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Background: Capsule endoscopy (CE) is increasingly used in patients with suspected or known Crohn's disease (CD)., Objective: To determine the diagnostic yield of CE and the distribution of small-bowel (SB) lesions in symptomatic patients with known CD., Design and Setting: Retrospective review of CE procedures performed in patients with CD between 2001 and 2005 in a tertiary care center., Patients: One hundred thirty-four patients with an established diagnosis of CD and symptoms suggestive of active disease., Interventions: Swallowing the capsule., Main Outcome Measurements: Diagnostic yield of CE and distribution of SB lesions in patients with CD., Results: One hundred forty-six CE procedures were performed on 134 CD patients. Fifty-two (39%) of 134 patients had CE findings diagnostic of active CD (> 3 ulcerations), and 17 (13%) had findings suggestive of active CD (< or = 3 ulcerations). Fifty-seven (42%) patients had normal findings, and 6% had normal but incomplete studies. The distribution of SB lesions was 32% in the duodenum, 53% in the jejunum, 67% in the proximal ileum, and 85% in the distal ileum. CE was comparable to ileoscopy in detecting ileal ulcerations (55% vs 48%), but superior to SB follow-through in detecting CD lesions in the SB (incremental yield of 32%; 95% CI, 9%-54%; P = .0017)., Limitations: Retrospective study from a single center., Conclusions: CE identified SB lesions in approximately half of symptomatic CD patients. Large-scale prospective studies are needed to evaluate whether positive CE findings may affect disease outcomes., (2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Retrograde double-balloon enteroscopy (rDBE) is technically a different procedure from its antegrade counterpart. Its unique indications, success rate, and learning curve have not been specifically reported., Objective: To examine technical issues specific to the rDBE approach., Design: Retrospective review., Setting: Single tertiary-care center., Patients: All patients referred for rDBE., Main Outcome Measurements: Procedure duration, technical success, learning curve, and complications related to rDBE., Results: A total of 59 rDBEs were performed on 56 patients for obscure GI bleeding (46.4%), metastatic carcinoids (23.2%), Crohn's disease (14.3%), and other indications. rDBE enabled a diagnosis in 47.5% of procedures and had a 38% diagnostic rate in finding primary small-bowel lesions that were responsible for metastatic carcinoids. The mean (standard deviation) total procedure time was 111.3 +/- 39.9 minutes. Procedure failure occurred in 12 cases (21%), which is significantly more than reported with antegrade procedures (2%). Failure was more common among patients with a prior abdominal or pelvic surgery (P = .001), and the time to achieve a stable ileal intubation was prolonged in these patients (13.9 vs 38.1 minutes; P = .0006). A trend was noted toward successful small-bowel access and increased lengths of small bowel examined after 20 procedures were performed., Limitations: Small retrospective study., Conclusions: rDBE is effective for the evaluation and the treatment of lower small-intestinal lesions; however, maintaining access through the ileocecal valve may be difficult. Prior surgery may be an important factor associated with failure. A minimum of 20 rDBE procedures was needed to minimize procedure failure, examine a substantial segment of the small-bowel, and shorten procedure duration.

Background: Double-balloon enteroscopy is a new technique that allows endoscopic therapy throughout the entire length of the small bowel. Diaphragm disease, characterized by thin septa that narrow the small-bowel lumen, is traditionally treated surgically by segmental resection., Objective: To report successful endoscopic treatment of diaphragm disease by double-balloon enteroscopy., Patients: Three patients., Design: Case report., Interventions: Double-balloon enteroscopy and stricture balloon dilation., Results: We report, for the first time, 3 cases in which diaphragm strictures were successfully treated during double-balloon enteroscopy. In 2 cases, a retained capsule endoscope was removed by the retrograde approach after stricture dilation., Limitations: Small number of patients and brief length of patient follow up., Conclusion: Double-balloon enteroscopy may be used to treat patients with diaphragm disease, thus avoiding potentially complicated surgery.

Background: Performance parameters for double-balloon enteroscopy (DBE) have not been described., Objective: To determine the learning curve for DBE., Design: Prospective cohort study., Setting: Six U.S. tertiary centers., Patients: A total of 188 subjects undergoing 237 DBE procedures; 130 (69%) with obscure GI bleeding., Interventions: Performance parameters from each center's initial 10 cases were compared to the subsequent examinations., Main Outcome Measurements: Exam duration, depth of insertion, and findings on DBE examination., Results: DBE was introduced by mouth in 149 (63%) cases, by rectum in 77 (33%) cases, and through a stoma in 6 (2.5%) patients. The mean (+/-SD) duration was 109.1 +/- 44.6 minutes for the first 10 cases and 92.4 +/- 37.6 minutes for subsequent cases (P = .005) but did not change for rectal DBE procedures. There was no change in mean depth of insertion, but the mean fluoroscopy time declined significantly (P = .025). Diagnostic or therapeutic maneuvers were performed in 64% of cases; DBE led to a diagnosis in 81 (43%) patients. A total of 78% of patients had prior capsule endoscopy (CE) with significant agreement between DBE and CE (kappa = 0.74). One perforation occurred (0.4%). Per-rectal cases failed to reach the small bowel in 24 (31%) cases., Limitations: All patients did not undergo initial CE. The therapeutic DBE scope was not available for the initial 8 months of the study., Conclusions: There was a significant decline in overall procedural time and fluoroscopy time after the initial 10 DBE cases. There was no improvement in performance parameters when DBE was performed via the rectal approach despite increased, but limited, operator experience.