Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022

Abstract

Main Recommendations MR1 ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2 ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3 ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4 ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5 ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6 ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7 ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn’s disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8 ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9 ESGE recommends, in patients with established Crohn’s disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10 ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11 ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

Deep-Learning and Device-Assisted Enteroscopy: Automatic Panendoscopic Detection of Ulcers and Erosions

“…While the introduction of CE exponentially increased the capacity of mucosa evaluation and detection of bowel lesions, its purely diagnostic nature demanded developing therapeutic deep enteroscopy procedures. Device-assisted enteroscopy (DAE), which comprehends single- and double-balloon enteroscopy, plus motorized spiral enteroscopy, enabled gastroenterologists to sample tissue and treat lesions [ 5 ]. DAE has a significant role in the approach of small intestinal lesions, mainly after a positive CE [ 5 , 6 ].…”

“…Device-assisted enteroscopy (DAE), which comprehends single- and double-balloon enteroscopy, plus motorized spiral enteroscopy, enabled gastroenterologists to sample tissue and treat lesions [ 5 ]. DAE has a significant role in the approach of small intestinal lesions, mainly after a positive CE [ 5 , 6 ]. Although the clinical setting and characterization of ulcerative lesions in CE may suggest probable etiologies, no distinctive macroscopic aspect can be used to make a definitive diagnosis.…”

Outcomes of Double Balloon-Enteroscopy in Elderly vs. Adult Patients: A Retrospective 16-Year Single-Centre Study

“…Two main techniques made the small bowel’s exploration possible: video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), both of which are constantly developing [ 1 , 2 , 3 , 4 ].…”

“…Device-assisted enteroscopy (DAE) is a generic term that includes any endoscopic technique for the exploration of the small bowel with a system of assisted progression (a balloon, overtube, or other stiffening device). DAE includes double-balloon enteroscopy (DBE, Fujinon Inc., Saitama, Japan), single-balloon enteroscopy (SBE, Olympus Optical Co., Tokyo, Japan), spiral enteroscopy (PowerSpiral; Olympus Medical, Tokyo, Japan), and balloon-guided endoscopy (NaviAid AB device, SMART Medical Systems Ltd., Ra’anana, Israel) [ 1 , 2 ].…”

“…In this case, the procedure is usually preceded by a diagnostic VCE or imaging study that detects the source of bleeding; however, DAE is indicated also in patients with obscure gastrointestinal bleeding, whether occult or overt. Another important application field of enteroscopy is Crohn’s disease (CD): recent guidelines by the European Society of Gastrointestinal Endoscopy (ESGE) recommends its use for diagnosis in patients with suspected small bowel localization of CD with non-contributory ileocolonoscopy, but also for therapeutic intervention, such as dilation of strictures or retrieval of retained capsules [ 2 ]. Furthermore, DAE allows endoscopic retrograde cholangiopancreatography (ERCP) for treatment of pancreaticobiliary diseases in patients with surgically altered anatomy, such as Roux-en-Y entero-enteric anastomosis [ 2 , 6 ].…”