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BackgroundIn the 1980’s and 1990’s combined Push and Sonde Enteroscopy was the primary endoscopic tool used to evaluate the small intestine in patients with obscure gastrointestinal bleeding (OGIB). It was available in only a few centers due to the technical difficulties associated with its use. The introduction of wireless capsule endoscopy in 2001 revolutionalized small bowel endoscopic imaging making Sonde enteroscopy a rarely used procedure despite the lack of studies comparing the efficacy of the two modalities. The aim of this study was to restrospectively compare the findings of Sonde enteroscopy with capsule endoscopy in patients with OGIB.MethodsDesign: One hundred patients who underwent Sonde enteroscopy and 101 patients who underwent capsule endoscopy were retrospectively studied. Setting: All patients had their procedures completed by physicians within the same gastroenterology practice. Patients: All patients who underwent either Sonde enteroscopy or capsule endoscopy were enrolled. Interventions: None. Main outcome measurements: Outcome was defined as the number of patients in which a distinct bleeding site could be identified.ResultsA total of 100 patients underwent Push and Sonde enteroscopy and a potential bleeding site was identified in 55 (55%) patients. A total of 101 patients underwent capsule endoscopy and a potential bleeding site was identified in 60 (59%) patients. A one-tailed P value showed no statistically significant difference in the diagnostic yield between the procedures.ConclusionsCapsule endoscopy is at least as efficacious as Push/Sonde enteroscopy in evaluating patients with OGIB. We can comfortably retire Sonde enteroscopy as a diagnostic tool.

INTRODUCTION: Duodenal involvement of sarcoidosis is infrequently reported. It can manifest with a spectrum of symptoms and mimic other gastrointestinal diagnoses. CASE DESCRIPTION/METHODS: This is the case of a 59-year-old man with a history of pulmonary sarcoidosis on hydrochloroquine and deep venous thrombosis on apixaban who presented with weight loss with associated abdominal pain, decreased appetite, early satiety, and intermittent dysphagia to both solids and liquids. He reported a colonoscopy 2 years prior that was normal. Labs were notable for a hemoglobin of 11.5 with an MCV of 77. CMP, TSH and HIV were normal. Physical exam revealed a thin male, unremarkable vital signs and normal cardiac, pulmonary and abdominal evaluations. He underwent upper endoscopy and was found to have white esophageal plaques suggestive of candidiasis, gastritis with gastric nodularity, and a normal duodenum. Gastric biopsies were consistent with gastritis with positive staining for H.pylori for which he was subsequently treated. He underwent abdominal CT revealing diffuse small bowel wall thickening and enlarged retroperitoneal and mesenteric lymph nodes. Decision was made to proceed with repeat upper endoscopy as well as endoscopic ultrasound. Upper endoscopy noted gastritis and new duodenitis. Gastric biopsies showed chronic gastritis, negative staining for H.pylori, and positive CD20 and CD3 staining consistent with a reactive process. Duodenal biopsies showed noncaseating granulomas and villous blunting (Figure 1). EUS was unrevealing except for peripancreatic and porta hepatis lymphadenopathy for which he underwent fine needle aspiration. Flow cytometry was negative. The patient was started on high dose steroids given the duodenal involvement of his sarcoidosis followed by a taper over a few months. During the taper, he returned with worsening anemia and diarrhea. Repeat upper endoscopy revealed more extensive involvement of the duodenum with severe inflammation and plan for outpatient colonoscopy and follow up with his sarcoidosis specialist to discuss treatment regimen. DISCUSSION: Although duodenal sarcoidosis is rare, it is important to include this in the differential diagnosis in the appropriate clinical setting. It's symptoms and pathology can have overlap with some common diseases such as celiac, Crohn's disease, and even lymphoma. Tissue acquisition is imperative to confirm the diagnosis and can be performed at the time of endoscopy with treatment aimed at management of the underlying disease process.

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