Elsevier

Gastrointestinal Endoscopy

Volume 64, Issue 3, September 2006, Pages 445-449
Gastrointestinal Endoscopy

Case Study
Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy

https://doi.org/10.1016/j.gie.2006.04.007Get rights and content

Background

Capsule endoscopy (CE) is increasingly being used to investigate the small bowel for various indications, including obscure GI bleeding (OGB). However, false negatives have been described. Double-balloon enteroscopy (DBE) is a new endoscopic technique developed to potentially view the entire small intestine while allowing therapeutic options to be carried out when appropriate.

Objective

We described 4 patients with small-bowel pathology missed on CE but detected by DBE.

Design

Descriptive retrospective study. All patients underwent CE followed by DBE.

Setting

Single-center tertiary referral hospital.

Patients

Four patients were included. Three patients had OGB that required blood transfusions. One patient with celiac disease, compliant on a strict gluten-free diet for 5 months, presented with persistent weight loss and abdominal pain.

Interventions

DBE followed by surgical exploration and resection of small-bowel pathology.

Main Outcome Measurements

Successful identification of pathology missed by CE. Definitive treatment of small-bowel pathology by surgical resection.

Results

CE did not identify the small-bowel pathology in all 4 patients. The 3 patients with OGB had small-bowel masses found by DBE. Two of these were GI stromal tumors and one was an adenocarcinoma. The patient with celiac disease had a malignant ulcer, confirmed to be a lymphoma after surgical resection.

Limitations

Retrospective study and small sample size.

Conclusions

CE and DBE are complementary investigations. If there is a high index of suspicion of small-bowel pathology despite a negative CE, DBE should be performed.

Section snippets

Case 1

A 51-year-old woman, with a history of chronic abdominal pain since her teenage years, was recently diagnosed with celiac disease based on a small-bowel biopsy. A gastroscopy revealed a typical scalloped appearance of the small-bowel mucosa, but no other pathology was found. A colonoscopy was normal. She had 2 cousins with celiac disease, a sister diagnosed with colorectal cancer at age 27, and a paternal aunt with carcinoma of the pancreas. She had no other relevant medical history. She had no

Discussion

Investigation of the small bowel has been the last frontier for endoscopists. The arrival of CE early this decade represented a promising, novel, noninvasive, and well-tolerated method of examining the small bowel. Multiple studies have reported a higher yield by CE compared with conventional investigations, including push enteroscopy and small-bowel barium radiography in the investigation of OGB.1

However, CE is not without its limitations. Both false positive and negative results have been

Acknowledgments

We thank the referring gastroenterologists for their contribution of patients and to Dr Phil Baird for providing images for histology.

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