Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding?

Abstract

Background: in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20 th century, made this technique to be relegated to a second level. Aims: evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding.Patients and methods: we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively.Results: with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleeding lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy's lesion (n = 2), bleeding from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively.Conclusions: intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable.

Does Intraoperative Endoscopy Still Apply in Obscure Gastrointestinal Bleeding Treatment? A Case Report and a Literature Review with a Diagnostic Algorithm Proposal

“…Latent OGIB accounts about 26% cases and causes positive fecal blood occult test or/and syderopenic anemia. About 50% of obscure bleeding stops spontaneously, medium age of patients suffering from OGIB is 59-66 years, correlation with sex was not confirmed [2,3,7,8]. We report a case of patient with obscure gastrointestinal bleeding who refused surgical treatment at the time of diagnosis and got recurrent bleeding requiring urgent operation and intraoperative endoscopic investigation.…”

“…10%. On the other hand, up to 80% of obscure GI bleeding is localized in a small bowel [2,7]. Medical terminology of GI is unfortunately not homogenous [5,9].…”

“…IOE enables mucosa visualization in 57% to 100% of cases and bowel resection during the same operation. Therapeutic index, which is identification of problem and elective treatment at once, is 55% to 78% for the procedure [2,7,11,15]. In the literature mortality rate related to IOE accounts for 2% to 18% of patients, recurrence rate is assessed for 25% to 60% [2,11].…”

“…Small bowel angiodysplasia 32% to 61% [1,2,4,5,10,12,14] Arteriovenous malformation (AVM) 9,1% [5] Ulceration 85 to 14,7% [1,4,5] Small bowel tumors 45 to 20% [1,4,5,14] Cameron erosion 5% to 15% [14] Upper GI tract angiodysplasia 45 to 10% [11,14] Crohn's disease 2% to 10% [14] Small bowel diverticula 3,3% to 5% [1,5,14] Colon dysplasia 2% to 4% [5] Varices haemorrhoidalis 0,4% to 5% [4,5,14] Dieulafoy lesions 0,4% to 3,5% [5,12,14] Unknown 16% to 20,7% [1,5] of cases transfusion of PRBC and FFP units is required [1,3,7]. It is discussed whether repeated endoscopy after failed first investigation is indicated because it was proven that it is not efficient enough and it enables visualization of only 3.5% to 5% of lesions responsible for bleeding.…”

“…It might be responsible even for 2% to 10% of all gastrointestinal (GI) bleeding cases, usually is asymptomatic and almost always recurrent [1][2][3][4]. Investigation is difficult, up to 80% of pathologies responsible for OGIB is localized in a small bowel but its visualization by endoscopy or radiology is technically limited unfortunately [4,5].…”