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Introduction: Crohn’s disease (CD) of the small bowel is associated with a severe course and increased risk of complications. Strictures at this location are challenging to diagnose and out-of-reach of colonoscopy. We aimed to evaluate the detection rate of small bowel strictures with magnetic resonance enterography (MRE) and assess the efficacy of double balloon enteroscopy-assisted endoscopic balloon dilatation (DBE-assisted EBD) in managing these strictures. Methods: A retrospective study included all patients with DBE-assisted EBD of small bowel strictures in CD in our facility. All patients had MRE to detect strictures prior to the dilatation. Sequential dilatation protocol was performed using through-the-scope (TTS) working channel balloons. The outcomes included technical success defined by the passage of the enteroscope post-dilatation, resolution of symptoms, and the requirement of repeated procedures or surgery during 12 months of follow-up. Results: Twenty DBE-assisted EBDs of small bowel strictures were attempted during 13 DBE procedures in 10 patients (6 males, median age 42). MRE identified 75% of the strictures with 100% accuracy in localisation. Retrograde DBE was the approach in 16/20 (80%) strictures. Anaesthetic intubation was used in 8/20 (40%). DBE reached 19/20 strictures. All the reached strictures were dilated successfully; the technical success following dilatation was 72.2%. The median DBE insertion time with TTS balloon dilatation was 66 min. Three patients required follow-up dilatations within 2–3 months. Surgery was not needed during the follow-up period. Conclusions: MRE is essential in diagnosing and localising small bowel strictures in CD. DBE reached 95% of strictures with successful dilatation. Immediate technical success was high, and safety was demonstrated. Planned repeat procedures for sequential dilatation were performed in a few patients. Surgical resection was avoided in all patients.

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Objectives: The aim of this paper relies on our clinical experience in a single center with an evaluation of feasibility, clinical benefits, and safety in daily practice based on diagnosis and therapeutic yield using a newly designed Motorized Spiral Enteroscope (MSE) marked by Olympus. Method: All examinations were conducted in the usual endoscopy suite with patients in the left lateral position with deep propofol sedation monitored by an anesthesiologist (bolus 2 ​mg/kg then 0.5 ​mg/kg on demand with mean total dose 300 ​mg (225.6–386 ​mg). For the anal route, MSE was performed on the X-ray table in order to monitor colonic passage and ileocecal intubation. Inflation was carried out with CO2 used. Results: From June 2019 to July 2022, 204 procedures have been carried out. 188 patients were involved as repeated MSE was required due to multiple bleeding (male 111, 57.1%, female 87, 46.2%). In all cases, we considered a successful MSE when the enteroscope was deeply inserted in the ileum and achieved diagnosis or therapeutic indications as an endpoint (195 patients, 95.5%). Diagnostic yield was achieved in 134 procedures (65.7%).Time to deep insertion was 11:36 ​± ​05.05 ​min, and the total procedure time was 22:07 ​± ​07:25 ​min. Minor mucosal damage occurred in 59 patients (28.9%). Conclusions: In our 204 procedures MSE is a safe and useful new tool in routine clinical practice with an overall benefit for our patients.

Abstract Background and Aim Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. Methods We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan–Meir survival curve showed GI bleed‐free survival following initial bleed and was compared using the log rank test. Results A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity‐score‐matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P

Crohn's disease (CD) affecting the jejunum and ileum is uncommon and its diagnosis can be challenging. This case report describes a 35 year old male patient who had been experiencing intermittent periumbilical pain, diarrhoea and fever for five years. Despite undergoing gastroscopy, colonoscopy and capsule endoscopy; no significant abnormalities were found. This case was seen at the Shenzhen Hospital of Traditional Chinese Medicine; Shenzhen, China. However, the patient underwent a double-balloon enteroscopy (DBE), which revealed multiple ulcers in the jejunum and ileum, leading to a confirmed diagnosis of CD. The patient was successfully treated with infliximab to relieve symptoms. DBE can be particularly valuable in diagnosing CD in young patients with symptoms when conventional endoscopic techniques have been unsuccessful. This case highlights the importance of considering small bowel disease in patients with CD symptoms and the potential benefits of DBE in diagnosing such cases.

Hereditary polyposis syndromes are a group of inherited disorders associated with a high risk of developing colorectal cancer. The best known ones are familial adenomatous polyposis (FAP), Peutz-Jeghers (PJS), juvenile polyposis and Cowden syndromes, as well as conditions predisposing to cancer, such as Lynch syndrome. Some of them are characterized by an increased risk of small bowel polyps occurrence. Literature search in PubMed was performed in November 2022 and a narrative review was carried out. Since performing small bowel polypectomy is important in such patients, device assisted enteroscopy (DAE) is the key for this procedure. A screening strategy for small bowel polyps is recommended only for PJS. Guidelines endorse either magnetic resonance imaging (MRI) or videocapsule endoscopy (VCE) every 1–3 years, according to the phenotype of the disease. Enteroscopy should be considered for therapeutic purpose in patients with a positive VCE or MRI. DAE has a central role in the resection of polyps larger than mm or causing symptoms of subocclusion or intussusception. Both single (SBE) and double balloon enteroscopy (DBE) are indicated and able to resect polyps up to 6–10 cm. American guidelines have restricted the indications to small bowel enteroscopy only to FAP patients with grade IV Spiegelman. Only some groups of patients (PJS, FAP with demonstrated small bowel polyp burden) may benefit from DAE. [ABSTRACT FROM AUTHOR]

Background and Aim: Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. Methods: We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan–Meir survival curve showed GI bleed‐free survival following initial bleed and was compared using the log rank test. Results: A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity‐score‐matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed‐free survival compared to those in the nonemergent group (P = 0.009). Conclusion: Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE. [ABSTRACT FROM AUTHOR]

Objective: Gastrointestinal bleeding is one of the surgical emergencies that is routinely visited in emergency departments. Although most of these patients are managed with endoscopic modalities, some of them are managed with surgical interventions. Most of emergency surgical interventions are done via laparotomy. With evolution in minimal invasive surgery, the role of laparoscopic surgeries in emergency settings is on a rise. Case Presentation: In this report we describe a case of lower gastrointestinal bleeding that was presented with melena and during workups no bleeding lesion was detected in colon, stomach or duodenum. Further investigations revealed bleeding of proximal jejunum mass that was resected with the laparoscopic approach which is rarely used in the emergency management of patients with gastrointestinal bleedings. Also, resection and anastomosis of proximal jejunal loop was challenging in this case. Conclusion: This report is intended to describe the feasibility of laparoscopy in proximal small bowel lesion resection in emergency settings as well as the role of CT angiography in detecting the source of obscure gastrointestinal bleeding.

Objectives: Double balloon enteroscopy (DBE) with retrograde contrast is useful as a monitoring tool for small intestinal lesions in Crohn's disease (CD), but these are burdensome for patients. Intestinal ultrasound (IUS) can be used with ease in daily clinical practice, but there is less evidence regarding the accuracy of detection of small intestinal stenosis in CD. This study aimed to examine the diagnostic power of IUS for small intestinal stenosis in patients with CD. Methods: The findings of DBE and IUS in 86 patients with CD with small intestinal lesions were evaluated. Using DBE as the reference standard, we examined the detection rate of IUS for small intestinal stenosis. We evaluated three parameters: luminal narrowing, prestenotic dilation, and to‐and‐fro movement for determining stenosis using IUS. In addition, we compared the characteristics between the stenosis‐detectable and stenosis‐undetectable groups by IUS. Results: Of the 86 patients, 30 had small intestinal stenosis. In IUS findings, when lesions that met two or more of the three parameters were judged as stenosis, the detection rate was 70.0% for sensitivity, 98.2% for specificity, and 88.4% for accuracy. Moreover, there were patients with a younger age at diagnosis (P < 0.05) and more ileocolonic disease location (P < 0.05) in the stenosis‐detectable group by IUS. The stenoses detected by IUS were significantly longer than those undetected by IUS (14.1 mm versus 5.2 mm, P < 0.05). Conclusions: IUS delivered reliable results for clinically important small intestinal stenosis of CD with high diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Small intestinal lipomas are rare, but may cause obscure gastrointestinal bleeding. The endoscopic unroofing technique excises only the upper third of the lipoma and allows both histological confirmation and complete treatment with minimal risk of perforation. We present a rare case of obscure gastrointestinal bleeding caused by a jejunal lipoma. A 75-year-old man on antiplatelet therapy presented to our department with melena and anemia. Computed tomography revealed he had a 45-mm jejunal submucosal tumor with fat attenuation. Endoscopic resection using an endoscopic unroofing technique with double balloon enteroscopy was successfully performed. The tumor was confirmed to be a lipoma. [ABSTRACT FROM AUTHOR]

Background: Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2 METHODS: We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE.Results: 131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE.Conclusions: Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Abstract Background Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2 Methods We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE. Results 131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE. Conclusions Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.

Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center. We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE–DBE concordance, hemoglobin (Hb) values before and after DBE, and complications. 807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1–5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients. VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs. [ABSTRACT FROM AUTHOR]

Background The commonest therapeutic indications for double balloon enteroscopy (DBE) includes removal of retained video capsules, dilatation of strictures, polypectomy, and managing obscure small bowel bleeding. We review our experience in managing active small bowel bleeding with DBE. Methods A retrospective review was done for all the cases undergoing DBE from August 2017 to July 2019. Patient follow-up data was collected. Results Among 25 cases with a median age of 46.8 (range 25–65 years), 17 males (68%) underwent DBE for suspected small bowel bleeding. The commonest presenting complaint was melena 19 (76%). The findings were positive (diagnostic yield) in 18 (72%) patients with an antegrade approach. Active bleeding was associated with Dieulafoy's lesion (n = 6), gastrointestinal stromal tumors (GIST) (n = 4), jejunal varices (n = 3), angioectasia (n = 3), and ulcer (n = 2), who then underwent successful intervention. The rest of the patients underwent both antegrade and retrograde approach but failed to immediately identify an alternative diagnosis. Mean (standard deviation [SD]) time taken for antegrade enteroscopy was 96.7 (15.3) mins and 67.8 (13.6) mins for retrograde enteroscopy. The median duration between the last bleeding episode and timing of DBE was 9 (range 6–15 hours). No major complications were seen during or immediately postprocedure. Conclusion DBE is useful in identifying and treating active small bowel bleeding. Being invasive and time-intensive, it is easy to miss lesions and, therefore, needs appropriate expertise. DBE does appear to be relatively cheaper, with better patient acceptance and time saving.

Introduction: The study of the small bowel is a challenging task that has sparked interest and progress in medicine. In this context, double balloon enteroscopy (DBE) has allowed the direct visualization of the small intestine. Objective: To describe indications, procedure characteristics, findings, complications, and follow-up of patients taken to DBE at the Hospital de San José, Bogotá, between November 2011 and April 2019. Methodology: Case series study. Patients with a clinical indication or diagnostic images suggestive of small bowel lesion were included. Descriptive statistics were used. Results: 45 enteroscopies were performed in 44 patients, with a median age of 58 years. The main indication was potential small bowel bleeding (53.3%) and chronic diarrhea (11.1%). Anterograde procedures were more frequent. Most of the results were normal (46.7%); tumors (11.1%), Crohn's disease (8.9%), and ulcers/erosions (6.7%) were among the most frequent findings. The diagnostic yield was 53.3% and the correlation with capsule endoscopy (CE) was 37.5%, and with imaging studies 42.9%. There were no complications. 91.1 % of patients were followed up on after a median of 56 months, with 78.1 % reporting symptom remission. The aim of enteroscopy was diagnostic in 84.4%. Conclusions: DBE is useful in the evaluation of the small intestine with a therapeutic possibility. The results are similar to those reported in the world literature. Follow-up can define the need for repeating the procedure, performing further studies, or symptom resolution. [ABSTRACT FROM AUTHOR]

Obscure gastrointestinal bleeding (OGIB) accounts for a small percentage of gastrointestinal (GI) bleeding. The underlying etiology includes small bowel lesions such as Meckel’s diverticulum, a differential to be considered in a young adult. Capsule endoscopy and double balloon enteroscopy (DBE) are important imaging modalities used in the evaluation of OGIB. We describe a case of a young adult male who presented with bleeding per rectum. Upper and lower GI endoscopies were negative and the patient was labeled to have OGIB. After further investigations, our patient was finally diagnosed to have Meckel’s diverticulum by DBE, strengthening its diagnostic utility.

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder comprised of venous malformation mostly involving the skin and gastrointestinal (GI) tract but can also involve other visceral organs. The most predominant site of GI tract involvement is the small bowel. In patients with GI lesions, treatment depends on the severity of bleeding, and extent of involvement. Conservative therapy with iron supplementation and blood transfusion is appropriate in cases with mild bleeding but in severe cases endoscopic and surgical interventions would be beneficial. Also, medical therapy with sirolimus significantly reduces bleeding. A 20-year-old woman was referred to our hospital after transfusion of six units of packed cell because of several episodes of lower GI bleeding within the past three months in the form of melena and a single episode of hematochezia. Her last hemoglobin level before admission was 10mg/dl. She underwent various unsuccessful investigations since she was eight years old to find the origin of refractory iron deficiency anemia. In upper endoscopy, five bleeding polypoid lesions were discovered in the jejunum. Lesions were excised by snare polypectomy. Over a six-month follow-up period, no signs of lower GI bleeding were noted and the patient had a normal hemoglobin level. [ABSTRACT FROM AUTHOR]

Objective: To explore the difference of small bowel CT and double-balloon enteroscopy in the diagnosis of Crohn's disease. Method: Choose 60 patients with Crohn's disease who were treated in our hospital from April 2017 to March 2019, and perform small bowel CT and double-balloon enteroscopy respectively, and compare the two detection methods to accurately diagnose Crohn's disease patients Rate and detection difference of lesion range, lesion location, mobility and complications. Results: The accuracy rate of CT in detecting Crohn's disease was 96.67%, and the accuracy of detecting Crohn's disease by double-balloon enteroscopy was 93.33%, and the difference was not statistically significant (P>0.05). Small bowel CT mainly showed 50 cases of intestinal stenosis (83.33%), 52 cases of intestinal wall thickening (86.67%), 46 cases of extraintestinal lymph nodes (76.67%), 21 cases of mesenteric edema and vascular changes (35.00%), extraintestinal Inflammation in 10 cases (16.67%), fistula in 3 cases (5.00%), fistula in 1 case (1.67%); double balloon enteroscopy showed ring ulcers, irregular ulcers, ring ulcers, etc., a total of 46 cases (76.67%), 22 cases (36.67%) of aphthous ulcers, 26 cases (43.33%) of mucosal hyperemia and edema, 6 cases (10.00%) of nodular hyperplasia, 16 cases (26.67%) of intestinal segmental stenosis of the small intestine, pseudo 9 cases of polyps (15.00%); pathological examination showed inflammatory infiltration of lymphocytes, neutrophils, eosinophils, and hyperplasia of lymphoid tissues and granulation tissues. CT showed extraintestinal inflammation, fistulas, fistulas, etc. There were 14 cases in total, and no complications were found with double balloon enteroscopy. Conclusion: Compared with double-balloon enteroscopy, small bowel CT can more accurately determine whether patients with Crohn’s disease are in an inflammatory state, and can more effectively detect the presence of extraintestinal complications, but small bowel CT and double-balloon enteroscopy are combined The application monitoring effect is better. [ABSTRACT FROM AUTHOR]

Introduction: Crohn's disease (CD) of the small bowel is associated with a severe course and increased risk of complications. Strictures at this location are challenging to diagnose and out-of-reach of colonoscopy. We aimed to evaluate the detection rate of small bowel strictures with magnetic resonance enterography (MRE) and assess the efficacy of double balloon enteroscopy-assisted endoscopic balloon dilatation (DBE-assisted EBD) in managing these strictures., Methods: A retrospective study included all patients with DBE-assisted EBD of small bowel strictures in CD in our facility. All patients had MRE to detect strictures prior to the dilatation. Sequential dilatation protocol was performed using through-the-scope (TTS) working channel balloons. The outcomes included technical success defined by the passage of the enteroscope post-dilatation, resolution of symptoms, and the requirement of repeated procedures or surgery during 12 months of follow-up., Results: Twenty DBE-assisted EBDs of small bowel strictures were attempted during 13 DBE procedures in 10 patients (6 males, median age 42). MRE identified 75% of the strictures with 100% accuracy in localisation. Retrograde DBE was the approach in 16/20 (80%) strictures. Anaesthetic intubation was used in 8/20 (40%). DBE reached 19/20 strictures. All the reached strictures were dilated successfully; the technical success following dilatation was 72.2%. The median DBE insertion time with TTS balloon dilatation was 66 min. Three patients required follow-up dilatations within 2-3 months. Surgery was not needed during the follow-up period., Conclusions: MRE is essential in diagnosing and localising small bowel strictures in CD. DBE reached 95% of strictures with successful dilatation. Immediate technical success was high, and safety was demonstrated. Planned repeat procedures for sequential dilatation were performed in a few patients. Surgical resection was avoided in all patients., Competing Interests: Rupert W Leong reports advisory board membership of AbbVie, Aspen, BMS, Celgene, Celltrion, Chiesi, Ferring, Glutagen, Hospira, Janssen, Lilly, MSW, Novartis, Pfizer, Prometheus Biosciences, and Takeda, and research grant support from McCusker Charitable Foundation, Joanna Tiddy grant University of Sydney, Celltrion, Shire, Janssen, Takeda, Gastroenterological Society of Australia, MRFF, NHMRC, Gutsy Group, and Pfizer. All other authors (A.A., A.A., J.Y., H.L., and E.V.) have no conflicts of interest to declare., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

An inflammatory fibroid polyp (IFP) is a mesenchymal tumor of the gastrointestinal tract. IFPs in the small intestine are the most frequently detected with symptoms, such as abdominal pain and tarry stool due to intussusception. Accordingly, few studies have reported jejunal IFP as a cause of occult gastrointestinal bleeding (OGIB) diagnosed via both of capsule endoscopy (CE) and double-balloon enteroscopy (DBE). A 68-year-old woman presented with a progression of anemia and a positive fecal occult blood test result. Esophagogastroduodenoscopy and total colonoscopy findings were unremarkable. CE revealed a tumor with bleeding in the jejunum. DBE also revealed a jejunal polypoid tumor. Bleeding from the tumor seemed to have caused anemia. The patient underwent partial laparoscopic resection of the jejunum, including resection of the tumor. The tumor was histopathologically diagnosed as IFP. To our knowledge, this is the first reported case of laparoscopic resection of jejunal IFP with OGIB diagnosed via CE and DBE preoperatively.

Surgically altered anatomy complicates endoscopical procedures of pancreatobiliary tree. Biliary or hepaticojejunal anastomosis strictures have been managed using percutaneous transhepatic or double balloon enteroscopy (DBE) techniques with multiple plastic stents, or fully covered self-expandable metal stents. We report the first seven cases with surgically altered anatomy treated with biodegradable stents with DBE. Seven cases with altered anatomy, all with Roux-en-Y hepaticojejunostomy (HJ), were treated for HJ anastomosis strictures (3 cases) and intrahepatic biliary stricture (4 cases). Fujifilm DB enteroscope with a 200 cm long and 3.2 mm wide working channel was used. Balloon dilatations were first performed and then 1–3 biodegradable stents were deployed with a pusher over a guidewire. Two patients had HJ due to liver resections, one due to biliary injury in cholecystectomy and four due to liver transplantation because of primary sclerosing cholangitis (PSC). Median duration of the procedures was 56 min. Deployment of the stents took less than 20 min per patient. There were no stent or cholangiography related adverse events, but one patient required endotracheal intubation for nose bleeding caused by the placement of nasopharyngeal tube. Two PSC patients had recurrent cholangitis in the follow up. There was one stent migration in 90 day follow up. With all the HJ anastomotic strictures resolution of strictures seemed to be achieved. Treatment of biliary or anastomosis strictures in altered anatomy is complex and time consuming. The biodegradable stent, which can be passed through working channel of a long enteroscope, seems promising in the treatment of these strictures. The benefit is that no stent removal is needed. [ABSTRACT FROM AUTHOR]

Background and Aims: Double balloon enteroscopy (DBE) has revolutionised the diagnosis and treatment of small bowel (SB) conditions. However, deep SB insertion can be challenging in patients with a history of abdominal surgery and a two-step procedure is required when findings are not amenable to endoscopic therapy. This case series reports the development of laparoscopically assisted DBE (LA-DBE) using single incision laparoscopic surgery (SILS).Methods: Retrospective review of LA-DBE procedures performed in a single tertiary centre over 6 years.Results: Seventeen patients (median age: 40 years, male 41%) underwent 17 LA-DBE procedures. The approach was oral in 13 and rectal in 4. Laparoscopic approach was standard (multi-port) in the first four cases, SILS was then used in all subsequent patients (13/17). Indications for LA-DBE were previously failed standard DBE (n = 16) and need for a combined procedure (n = 1). Indications for DBE were Peutz-Jeghers syndrome (PJS) (n = 10), suspected submucosal/polypoid lesion at small bowel imaging (n = 5) and obscure gastrointestinal bleeding (OGIB) with vascular abnormalities seen at capsule endoscopy (n = 2). In 1/17 the suggested pathology on imaging was not identified. Therapy was applied in 15/17 (88%) cases. Diagnoses were PJS polyps (n = 8), neuroendocrine tumour (NET) (n = 2), PJS and NET (n = 1), transmural arteriovenous malformation (n = 1), angioectesia (n = 1), inflammatory polyp (n = 1), leiomyoma (n = 1) and Meckel's diverticulum (n = 1). The median (range) procedure time was 147 (84-210) mins. Median (range) length of stay post-procedure was 2 (1-19) days. Three patients developed complications. The 30-day mortality rate was 0%.Conclusions: LA-DBE is a safe, effective and minimally invasive procedure that can be applied for the management of selected patients with small bowel pathology. A SILS approach allows all therapeutic modalities to be available, including conversion to intraoperative enteroscopy (IOE), laparoscopic small bowel resection and laparotomy. [ABSTRACT FROM AUTHOR]

Intestinal lipomatosis is a proliferation of histologically normal fatty tissue in the gastrointestinal tract. It is characterized benign, asymptomatic, slow growing tumors with sub-epithelial origins. On rare occasions, they become symptomatic and can be associated with major complications such as gastrointestinal obstructions and bleeding. This rare pathology has been reported several times in the literature but not in Colombia prior to this study. We present two cases that were evaluated and followed up at the Unión de Cirujanos SAS and the University of Caldas in Manizales, Colombia. The first is a 70-year-old man who had a history of colic associated with bloating and postprandial diarrhea. The initial upper digestive endoscopy reported multiple yellowish, submucosal lesions in the duodenum. His histological diagnosis was lipomas. In this case, an endoscopic video capsule determined the distribution and characteristics of the lesions throughout the gastrointestinal tract and assessed complications. The second is an 81-year-old man who entered the institution due to lipothymia and rectal bleeding. Upper endoscopy and colonoscopy were normal, but a videocapsule endoscopy showed lipomatous lesions one of which was bleeding and had adjacent angiodysplasia. He was treated with double balloon enteroscopy and Argon plasma therapy. [ABSTRACT FROM AUTHOR]

Background  The commonest therapeutic indications for double balloon enteroscopy (DBE) includes removal of retained video capsules, dilatation of strictures, polypectomy, and managing obscure small bowel bleeding. We review our experience in managing active small bowel bleeding with DBE. Methods  A retrospective review was done for all the cases undergoing DBE from August 2017 to July 2019. Patient follow-up data was collected. Results  Among 25 cases with a median age of 46.8 (range 25–65 years), 17 males (68%) underwent DBE for suspected small bowel bleeding. The commonest presenting complaint was melena 19 (76%). The findings were positive (diagnostic yield) in 18 (72%) patients with an antegrade approach. Active bleeding was associated with Dieulafoy's lesion (n = 6), gastrointestinal stromal tumors (GIST) (n = 4), jejunal varices (n = 3), angioectasia (n = 3), and ulcer (n = 2), who then underwent successful intervention. The rest of the patients underwent both antegrade and retrograde approach but failed to immediately identify an alternative diagnosis. Mean (standard deviation [SD]) time taken for antegrade enteroscopy was 96.7 (15.3) mins and 67.8 (13.6) mins for retrograde enteroscopy. The median duration between the last bleeding episode and timing of DBE was 9 (range 6–15 hours). No major complications were seen during or immediately postprocedure. Conclusion  DBE is useful in identifying and treating active small bowel bleeding. Being invasive and time-intensive, it is easy to miss lesions and, therefore, needs appropriate expertise. DBE does appear to be relatively cheaper, with better patient acceptance and time saving. [ABSTRACT FROM AUTHOR]

Continuous flow-left ventricular assist devices (CF-LVADs) have become a therapeutic option in the management of advanced heart failure. Several studies show that patients with CF-LVAD are at an increased risk of gastrointestinal bleeding (GIB). However, few reports have presented the characteristics of GIB in Japanese populations. We investigated the incidence, etiology, and outcome of GIB in patients with CF-LVAD. Records of adult patients who received CF-LVADs between October 2008 and January 2017 were reviewed. GIB was defined as detection of bleeding sites by any type of diagnostic imaging. 54 patients received CF-LVAD, of which eight (14%) presented with overt GIB (12 events). GIB patients are significantly older (p = 0.04) and their pre-operative inferior vena cava diameter was larger (p = 0.02). Multivariate analysis revealed that the use of Jarvik 2000 (p = 0.003) was a risk factor for GIB. In total, 85.8% of patients were free from GIB at 1 year. The most common site was the small intestine (67%). The most common cause was angiodysplasia (50%). Six patients required blood transfusion (nine events) and four underwent endoscopic clippings (five events); however, no patients needed surgeries. The incidence of GIB in our cohort was similar to the global registry data. Double balloon endoscopy is useful for diagnosis and treatment of small intestinal lesions. Future efforts to further understand the incidence of GIB in Japanese populations by multicenter data are needed. [ABSTRACT FROM AUTHOR]

Abstract Background Familial adenomatous polyposis (FAP) is a rare, autosomal dominant disease clinically characterized by the early onset of many adenomatous polyps throughout the colon, which turn into colon cancer, if left untreated. In FAP patients, polyps can also occur in the upper gastrointestinal (GI) tract, especially in the duodenum. Adenomas beyond duodenum are rare and mostly located in the proximal jejunum and distal ileum. The management of such polyps can be either surgical or endoscopic, depending on the features of the polyp, Spigelman stage and patient’s clinical conditions. Endoscopic mucosal resection (EMR) of jejunal polyps can be challenging, because of the thinner wall of jejunum, compared to the rest of the GI tract, and of the difficulty of maintaining control and stability of the scope. For these reasons, jejunal perforation is a likely occurrence. Case presentation A 65-year-old woman with a stage IV FAP, who had previously undergone abdominal surgery because of her disease, came to our attention because of numerous adenomatous-looking duodenal polyps and a 25 mm lesion in proximal jejunum. According to Spigelman staging system, patient was candidate for surgical resection, in light of the risk of developing small bowel cancer. Despite the benefits of surgery were clearly explained to her, she refused to undergo small bowel resection. Therefore, EMR of the largest duodenal polyp and of the jejunal lesion was planned. After the removal of the jejunal polyp, a small perforation was noted. We were able to rapidly close such perforation by using the Over-The-Scope-Clip system (OTSC, 12/6 t; Ovesco, Tübingen, Germany) pre-mounted onto a double balloon (DB) enteroscope. Conclusions The endoscopic management of jejunal perforation can be tricky and the placement of traditional through-the-scope clips in a narrow space like jejunum may be difficult and time consuming. This case describes the use of the OTSC system pre-mounted onto a DB enteroscope for the closure of post-EMR jejunal perforation.

Small bowel malignancy is still a rare case as a cause of gastrointestinal bleeding. The symptoms of small bowel malignancy are not specific. One of the symptoms is obscure gastrointestinal bleeding. Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent gastrointestinal bleeding when the result esophagogastroduodenoscopy and colonic endoscopy is negative. OGIB accounts for approximately 5% of all gastrointestinal bleeding events. Most OGIB events are attributable to small bowel disease. Double-balloon enteroscopy, also known as push-and-pull enteroscopy is an endoscopic technique for visualization of the small bowel. Here we present 5 cases of small bowel tumours in patient with obscure gastrointestinal bleeding who underwent double balloon enteroscopy at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Three patients had confirmed gastrointestinal stromal tumour (GIST) from the histopathology examination, while 2 patients were diagnosed with adenocarcinoma.

Device assisted enteroscopy (DAE) is increasingly being carried out in elderly patients. This provides a challenge due to the underlying varied physiology and comorbidities these patients have. We performed a systematic literature search for studies on elderly patients undergoing DAE. We calculated the pooled diagnostic (DY) and therapeutic yields (TY), major adverse events, length of small bowel examined and sedation administered. These were also compared to younger patients. Fourteen high quality articles on DAE in the elderly were included in this analysis (3289 total, 1712 elderly) patients. Nine of these studies were included in the final meta-analysis (681 elderly, 1577 young patients). The overall DY of DAE, double balloon enterosocpy (DBE) and single balloon enteroscopy (SBE) were 0.68 (p = 0.000001), 1.74 (p = 0.0001) and 1.90 (p = 0.009). The TY of DAE, DBE and SBE were 0.45 (p = 0.00001), 2.20 (p = 0.00001) and 2.36 (p = 0.00001). On comparison of elderly and young patients, DY (1.83; 95% CI: 1.49, 2.24; p = 0.00001) and TY (2.28; 95% CI: 1.79, 2.89) were better in elderly patients. There was no difference in adverse events in both groups (2.16; 95% CI: 0.82, 5.69, p = 0.12). Elderly patients were given less sedation than younger patients during DAE. DAE has a higher DY and TY in the elderly than younger patients. DAE can be safely carried out in the elderly with less sedation. [ABSTRACT FROM AUTHOR]

Double balloon enteroscopy (DBE) was introduced 15 years ago. The complications of diagnostic DBE are rare, acute pancreatitis is most redoubtable one (incidence about 0.3%). Hyperamylasemia after DBE seems to be a rather common condition respectively. The most probable cause seems to be a mechanical straining of the pancreas. We tried to identify patients in a higher risk of acute pancreatitis after DBE. We investigated several laboratory markers before and after DBE (serum cathepsin B, lactoferrin, E-selectin, SPINK 1, procalcitonin, S100 proteins, alfa-1-antitrypsin, hs-CRP, malondialdehyde, serum and urine amylase and serum lipase). Serum amylase and lipase rose significantly with the maximum 4 hours after DBE. Serum cathepsin and procalcitonin decreased significantly 4 hours after DBE compared to healthy controls and patients values before DBE. Either serum amylase or lipase 4 hours after DBE did not correlate with any markers before DBE. There was a trend for an association between the number of push-and-pull cycles and procalcitonin and urine amylase 4 hours after DBE; between procalcitonin and alfa-1-antitrypsin, cathepsin and hs-CRP; and between E-selectin and malondialdehyde 4 hours after DBE. We found no laboratory markers determinative in advance those patients in a higher risk of acute pancreatitis after DBE.

Pancreatic and gastric heterotopias are rare clinical entities which have been identified throughout the entire length of the gastrointestinal tract. Combined gastric and pancreatic heterotopias, although unusual, have been described in the duodenum and jejunum, and in other structures, including Meckel's diverticulum and the ampulla of Vater. We report a novel case of pancreatic and gastric heterotopia with an associated submucosal lipoma in a 38-year-old female with a recent history of rectal cancer and chronic crampy abdominal pain. On computed tomography, a 7-cm luminal polypoid mass extending into the distal ileum was discovered. The mass was successfully resected using retrograde double balloon enteroscopy. We believe this is the first report of all three histological entities co-existing in an obstructive ileal lesion in an adult. It highlights endoscopic resection trough double enteroscopy as a safe alternative to more invasive surgical approaches for this type of lesion.

Background: The management of patients with recurrent anaemia and small bowel angioectasia (SBA) is costly and challenging., Aims/methods: In this retrospective cohort study, we examined the clinical and cost implication of a combination therapy of Somatostatin analogues (SA) and endoscopic ablation, endoscopic therapy alone, and conservative management., Results: Median number of bleeding episodes reduced from 3.5 (IQR 4) in the year before, to 1 (IQR 2) in the year after starting combination therapy with SA (p = 0.002). There were no differences in number of bed days (13.7 vs. 15.3, p = 0.66) and cost (£10,835 vs £11,653, p = 0.73) in the year before and after starting combination therapy. There was a trend towards a reduction in median number of blood transfusions episodes (17 vs 5, p = 0.07) and therapeutic endoscopies (1 vs. 0, p = 0.05) after starting SA. In patients suitable for endoscopic therapy alone, time spent in hospital was reduced (-3.5 days, p = 0.004), but bleeding episodes, transfusions and cost of treatment were not different. Patients requiring a combination therapy were significantly more co-morbid with a mean (± sd) Charlson comorbidity index (CCI) of 7.1 (± 2.7). Higher CCI (OR 2.1, 95% CI 1.1-3.9) and presence of chronic renal failure (OR 4.1, 95% CI 1.4-12.4) predicted escalation to combination therapy., Conclusions: SAs may be a useful adjunct to endoscopic therapy for transfusion dependent comorbid patients. In the first year they reduce bleeding episodes. Cost in the 1-year before and after adding on SA are no different suggesting additional clinical benefit can be gained without additional cost., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Small bowel bleeding occurs in 10% of patients with gastrointestinal bleeding. In these patients, the origin of the bleeding is not found after performing upper and lower digestive endoscopy. Persistent small bowel bleeding is characterized by continuous presence of melena and/or hematochezia and is severe when is accompanied by hemodynamic instability. The diagnostic studies for this pathology are: videocapsule endoscopy, balloon-assisted enteroscopy, CT angiography, mesenteric angiography, scintigraphy with red blood cells and intraoperative enteroscopy. [ABSTRACT FROM AUTHOR]

The aim of the study was to improve the results of treatment of patients with intrahepatic cholangiolithiasis for hepaticojejunostomy stricture with use of miniinvasive methods. In our centre during the period from 2002 till 2016 were treated in 58 patients with hepaticojejunostomy strictures. Thirteen patients from their was coexistant intrahepatic cholangiolithiasis. Forty-six (79.3%) patients was performed rehepaticojejunostomy. Twelve patients was performed a minimally invasive intervention such as laser recanalisation using double balloon enteroscopy (7 patients) and lithoextraction with double balloon enteroscopy (1), transhepatic cholangioscopy (2 patients) with laser lithotripsy (1), balloon dilatation of the stricture rehepaticojejunostomosis (4), lithoextraction (4), including with double balloon enteroscopy ("randevoux" procedure) (1), stenting (2). We observed several complication such as cholangitis (5); recurrent cholangiolithiasis (1); restricture of rehepaticojejunostomosis (2). Miniinvasive endoscopic techniques treatment and endobiliary correction of rehepaticojejunostomosis strictures and cholangiolithiasis have shown good results. [ABSTRACT FROM AUTHOR]

Background To evaluated the experiences of double balloon enteroscopy (DBE) for obscure gastrointestinal bleeding. Methods From October 2003 to November 2009, a total of 124 patients with obscure gastrointestinal bleeding were investigated using DBE. A total of 142 procedures (84 per oral and 58 per rectal route) were performed by the same endoscopist. Results The average insertion time was 71.4 (20–199) minutes per-orally; the average insertion time was 139.2 min for the first 5 procedures, 109.4 min for 6–10 procedures, 76.6 min for 11–15, 66.4 min for 16–20, 67.4 min for 21–25, 59 min for 26–30, 66 min for 31–35, 52 min for 36–40, 42.9 min for 41–45, 44.6 min for 46–50, 42.2 min for 51–55, 38.6 min for 56–60, 44.6 min for 61–65, 37.8 min for 66–70, 38.8 min for 71–75, 44.3 min for 76–80, and 36.6 min for 61–84 procedures; there was no statistical difference after the first ten procedures. The average insertion time was 92.1 (22–260) minutes per-rectally; the average insertion time was 159.6 min for the first 5 procedures, 98.4 min for 6–10 procedures, 86.6 min for 11–15, 76.4 min for 16–20, 82.4 min for 21–25, 75.0 min for 26–30, 78.2 min for 31–35, 72.4 min for 36–40, 68.2 min for 41–45, 66.9 min for 45–50, and 71.4 min for 51–58 procedures; there was no statistical difference after the first five procedures. For the different genders these was no statistically significant difference. There were no differences regarding the diagnostic yield between the previous factors. The overall diagnostic yield was 82.4%. Conclusion DBE is a safe and effective means of diagnosing and managing patients with obscure gastrointestinal bleeding. However, because of its time-consuming, DBE has a learning curve to overcome before a physician can become an expert to achieve adequate insertion times with good diagnostic and therapeutic rates. [ABSTRACT FROM AUTHOR]

Introduction: Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging. [ABSTRACT FROM AUTHOR]

Background: Familial adenomatous polyposis (FAP) is a rare, autosomal dominant disease clinically characterized by the early onset of many adenomatous polyps throughout the colon, which turn into colon cancer, if left untreated. In FAP patients, polyps can also occur in the upper gastrointestinal (GI) tract, especially in the duodenum. Adenomas beyond duodenum are rare and mostly located in the proximal jejunum and distal ileum. The management of such polyps can be either surgical or endoscopic, depending on the features of the polyp, Spigelman stage and patient's clinical conditions. Endoscopic mucosal resection (EMR) of jejunal polyps can be challenging, because of the thinner wall of jejunum, compared to the rest of the GI tract, and of the difficulty of maintaining control and stability of the scope. For these reasons, jejunal perforation is a likely occurrence.Case Presentation: A 65-year-old woman with a stage IV FAP, who had previously undergone abdominal surgery because of her disease, came to our attention because of numerous adenomatous-looking duodenal polyps and a 25 mm lesion in proximal jejunum. According to Spigelman staging system, patient was candidate for surgical resection, in light of the risk of developing small bowel cancer. Despite the benefits of surgery were clearly explained to her, she refused to undergo small bowel resection. Therefore, EMR of the largest duodenal polyp and of the jejunal lesion was planned. After the removal of the jejunal polyp, a small perforation was noted. We were able to rapidly close such perforation by using the Over-The-Scope-Clip system (OTSC, 12/6 t; Ovesco, Tübingen, Germany) pre-mounted onto a double balloon (DB) enteroscope.Conclusions: The endoscopic management of jejunal perforation can be tricky and the placement of traditional through-the-scope clips in a narrow space like jejunum may be difficult and time consuming. This case describes the use of the OTSC system pre-mounted onto a DB enteroscope for the closure of post-EMR jejunal perforation. [ABSTRACT FROM AUTHOR]

Background and study aims Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of unknown origin that persists or recurs after an initial negative investigation. Identifying the source of OGIB represents a diagnostic challenge that is frequently focused on visualizing the small intestine. Conventional diagnostic methods, such as push enteroscopy, small-bowel follow-through, radionuclide scanning, and angiography, each exhibit inherent limitations. Double balloon enteroscopy (DBE) was designed specifically to evaluate the entire small bowel. DBE allows for better visualization, biopsy of the identified lesions and application of therapeutic techniques. This study sought to assess the role of DBE in the diagnosis and management of patients with OGIB. Patients and methods This prospective study was conducted to analyse data from 31 patients presenting with OGIB referred for DBE in the Endoscopy Unit at the Internal Medicine Department of the Faculty of Medicine, Cairo University. Results Five patients had lesions in locations other than the small intestine that accounted for GI bleeding. Thus, the potential source of OGIB was defined as the small intestine in 18 of 26 patients (69.2%), and negative DBE findings were noted in eight patients (30.8%). Major findings included small intestinal tumours in eight patients, vascular bleeding lesions in 8 patients and ulcerations in 2 patients. Endoscopic haemostasis was performed in eight patients with vascular lesions. The three patients with Petuz-Jegher syndrome underwent polypectomy of their major polyps. Patients with gastrointestinal tumours were referred for surgery. Conclusion DBE is an excellent endoscopic procedure that has a relatively high diagnostic and therapeutic yield. The procedure is feasible and exhibits a high safety profile with a low complication rate when performed by an experienced endoscopist. [ABSTRACT FROM AUTHOR]

A 75-year-old man who had undergone partial gastrectomy was referred to our hospital due to worsening leg edema, loose stools and malnutrition. Double balloon enteroscopy followed by insertion of an indwelling ileus tube was performed to investigate the microbial flora and for washing inside the blind loop. Trophozoites of Giardia were detected in the sampled fluid from the blind loop and DNA analysis disclosed an assemblage of genotype A-II of Giardia duodenalis. Treatment with oral metronidazole was effective. This case emphasizes the importance of a correct diagnosis when treating patients with blind loop syndrome in the digestive tract.

Primary intestinal lymphangiectasia (PIL) or Waldmann’s disease is a rare protein-losing enteropathy presenting with diarrhea. The etiology and prevalence of PIL remain unknown.

Background and objective: Little is known about the clinical impact of double-balloon enteroscopy (DBE) in patients with Peutz-Jeghers syndrome (PJS). The aim of this study was to assess the efficacy and safety of DBE in the management of small-bowel polyps in PJS patients. Patients and methods: We conducted a multicentre, retrospective cohort study, which included all consecutive patients diagnosed with PJS who underwent DBE for polypectomy between January 2006 and August 2012. In all cases, previous videocapsule enteroscopy had shown at least one polyp ≥ 10 mm in size. Results: Twenty-five patients (13 men; median age 36 years; 14 with prior laparotomy) underwent 46 DBE procedures (1 to 5 per patient, 44 via oral route). Polypectomy was performed in 39/46 DBEs. A total of 214 polyps were removed (median-size 30 mm), with a median number of polypectomies per procedure of 5.0 (range 1-18). The estimated maximum-sizes of resected polyps significantly decreased at each session: 30.0, 25.0, 20.0, 15.0, and 17.5 mm (p = 0.02). In 7 DBEs no polypectomy was performed (4-only minor polyps detected; 3-endoscopic irresecability). Complications occurred in 3/39 of therapeutic procedures (2-minor delayed bleeding; 1-mucosal tear), all of them dealt with conservative or endoscopic therapy. Six patients underwent elective surgery post DBE due to polyps not amenable for endoscopic resection. There were no small-bowel polyp related complications during a median follow-up of 56.5 months. Conclusion: DBE showed to be a safe and effective technique in the management of small-bowel polyps in PJS patients, allowing a presymptomatic and non-surgical approach.

Hookworm infections are widely prevalent in tropical and subtropical areas, especially in low income regions. In the body, hookworms parasitize the proximal small intestine, leading to chronic intestinal hemorrhage and iron deficiency anemia. Occasionally, hookworms can cause overt gastrointestinal bleeding, but this is often ignored in heavily burdened individuals from endemic infectious areas. A total of 424 patients with overt obscure gastrointestinal bleeding were diagnosed by numerous blood tests or stool examinations as well as esophagogastroduodenoscopy, colonoscopy, capsule endoscopy or double-balloon enteroscopy. All of the patients lived in hookworm endemic areas and were not screened for hookworm infection using sensitive tests before the final diagnosis. The patients recovered after albendazole treatment, blood transfusion, and iron replacement, and none of the patients experienced recurrent bleeding in the follow-up. All the 31 patients were diagnosed with hookworm infections without other concomitant bleeding lesions, a rate of 7.3% (31/424). Seventeen out of 227 patients were diagnosed with hookworm infections in the capsule endoscopy (CE), and 14 out of 197 patients were diagnosed with hookworm infections in the double balloon enteroscopy (DBE). Hookworm infections can cause overt gastrointestinal bleeding and should be screened in patients with overt obscure gastrointestinal bleeding (OGIB) in endemic infectious areas with sensitive methods. Specifically, the examination of stool specimens is clinically warranted for most patients, and the proper examination for stool eggs relies on staff's communication. [ABSTRACT FROM AUTHOR]