PROSPECTIVE EVALUATION OF SMALL BOWEL INSERTION DEPTH ACHIEVED WITH PUSH ENTEROSCOPY BY USING CAPSULE ENDOSCOPY

ABSTRACT

DDW 2022 Author Disclosures Ryosuke Kobayashi NO financial relationship with a commercial interest ;Natalia C. Calo NO financial relationship with a commercial interest ;Bong Sik Kim NO financial relationship with a commercial interest ;Christopher Teshima NO financial relationship with a commercial interest Aims: Push enteroscopy (PE) is commonly used in patients with obscure GI bleeding after a negative esophagogastroduodenoscopy and colonoscopy to investigate for a bleeding source within the proximal small bowel. However, there is almost no literature that has measured the anticipated proportion of the small intestine that can be evaluated by using the PE technique. The primary aim of this study was to quantify the percentage of small bowel examined by PE by using capsule endoscopy (CE). Methods: Prospective patients referred for small bowel investigation of obscure GI bleeding were offered single session PE followed by CE. PE was performed using a pediatric colonoscope fitted with a distal attachment cap that was advanced as far as possible into the small intestine using a water immersion method and aided by multiple reduction maneuvers. Two endoscopic clips were placed to denote the maximal insertion point reached by PE. Potential bleeding sources identified during PE were treated during careful endoscope withdrawal. CE was then performed with direct endoscopic placement of the capsule into the duodenum by use of a gastroscope fitted with a capsule delivery device. CE was then performed as per usual standard-of-care. The clips were identified during CE and the small bowel insertion depth of PE was quantified by the percentage of small bowel transit time (SBTT) and of small bowel progress (SBP) from the CE examination. The study was approved by our center’s IRB. Results: Fifty-six patients were enrolled between August 2019 and November 2021;mean age 62 years;59% male. Study recruitment was hindered by our institution’s pausing of clinical research recruitment in the first year of the Covid-19 pandemic. Five cases were excluded due to incomplete small bowel examination by CE and 1 case in which PE could not be performed;leaving 50 cases for the analysis. The median CE SBTT was 4h 55m. The median SBP and SBTT percentage as determined by the location of the endoscopic clips placed during PE were 14% (IQR 5-26) and 11% (IQR 4-21), respectively. Bleeding lesions were detected by PE in the stomach in 10 cases and in the duodenum/jejunum in 20 cases. CE identified potential bleeding lesions within the segments of small bowel examined by PE in 12 cases and distal to the clips in 22 cases. CE detected only 69% of angioectasias that had been treated by PE and did not visualize 2 cases of submucosal tumor that were discovered during PE. Conclusions: PE achieves an average examination of the proximal 14% of the small bowel. This should inform appropriate selection of PE vs. DBE when a bleeding lesion is detected by CE. However, notable lesions may be missed by both PE and CE examinations.