Non-surgical access for enteral nutritional: gastrostomy and jejunostomy, technique and results.

Gastrostomy is the most efficient and best tolerated method of prolonged nutritional support. Jejunostomy is used more rarely. Indications for both techniques have increased because of progress in insertion techniques under endoscopic or radiologic guidance. The procedure is simple and rapid, performed under simple sedation with a success rate over 95% for gastrostomy, irrespective of the technique. Mortality directly related to the technique is less than 5%, but associated co-morbidity also explains a more variable but often higher 30-day mortality. Local care and maintenance of the catheter should help avoid most of the late complications such as peristomal leaks, local infection or sepsis of the tunneled catheter in the abdominal wall. The main indications are neurologic swallowing disorders, mechanical dysphagia from ENT or esophageal disease, when the expected duration of enteral nutrition is at least longer than 3 weeks. In patients with severe dementia, no benefit for either nutritional status or quality of life has been demonstrated. In all cases, adequate patient information and careful evaluation of the risk/benefit ratio are capital.

Colon capsule endoscopy vs. colonoscopy in patients at average or increased risk of colorectal cancer.

BACKGROUND: Colon capsule endoscopy (CCE) is a new, non-invasive technology. AIM: To conduct a prospective, multicentre trial to compare CCE and colonoscopy in asymptomatic subjects enrolled in screening or surveillance programmes for the detection of colorectal neoplasia. METHODS: Patients underwent CCE on day one and colonoscopy (gold standard) on day two. CCE and colonoscopy were performed by independent endoscopists. RESULTS: A total of 545 patients were recruited. CCE was safe and well-tolerated. Colon cleanliness was excellent or good in 52% of cases at CCE. Five patients with cancer were detected by colonoscopy, of whom two were missed by CCE. CCE accuracy for the detection of polyps ≥ 6 mm was 39% (95% CI 30-48) for sensitivity, 88% (95% CI 85-91) for specificity, 47% (95% CI 37-57) for positive predictive value and 85% (95% CI 82-88) for negative predictive value. CCE accuracy was better for the detection of advanced adenoma, in patients with good or excellent cleanliness and after re-interpretation of the CCE videos by an independent expert panel. CONCLUSIONS: Although well-tolerated, CCE cannot replace colonoscopy as a first line investigation for screening and surveillance of patients at risk of cancer. Further studies should pay attention to colonic preparation (Clinicaltrial.gov number NCT00436514).

Small-bowel capsule endoscopy diagnoses early and advanced neoplasms in asymptomatic patients with Lynch syndrome.

BACKGROUND AND STUDY AIMS: Patients with Lynch syndrome are at increased risk of developing small-bowel adenocarcinoma, which usually has a bad prognosis and needs to be diagnosed early. Our aim was to evaluate the yield of capsule endoscopy and CT enteroclysis in this situation. PATIENTS AND METHODS: We performed a prospective, blinded, comparative study of capsule endoscopy and CT enteroclysis in five academic centers. Thirty-five consecutive asymptomatic patients with Lynch syndrome, all with one proven deleterious mutation, were included. A double reading was performed blind for both types of examination. RESULTS: Histologically confirmed small-bowel neoplasms were diagnosed in three patients (8.6 %): one adenocarcinoma (T3N0M0) and two adenomas with low-grade dysplasia. Capsule endoscopy identified all neoplasms. CT enteroclysis raised suspicion of one neoplasm (adenocarcinoma) but missed the two others. Concordance between the two capsule readings was high with a κ value of 0.78 (95 %CI 0.55 to 1.0), which was not the case for CT enteroclysis, where the κ value was 0.15 (95 %CI -0.27 to 0.58). CONCLUSION: Curable early or advanced neoplasms in asymptomatic patients with Lynch syndrome using capsule endoscopy can be detected with a better reproducibility than with CT enteroclysis. The clinical usefulness of systematic small-bowel screening in these patients should be confirmed through large prospective studies.

Application of ANAES guidelines for colonoscopy in France: a practical survey.

OBJECTIVES: In 2004, the French health authorities published guidelines on the indications for colonoscopy. However, no study has evaluated the awareness of healthcare practitioners of these guidelines. The aim of this study was to determine the level of awareness of the ANAES guidelines among French gastroenterologists. PATIENTS AND METHODS: A questionnaire comprising 20 multiple choice questions (MCQ) was presented to a group of 79 gastroenterologists between February and June in 2008. The questions covered screening tests for colon cancer (one question), endoscopic mucosal resection (two questions) and the ANAES guidelines (17 questions). According to the number of colonoscopies performed per year (less than 100, 100-500, more than 500), the answers to these questions were analyzed separately. RESULTS: Among the practitioners carrying out less than 100, 100-500 and more than 500 colonoscopies per year, the guidelines for colon cancer screening were known by 33, 50 and 56%, respectively, the quality criteria for endoscopic mucosal resection by 0, 0 and 3.7%, respectively, and the ANAES guideline indications for colonoscopy by 34.3, 51.2 and 48.9%, respectively (P<0.001). The ANAES guidelines were significantly better known by practitioners who were performing more than 100 colonoscopies per year, while the indications for control colonoscopy were less often correctly anticipated. No differences were found concerning postponed indications. CONCLUSION: The ANAES guidelines consists of the following elements: (1) awareness of the ANAES guidelines is poor, with control colonoscopy being correctly anticipated in just over a third of the gastroenterologists; (2) performing more than 100 colonoscopies per year improves knowledge of the ANAES guidelines; and (3) the ANAES guidelines need to be simplified and should be covered by continuing medical education.

Diagnostic accuracy of esophageal capsule endoscopy versus conventional upper digestive endoscopy for suspected esophageal squamous cell carcinoma.

BACKGROUND AND STUDY AIM: A video capsule similar to that used in small-bowel capsule endoscopy is now available for esophageal exploration. The aim of our study was to compare the accuracy of upper endoscopy (esophageal gastroduodenoscopy [EGE]) with esophageal capsule endoscopy (ECE) in patients at risk of esophageal squamous cell cancer (SCC). PATIENTS AND METHODS: 68 patients at risk of SCC secondary to a history of head and neck neoplasia were included in this comparison of techniques for detecting SCC and dysplasia. ECE was done using the first generation Pillcam ESO and EGE was performed in accordance with the usual practice of each center, followed by examination with 2 % Lugol staining and biopsy of unstained areas (39 neoplasia comprising 5 low grade dysplasia, 8 high grade dysplasia and 26 SCC). RESULTS: Compared with EGE with and without Lugol staining, the sensitivities of ECE for neoplasia diagnosis were 46 % and 54 %, respectively. On a per-patient basis, the sensitivity, specificity, and positive and negative predictive value of ECE were 63 %, 86 %, 77 % and 76 %, respectively, compared with EGE without staining, and 61 %, 86 %, 77 % and 73 % compared with EGE with iodine staining. Neither the ECE transit time nor the distance between the esopharyngeal line and the neoplastic lesion differed between the 21 false-negative and 18 true-positive cases diagnosed by ECE; the only difference was a smaller median diameter among false negatives ( P < 0.001). CONCLUSION: In a cohort at high risk for esophageal SCC, ECE is not sensitive enough to diagnose neoplastic lesions.

Esophageal capsule endoscopy vs. EGD for the evaluation of portal hypertension: a French prospective multicenter comparative study.

OBJECTIVES: Esophagogastroduodenoscopy (EGD) is the standard method for the diagnosis of esophago-gastric varices. The aim of this prospective multicenter study was to evaluate the PillCam esophageal capsule endoscopy (ECE) for this indication. METHODS: Patients presenting with cirrhotic or noncirrhotic portal hypertension underwent ECEfollowed by EGD at the time of diagnosis. Capsule recordings were blindly read by two endoscopists. RESULTS: A total of 120 patients (72 males, mean age: 58 years; mean Child-Pugh score: 7.2) were included. Esophageal varices were detected in 74 patients. No adverse event was observed after either EGD or ECE. Seven (6%) patients were unable to swallow the capsule. The mean recording time was 204 s (range 1-876). Sensitivity, specificity, negative predictive value, and positive predictive value of ECE for the detection of esophageal varices were 77%, 86%, 69%, and 90%, respectively. Sensitivity, specificity, negative and positive predictive values of ECE for the indication of primary prophylaxis (esophageal varices > or = grade 2 and/or red signs) were 77, 88, 90, and 75%, respectively, and 85% of the patients were adequately classified for the indication (or not) of prophylaxis. Interobserver concordance for ECE readings was 79.4% for the diagnosis of varices, 66.4% for the grading of varices, and 89.7% for the indication of prophylaxis. CONCLUSIONS: This large multicenter study confirms the safety and acceptable accuracy of ECE for the evaluation of esophageal varices. ECE might be proposed as an alternative to EGD for the screening of portal hypertension, especially in patients unable or unwilling to undergo EGD.

Quality control of colonoscopy procedures: a prospective validated method for the evaluation of professional practices applicable to all endoscopic units.

OBJECTIVES: To produce valid information, an evaluation of professional practices has to assess the quality of all practices before, during and after the procedure under study. Several auditing techniques have been proposed for colonoscopy. The purpose of this work is to describe a straightforward original validated method for the prospective evaluation of professional practices in the field of colonoscopy applicable in all endoscopy units without increasing the staff work load. METHODS: Pertinent quality-control criteria (14 items) were identified by the endoscopists at the Cochin Hospital and were compatible with: findings in the available literature; guidelines proposed by the Superior Health Authority; and application in any endoscopy unit. Prospective routine data were collected and the methodology validated by evaluating 50 colonoscopies every quarter for one year. RESULTS: The relevance of the criteria was assessed using data collected during four separate periods. The standard checklist was complete for 57% of the colonoscopy procedures. The colonoscopy procedure was appropriate according to national guidelines in 94% of cases. These observations were particularly noteworthy: the quality of the colonic preparation was insufficient for 9% of the procedures; complete colonoscopy was achieved for 93% of patients; and 0.38 adenomas and 0.045 carcinomas were identified per colonoscopy. CONCLUSION: This simple and reproducible method can be used for valid quality-control audits in all endoscopy units. In France, unit-wide application of this method enables endoscopists to validate 100 of the 250 points required for continuous medical training. This is a quality-control tool that can be applied annually, using a random month to evaluate any changes in routine practices.

[Surgical management of primary esophageal motility disorders]. / Traitement chirurgical des troubles moteurs de l'oesophage.

Primary esophageal motility disorders are rare, the most common diagnoses being achalasia and diffuse esophageal spasm. Treatment aims to alleviate symptoms and may be medical, endoscopic, or surgical. Achalasia is most commonly treated by pneumatic dilatation or by laparoscopic Heller cardiomyotomy. Pneumatic dilatation is effective in 60-80% of cases, but functional results deteriorate over time. Surgical treatment is indicated when endoscopic dilatation is contraindicated or has failed. Functional results after cardiomyotomy are satisfactory in 90% of cases and results appear to be stable over time. The need for an associated antireflux procedure and the type of fundoplication remain controversial. For diffuse esophageal spasm, extended esophageal myotomy has yielded satisfactory functional results, but surgical treatment should be reserved for selected patients with severe symptoms.

Esophageal lichen planus: a series of eight cases including a patient with esophageal verrucous carcinoma. A case series.

Esophageal lichen planus is a rare condition. Its risk of malignant transformation is unknown. We report a series of eight patients with esophageal lichen planus referred to our unit between 1990 and 2005. Clinical, endoscopic, radiological and histological data of these patients were retrospectively reviewed. Seven patients were women. All patients had oral lichen planus. Endoscopic lesions were located in the upper third of the esophagus in seven patients and in the mid third in two patients. Five patients had esophageal stricture. Seven patients had peeling, friable esophageal mucosa. Histological examination of esophageal biopsies found characteristic features of lichen planus in two patients and nonspecific changes in five patients. All patients received corticosteroids. Patients with stricture underwent esophageal dilation. Esophageal perforation after dilation occurred in one patient. Corticosteroids improved dysphagia in all patients; steroid dependence occurred in two patients with stricture. One patient had an esophageal verrucous carcinoma, which was treated with radiotherapy and chemotherapy. Upper endoscopy should be performed in patients with mucosal lichen planus presenting with dysphagia to assess esophageal involvement. Esophageal strictures are frequent and require dilation. Corticosteroids are the first-line treatment, but steroid dependence may occur. Cancer can arise on esophageal lichen planus and justifies endoscopic follow-up.

Computed virtual chromoendoscopy system (FICE): a new tool for upper endoscopy?

OBJECTIVES: A newly developed computed virtual chromoendoscopy system, Fuji Intelligent Color Enhancement (FICE) technology, decomposes images by wavelength, then directly produces reconstructed images with enhanced mucosal surface contrast. The aims of the present study were to determine the quality of information provided by computed virtual chromoendoscopy for detecting gastrointestinal polyps and to identify the best channel setting for imaging. PATIENTS AND METHODS: Thirty-one upper endoscopy procedures were performed in 31 patients using Fujinon 1.3-million-pixel endoscopes with zoom. A polyp was diagnosed in 45% of the patients. Six experienced endoscopists, who had never used the computed virtual chromoendoscopy system before, analysed the 31 endoscopy reports. Each endoscopy report included 11 images (one conventional image and one image for each FICE channel). The endoscopists used a 10-cm analog visual scale to determine the three best FICE channels, and to evaluate the quality and pit pattern of the chromoendoscopy images. RESULTS: Channel 4 (red: 520; green: 500; blue: 405) was considered the best channel in 39.7% of the reports (p<0.0001) and was among the best three in 77%. For 94.1% of the reports, the best FICE channel image was considered superior to the conventional image (p<0.0001). Median pit pattern score was 9.43 for computed virtual chromoendoscopy and 7.08 for conventional endoscopy (p<0.001). CONCLUSION: Fuji Intelligent Color Enhancement (FICE) channel 4 images were significantly better than conventional images. Computed virtual chromoendoscopy enabled better analysis of the pit pattern and the normal-pathological mucosal junction. Computed virtual chromoendoscopy can be used to identify gastroduodenal polyps and to assist in complete polypectomy.

Functional results after extended myotomy for diffuse oesophageal spasm.

BACKGROUND: The role of surgery in the management of patients with diffuse oesophageal spasm (DOS) remains controversial. The aim of this study was to assess functional results after extended myotomy for DOS. METHODS: This prospective study evaluated 20 patients who had extended myotomy (14 cm on the oesophagus and 2 cm below the oesophagogastric junction) with anterior fundoplication via a laparotomy for severe DOS. Median follow-up was 50 (range 6-84) months. Functional data were assessed by means of dysphagia (range 0-3), chest pain (range 0-3) and overall clinical (range 0-12, including dysphagia, chest pain, regurgitation, gastro-oesophageal reflux) scores. RESULTS: All patients had severe DOS. The median preoperative overall clinical score was 6 (range 3-8) with a dysphagia score of at least 2. Median postoperative functional scores were significantly lower than preoperative values (overall clinical score 1 versus 6, dysphagia score 0 versus 3, chest pain score 0 versus 2). At final follow-up, good or excellent results were obtained for overall clinical score in 16 patients, for dysphagia score in 18 and for chest pain score in all 20 patients. Postoperative gastro-oesophageal reflux was noted in two of the 20 patients. CONCLUSION: Extended myotomy with anterior fundoplication is an effective treatment for severe DOS. Medium-term postoperative functional results were excellent, especially in terms of dysphagia and chest pain.

[Digestive tract and botulinum toxin]. / Tube digestif et toxine botulique.

INTRODUCTION: the aim of this work was to check literature to assess botulinum toxin injection efficacy in gastrointestinal motor disorders with special emphasis on controlled clinical trials. METHODS: literature was carried out with the Medline data bank. RESULTS: seventy three articles in French and in English including a recent general review were retained. Comparative clinical trials only concerned achalasia and anal fissure. The other gastrointestinal motor disorders only gave rise to open non-controlled trials assessed on clinical end points. DISCUSSION: this review of literature helps to determine usefulness and safety of Botulinum toxin injection in the treatment of esophageal achalasia and anal fissure. The main limitation is its brief duration of action. Studies concerning the others spastic motor disorders are based on unknown physiopathology and controlled trials are required to assess its efficacy. CONCLUSION: botulinum toxin is increasingly used for gastrointestinal motor disorders with worthwhile results. Its efficacy has been yet established for only two disorders : it has a valuable palliative role in achalasia and may be curative for anal fissure.

Assessment of hypothalamic-pituitary-adrenal axis function after corticosteroid therapy in inflammatory bowel disease.

OBJECTIVES: In patients with inflammatory bowel disease (IBD), little is known about the effect of long term corticosteroid therapy (CT) on the hypothalamic-pituitary-adrenal (HPA) axis function. Our aim was to assess HPA axis function in IBD, before the end of CT, during the tapering phase. METHODS: HPA axis function was assessed with cortisol (ng/ml) measurement before (T0) (normal > 100) and 60 min (normal > 210) after 0.25 mg tetracosactide (Synacthen immédiat) injection (T60) in 55 consecutive cases of IBD attacks. Abnormal response was defined as a T60 <210. The attacks were separated into two groups according to the result of the Synacthen test (ST). RESULTS: In all, 36 of 55 ST were abnormal. The time for recovery normal HPA axis function was 7.2+/-1.3 months. Duration of disease since onset, past history of surgical or immunosuppressive treatment, severity and extension of the attack, need for surgical or immunosuppressive treatment, total cumulative and mean daily corticosteroid dose, total duration of CT, and steroid dose at the time of ST were not significantly different in the two groups. In multivariate analysis a past history of CT was predictive of abnormal ST (OR = 8.4, 95% CI = 2.2-31.5, p = 0.0009). Among patients with a past history of CT, the time (months) elapsed between the last course of CT was significantly longer in those with normal ST than in those with abnormal ST (45.5+/-13.5 vs 15.4+/-6.0; p = 0.02), and in multivariate analysis a duration free of CT < 15 months was predictive of abnormal ST (OR = 15.00, CI = 1.23-183.00, p = 0.03). CONCLUSIONS: In all, 65% of the ST were abnormal. These results suggest that ST should be performed before corticosteroid withdrawal, especially in patients with recent past history of CT.

Long-term outcome of patients with gastrointestinal bleeding of obscure origin explored by push enteroscopy.

BACKGROUND AND STUDY AIMS: Little is known of the long-term outcome in patients with gastrointestinal bleeding of obscure origin, who undergo investigation by means of push enteroscopy. The aim of this study was to assess the rate of recurrent bleeding and its predictive factors in patients with gastrointestinal bleeding of obscure origin, after exploration by push enteroscopy. PATIENTS AND METHODS: 105 patients with gastrointestinal bleeding of obscure origin (iron-deficiency anemia: n = 56; overt bleeding: n = 49) underwent exploration by push enteroscopy from December 1994 to December 1998. They were classified into three groups according to enteroscopy findings: no lesion found (group A; 56 patients), arteriovenous malformations (group B; 18 patients), and other gastrointestinal lesions (group C; 31 patients). Actuarial rates of rebleeding during follow-up were calculated and factors associated with rebleeding were assessed by means of univariate and multivariate analysis. RESULTS: Follow-up data were obtained for 101 patients (96 %). The mean follow-up was 29 months (6 - 54 months). The 2-year actuarial rate of rebleeding was 31 % in the overall population, and 27.6 %, 56 % and 24 % in groups A, B, and C, respectively (P = 0.13). The number of previous bleeding episodes and the number of packed red cell units transfused were two independent factors predictive of recurrent bleeding. The modality of recurrent bleeding (anemia or overt bleeding) was similar to that of the initial episode in 94 % of cases. In group A, a gastrointestinal lesion was found after rebleeding in one of the 12 patients with iron-deficiency anemia, and in four of the five patients with overt bleeding. CONCLUSION: Recurrent bleeding occurs in about one-third of patients who undergo investigation by push enteroscopy for gastrointestinal bleeding of obscure origin, with a trend towards more frequent rebleeding in patients with arteriovenous malformations. Frequent previous bleeding episodes and transfusion requirements are predictive of recurrent bleeding.

[Dysphagia in a trisomic adult operated on for esophageal atresia: achalasia or pseudo-achalasia?]. / Dysphagie chez un trisomique adulte opéré d'une atrésie de l'oesophage: achalasie ou pseudo-achalasie?

Esophageal involvement is frequent in Down syndrome. We report a case of dysphagia in a 21-year-old patient with Down syndrome and repaired esophageal atresia. Radiology, endoscopy, and manometry showed typical features of achalasia. The patient was treated first by botulinum toxin injection and afterwards by Heller myotomy with good result. The role of motor disorders associated with esophageal atresia or with primary achalasia in this patient is discussed.

Results of pneumatic dilatation in patients with dysphagia after antireflux surgery.

BACKGROUND: The mechanisms and treatment of persistent dysphagia after antireflux surgery are not well established. The results of pneumatic dilatation were evaluated in a retrospective study. METHODS: Sixteen patients were reviewed. All had severe and persistent postoperative dysphagia evaluated by oesophageal manometry before pneumatic dilatation. RESULTS: Seven patients had one dilatation and nine had two dilatations. There was no complication and no relapse of reflux symptoms. Results were satisfactory in nine patients (mean(s.e.m.) follow-up 19.2(6.9) months) and poor in seven, who required revisional surgery. Age, time since operation and weight loss were not related to the outcome. Thirteen patients had abnormal manometry with an 'achalasia-like' motor pattern in four. Lower oesophageal sphincter (LOS) pressure, LOS relaxation and oesophageal contraction amplitude were similar in the two groups. The only difference was in the percentage of normal peristaltic contractions (mean(s.e.m.) 82.2(11) versus 39.1(13.8) per cent for satisfactory and poor results respectively; P < 0.05). CONCLUSION: In this retrospective study pneumatic dilatation was effective and safe in nine of 16 patients with dysphagia following antireflux surgery. Peristalsis was normal in eight patients, in seven of whom it was associated with satisfactory results.

Technetium Tc 99m hexamethyl propylene amine oxine leukocyte scintigraphy in patients with ulcerative colitis: correlation with clinical, biologic, endoscopic, and pathologic intensity, and local release of interleukin 8.

BACKGROUND: Technetium Tc 99m hexamethyl propylene amine oxine (99mTc-HMPAO) has been used to radiolabel leukocytes with promising results for its clinical use in inflammatory bowel disease. During active ulcerative colitis, colonoscopy is indicated to determine the extent and the intensity of the disease for proper management. The aim of this prospective study was to determine whether 99mTc-HMPAO-labeled leukocyte scintigraphy can give information similar to that obtained with colonoscopy during acute attacks of ulcerative colitis. METHODS: Thirty-three consecutive patients with 50 acute episodes of ulcerative colitis underwent 99mTc-HMPAO scintigraphy and colonoscopy with biopsies. Scintigraphic determination of disease extent and intensity were compared with those obtained by colonoscopy with biopsies and clinicobiologic markers. RESULTS: The scintigraphic index of disease intensity was correlated with endoscopic index, Truelove index, biologic markers, and local release of interleukin-8. The extent measured by scintigraphy was well correlated to the endoscopic and histologic extent. CONCLUSIONS: 99mTc-HMPAO scintigraphy accurately determines the extent and the intensity of acute ulcerative colitis lesions. This noninvasive method can specify the extent and the intensity of an acute attack in patients with previously known ulcerative colitis.

[Comparison of push-type endoscopy and barium transit study of the small intestine in digestive bleeding and unexplained iron-deficiency anemia]. / Comparaison de l'entéroscopie poussée et du transit baryté de l'intestin grêle dans les saignements digestifs et les anémies ferriprives inexpliqués.

OBJECTIVES: A radiological examination of the small bowel is often performed in case of gastrointestinal bleeding of obscure origin. More recently, push-type enteroscopy has been reported as a valuable tool in this indication. The purpose of this study was to compare the diagnosis efficiency of these two procedures. METHODS: From February 1994 to February 1996, 40 patients (mean age: 52 years) with obscure gastrointestinal bleeding (iron-deficiency anemia without obvious cause of blood loss or malabsorption: n = 17; macroscopic gastrointestinal bleeding: n = 23) were examined by small bowel follow-through and push-type enteroscopy (jejunoscopy n = 19; double way examination n = 21). Each patient had negative upper and lower gastrointestinal tract endoscopies prior to small bowel examinations. RESULTS: Small bowel follow-through revealed only one lesion potentially responsible for blood loss (2.5%), corresponding to a jejunal leiomyoma. Push-type enteroscopy detected small bowel lesions potentially responsible for blood loss in 6 patients (15%). The lesions were located in the jejunum in 5 cases (arteriovenous malformations: n = 3; metastasis: n = 1; leiomyoma: n = 1), in the ileum in 1 case (leiomyoma). The efficiency of push-type enteroscopy for the detection of a small bowel lesion was of 22% in case of macroscopic bleeding and of 6% in case of iron-deficiency anemia. Push-type enteroscopy also revealed lesions previously undetected by gastroscopy or colonoscopy in 8 patients (20%). CONCLUSION: Push-type enteroscopy was more effective than small bowel follow-through to detect the origin of obscure gastrointestinal bleeding. Push-type enteroscopy revealed a cause of bleeding in 35% of patients, located in the small bowel in only 15% of the patients.

Diagnostic yield of push-type enteroscopy in relation to indication.

BACKGROUND: Push-type enteroscopy, a recent method for investigating the small intestine, is currently undergoing assessment. Its diagnostic yield varies in the studies reported to date. AIM: To assess the diagnostic value of push-type enteroscopy according to indication. PATIENTS AND METHODS: From January 1994 to September 1995, 152 consecutive patients (mean age 34 years) underwent push-type enteroscopy (jejunoscopy, n = 93; retrograde ileoscopy, n = 17; and double way enteroscopy, n = 42). The indications were: unexplained iron deficiency anaemia or macroscopic gastrointestinal bleeding (n = 76), radiological abnormalities of the small intestine (n = 23), chronic diarrhoea and/or malabsorption syndrome (n = 18), abdominal pain (n = 12), and miscellaneous (n = 23). All patients had undergone previous negative aetiological investigations. RESULTS: The jejunum and ileum were explored through 120 cm (30-160 cm) and 60 cm (20-120 cm). Digestive bleeding: lesions of the small bowel were found in 6% of the patients with isolated iron deficiency anaemia and 20% of patients with patent digestive haemorrhage. Radiological abnormalities of the small intestine: push-type enteroscopy provided a diagnosis or modified the interpretation of radiological findings in 18/23 cases (78%). Chronic diarrhoea and/or malabsorption: push-type enteroscopy yielded explanatory findings in four cases (22%). Abdominal pain: push-type enteroscopy provided no diagnosis. CONCLUSION: In this series, push-type enteroscopy was of particular value in investigating patients with radiological abnormalities of the small intestine. It was of some value in the exploration of patent digestive haemorrhage or chronic diarrhoea, but not of abdominal pain. Its value was limited in the exploration of iron deficiency anaemia.