds ratio (OR) 1.97 [95% confidence interval (CI) 1.14–3.41]. Therapeutic yield was significantly higher in all three older age groups compared with <55 years, 20.3%: 55–64 years, 44.4%, OR 3.13(95% CI 1.7–5.78); 65–74 years, 42%, OR 2.84 (95% CI 1.59–5.06); and >75 years, 47.5%, OR 3.55 (95% CI 1.96–6.43). No significant difference was seen between age groups in complications or failures. Our overall complication rate was 2.3% with 5 minor and 5 major complications. There was a higher yield of angioectasias in the elderly. Argon plasma coagulation (APC) and multipolar electrocoagulation were used more often in older age groups. Conclusion: SBE is safe in elderly patients and delivers higher diagnostic and therapeutic yields compared to younger patients. The elderly are more likely to have angioectasias and undergo APC and electrocoagulation.

Timing of single balloon enteroscopy: significant or not?

Background: The development of balloon assisted enteroscopy (BAE) has revolutionized diagnostic and therapeutic modalities for small-bowel disorders. Although the role of emergent esophagogastroduodenoscopy and colonoscopy for upper and lower gastrointestinal bleeding is well defined, there is scarce data with regard to emergent BAE for gastrointestinal bleeding. Study: We performed a retrospective cohort study including 110 hospitalized patients with obscure gastrointestinal bleeding who underwent single balloon enteroscopy (SBE) between January 2010 and August 2013. Patients were divided into two groups based on procedures performed emergently (within 24 hours) versus non-emergently (greater than 24 hours). Data on patient demographics, hemodynamic characteristics, type of obscure bleed, lesions identified, location of lesions, endoscopic intervention performed, need for further surgical or radiological intervention, diagnostic and therapeutic yield, and adverse events were compared between groups. Independent samples t test and Fisher’s exact test were used to assess the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and 95 % confidence intervals (CI), and for binary as odds ratio and 95 %CI. Results: Although patients in the group where enteroscopy was performed within 24 hours had a significantly higher incidence of radiological intervention (10.0 % vs. 0.0 %, P = 0.019), the diagnostic and therapeutic yields between the two groups were not significantly different. Additionally, there were no statistically significant differences between the groups for overt and occult bleeding, transfusion requirements, type and location of lesions, endoscopic intervention performed, or adverse events. Hospital stay was shorter in the patients who had SBE within 24 hours of admission (6.2 vs. 11.3 days, P < 0.001). Conclusions: Although the diagnostic and therapeutic yields of SBE were not significantly different between patients having the procedure within 24 hours and those having it later, the early SBE group required more interventional radiology procedures. While endoscopists may not necessarily have to perform emergent assessment within 24 hours in patients with obscure gastrointestinal bleeding (OGIB) for greater diagnostic or therapeutic yield, early intervention may allow for earlier stabilization and thus shorter hospital stays. Prospective studies further evaluating these findings are indicated.

Ischemic Colitis, the Great Imitator: A Mass Completely Resolved

Ischemic colitis (IC) is the most common type of intestinal ischemia, with a vast clinical spectrum of injury ranging from mild and transient ischemia to acute fulminant colitis. The pattern of injury is usually segmental, but it is mainly dictated by individual anatomy, duration of ischemia, and degree of re-perfusion injury. Analysis of clinical presentation, early endoscopic evaluation, and biopsy are all essential for prevention of misdiagnosis. We present a unique case of IC with mass-like features on regular imaging, emphasizing the importance of endoscopy and biopsy for accurate diagnosis.

Atypical Locations of Primary Squamous Cell Carcinoma of the Gastrointestinal Tract: a Case Series and Review of Literature

An 87-year-old African-American male with a past medical history of Alzheimer’s disease was admitted from his nursing home for vague abdominal pain and unintentional weight loss. Adequate history was difficult to obtain secondary to patient’s underlying dementia. Physical examination was notable for a thin cachectic male with scleral icterus, a non-tender abdomen, and a palpable right-sided abdominal mass. Laboratory results were significant for elevated total bilirubin of 4.5 mg/dL, aspartate aminotransferase of 238 IU/L, alanine aminotransferase of 263 IU/L, and alkaline phosphatase of 499 IU/L. The remainder of the labs including lipase and carbohydrate antigen 19-9 (CA 19-9) were unremarkable. Subsequent computed tomography (CT) scan revealed a pancreatic head mass with areas of internal necrosis resulting in biliary and pancreatic ductal dilation (Fig. 1a). Esophagogastroduodenoscopy (EGD) showed an infiltratingmass in the duodenal bulb extending for approximately 7 cm into the second portion of the duodenum, from which multiple biopsies were taken (Fig. 1b). The major papilla was edematous and abnormal appearing from tumor infiltration. We were unable to endoscopically place a biliary stent for decompression; therefore, a percutaneous biliary drain was placed by interventional radiology. Pathology of the infiltrating duodenal mass revealed only squamous features, however likely adenosquamous pancreatic carcinoma (Fig. 1c). Thorough investigation including full body CT did not reveal any metastatic disease. The patient was not a candidate for surgical resection, and his family wished against chemotherapy. He was made comfort measure only and was discharged under hospice care, eventually succumbing to this condition within 3 months.