Non-small-bowel lesions encountered during double-balloon enteroscopy performed for obscure gastrointestinal bleeding

AIM:To report the incidence of non-small-bowel bleeding pathologies encountered during double-balloon enteroscopy (DBE) procedures and to analyse their significance.METHODS: A retrospective study of a prospective DBE database conducted in a tertiary-referral center was conducted. A total of 179 patients with obscure gastrointestinal bleeding (OGIB) referred for DBE from June 2004 to November 2008 were analysed looking for the incidence of non-small-bowel lesions (NSBLs; all and newly diagnosed) encountered during DBE.RESULTS: There were 228 (150 antegrade and 78 retrograde) DBE procedures performed in 179 patients. The mean number of DBE procedures was 1.27 per patient. The mean age (SD) of the patients was 62 ± 16 years old. There were 94 females (52.5%). The positive yield for a bleeding lesion was 65.9%. Of the 179 patients, 44 (24.6%) had NSBLs (19 of them had dual pathology with small-bowel lesions and NSBLs); 27 (15.1%) had lesions not detected by previous endoscopies. The most common type of missed lesions were vascular lesions.CONCLUSION: A significant proportion of patients (24.6%) had lesions within reach of conventional endoscopy. Careful repeat examination with gastroscopy and colonoscopy might be required.

Negative capsule endoscopy in patients with obscure gastrointestinal bleeding reliable: Recurrence of bleeding on long-term follow-up

AIM: To assess the rate of recurrent bleeding of the small bowel in patients with obscure bleeding already undergone capsule endoscopy (CE) with negative results. METHODS: We reviewed the medical records related to 696 consecutive CE performed from December 2002 to January 2011, focusing our attention on patients with recurrence of obscure bleeding and negative CE. Evaluating the patient follow-up, we analyzed the recurrence rate of obscure bleeding in patient with a negative CE. Actuarial rates of rebleeding during follow-up were calculated, and factors associated with rebleeding were assessed through an univariate and multivariate analysis. A P value of less than 0.05 was regarded as statistically significant. The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of negative CE were calculated. RESULTS: Two hundred and seven out of 696 (29.7%) CE studies resulted negative in patient with obscure/overt gastrointestinal bleeding. Overall, 489 CE (70.2%) were positive studies. The median follow-up was 24 mo (range 12-36 mo). During follow-up, recurrence of obscure bleeding was observed only in 34 out of 207 negative CE patients (16.4%); 26 out of 34 with obscure overt bleeding and 8 out of 34 with obscure occult bleeding. The younger age (< 65 years) and the onset of bleeding such as melena are independent risk factors of rebleeding after a negative CE (OR = 2.6703, 95%CI: 1.1651-6.1202, P = 0.0203; OR 4.7718, 95%CI: 1.9739-11.5350, P = 0.0005). The rebleeding rate (CE+ vs CE-) was 16.4% vs 45.1% (χ 2 test, P = 0.00001). The sensitivity, specificity, and PPV and NPV were 93.8%, 100%, 100%, 80.1%, respectively. CONCLUSION: Patients with obscure gastrointestinal bleeding and negative CE had a significantly lower rebleeding rate, and further invasive investigations can be deferred.

Double-balloon enteroscopy for obscure gastrointestinal bleeding: A single center experience in China

AIM: To evaluate the diagnostic value of double-balloon enteroscopy (DBE) for obscure gastrointestinal bleeding (OGIB). METHODS: The data about 75 OGIB patients who underwent DBE in January 2007-June 2009 in our hospital were retrospectively analyzed. RESULTS: DBE was successfully performed in all 75 patients without complication. Of the 75 patients, 44 (58.7%) had positive DBE findings, 22 had negative DBE findings but had potential bleeding at surgery and capsule endoscopy, etc . These 66 patients were finally diagnosed as OGIB which was most commonly caused by small bowel tumor (28.0%), angiodysplasia (18.7%) and Crohn’s disease (10.7%). Lesions occurred more frequently in proximal small bowel than in distal small bowel (49.3% vs 33.3%, P = 0.047). CONCLUSION: DBE is a safe, effective and accurate procedure for the diagnosis of OGIB.

Yield,etiologies and outcomes of capsule endoscopy in Thai patients with obscure gastrointestinal bleeding

AIM:To investigate the yield,etiologies and impact of capsule endoscopy(CE) in Thai patients with obscure gastrointestinal bleeding(OGIB).METHODS:The present study is a retrospective cohort study.All patients with OGIB who underwent CE in Siriraj Hospital,Bangkok,Thailand during 2005-2009 were included in the study.All the patients' medical records and results of the CE videos were reviewed.CE findings were classified as significant,suspicious/equivocal and negative.Sites of the lesions were located to duodenum,jejunum,jejunoileum,ileum and diffuse lesions by the localization device of the CE.Impact of CE on the patients' management was defined by any investigation or treatment given to the patients that was more than an iron supplement or blood transfusion.Patients' outcomes(rebleeding,persistent bleeding,anemia or requirement of blood transfusion) were collected from chart reviews and direct phone interviews with the patients.RESULTS:Overall,there were 103 patients with OGIB included in the study.Mean age of the patients was 64 ± 16 years(range 9-88 years) and 57 patients(55%) were male.Types of OGIB were overt in 80(78%) and occult in 23 patients(22%).The median time interval of CE after onset of OGIB was 10 d(range 1-180 d).The median time of follow-up was 19 mo(range 1-54 mo).Capsules reached caecum in 77 patients(74%) and capsule retention was found in 1 patient(1%).The diagnostic yield of CE revealed significant lesions in 37 patients(36%),suspicious/equivocal lesions in 15 patients(15%) and 51 patients(49%) had negative CE result.Among the significant lesions,the bleeding etiologies were small bowel ulcers in 44%,angiodysplasia in 27%,small bowel tumor in 13%,miscellaneous in 8% and active bleeding without identifiable causes in 8%.Patients with small bowel ulcers were significantly associated with the use of non-steroidal anti-inflammatory drugs(48%,P = 0.034),while patients with small bowel tumors were more commonly female(86%,P = 0.043) compared to the other etiologies.The rate of rebleeding,persistent bleeding or anemia in patients with positive,equivocal and negative CE results were 5%,0% and 18%,respectively(P = 0.078).All the 9 patients with rebleeding after negative CE were subsequently found to be from hematologic disorders(4),colonic diverticulosis(2),colonic Dieulafoy's(1),hemorrhoid(1) and hemosuccus pancreaticus(1).Results of CE had a positive impact on the patients' management in 35% of the patients whose results were positive,but none on the patients whose results were equivocal or negative CE(P < 0.001).CONCLUSION:In Thai OGIB patients,CE had low yield and small bowel ulcer was most common.Positive CE impacted managements and outcomes.Negative CE caused low rebleeding.

Small bowel parasitosis as cause of obscure gastrointestinal bleeding diagnosed by capsule endoscopy

Hookworm infection is a relatively common cause of anemia in endemic areas.However,it is rarely encountered in Europe.In this report we describe the case of a 24-year old patient originating from an endemic area who was admitted due to severe anemia,with an Hct of 15.6%and eosinophilia(Eosinophils:22.4%).While both esophagogastroduodenoscopy and colonoscopy were non-diagnostic,capsule endoscopy revealed a large number of hookworms infesting his small bowel and withdrawing blood.The patient was successfully treated with Albendazole.Capsule endoscopy was proven an important tool in diagnosing intestinal parasitosis.

Single-center experience of 309 consecutive patients with obscure gastrointestinal bleeding

AIM: To investigate the diagnostic yield of capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding (OGIB), and to determine whether the yield was affected by different bleeding status. METHODS: Three hundred and nine consecutive patients (all with recent negative gastric and colonic endoscopy results) were investigated with CE; 49 cases with massive bleeding and 260 cases with chronic recurrent overt bleeding. Data regarding OGIB were obtained by retrospective chart review and review of an internal database of CE fi ndings.RESULTS: Visualization of the entire small intestine was achieved in 81.88% (253/309) of cases. Clinically positive findings occurred in 53.72% (166/309) of cases. The positivity of the massive bleeding group was slightly higher than that of the chronic recurrent overt bleeding group but there was no significant difference (59.18% vs 52.69%, P > 0.05) between the two groups. Small intestinal tumors were the most common fi nding in the entire cohort, these accounted for 30% of clinically signifi cant lesions. In the chronic recurrent overt bleeding group angioectasia incidence reached more than 29%, while in the massive bleedinggroup, small intestinal tumors were the most common finding at an incidence of over 51%. Increasing patient age was associated with positive diagnostic yield of CE and the findings of OGIB were different according to age range. Four cases were compromised due to the capsule remaining in the stomach during the entire test, and another patient underwent emergency surgery for massive bleeding. Therefore, the complication rate was 1.3%. CONCLUSION: In this study CE was proven to be a safe, comfortable, and effective procedure, with a high rate of accuracy for diagnosing OGIB.

Occult and obscure gastrointestinal bleeding:Causes and diagnostic approach in 2009

Gastrointestinal bleeding can be obscure or occult(OGIB),the causes and diagnostic approach will be discussed in this editorial.The evaluation of OGIB consists on a judicious search of the cause of bleeding,which should be guided by the clinical history and physical findings.The standard approach to patients with OGIB is to directly evaluate the gastrointestinal tract by endoscopy,abdominal computed tomography,angiography,radionuclide scanning,capsule endoscopy.The source of OGIB can be identified in 85%-90%,no bleeding sites will be found in about 5%-10% of cases.Even if the bleedings originating from the small bowel are not frequent in clinical practice(7.6% of all digestive haemorrhages,in our casuistry),they are notoriously difficult to diagnose.In spite of progress,however,a number of OGIB still remain problematic to deal with at present in the clinical context due to both the difficulty in exactly identifying the site and nature of the underlying source and the difficulty in applying affective and durable diagnostic approaches so no single technique has emerged as the most efficient way to evaluate OGIB.

Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding

AIMTo define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.METHODSSmall-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.RESULTSWe retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 &#x000b1; 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P &#x0003c; 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P &#x0003c; 0.001). Age and small-bowel transit time were correlated (P &#x0003c; 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).CONCLUSIONIn this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.

Outcome in obscure gastrointestinal bleeding after capsule endoscopy

AIM: To investigate the clinical impact of capsule endoscopy(CE) after an obscure gastrointestinal bleeding(OGIB) episode, focusing on diagnostic work-up, followup and predictive factors of rebleeding. METHODS: Patients who were referred to Hospital del Mar(Barcelona, Spain) between 2007 and 2009 for OGIB who underwent a CE were retrospectively analyzed. Demographic data, current treatment with non-steroid antiinflammtory drugs or anticoagulant drugs, hemoglobin levels, transfusion requirements, previous diagnostic tests for the bleeding episode, as well as CE findings(significant or non-significant), work-up and patient out-comes were analyzed from electronic charts. Variables were compared by χ 2 analysis and Student t test. Risk factors of rebleeding were assessed by Log-rank test, Kaplan-Meier curves and Cox regression model. RESULTS: There were 105 patients [45.7% women, median age of 72 years old(interquartile range 56-79)] and a median follow-up of 326 d(interquartile range 123-641) included in this study. The overall diagnostic yield of CE was 58.1%(55.2% and 63.2%, for patients with occult OGIB and overt OGIB, respectively). In 73 patients(69.5%), OGIB was resolved. Multivariate analysis showed that hemoglobin levels lower than 8 g/dL at diagnosis [hazard ratios(HR) = 2.7, 95%CI: 1.9-6.3], patients aged 70 years and above(HR = 2.1, 95%CI: 1.2-6.1) and significant findings in CE(HR = 2.4, 95%CI: 1.1-5.8) were independent predictors of rebleeding. CONCLUSION: One third of the patients presented with rebleeding after CE; risk factors were hemoglobin levels < 8 g/dL, age ≥ 70 years or the presence of significant lesions.

Evaluation and outcomes of patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding(OGIB) is defined as recurrent or persistent bleeding or presence of iron deficiency anaemia after evaluation with a negative bidirectional endoscopy. OGIB accounts for 5% of gastrointestinal bleeding and presents a diagnostic challenge. Current modalities available for the investigation of OGIB include capsule endoscopy, balloon assisted enteroscopy, spiral enteroscopy and computed tomography enterography. These modalities overcome the limitations of previous techniques. Following a negative bidirectional endoscopy, capsule endoscopy and double balloon enteroscopy remain the cornerstone of investigation in OGIB given their high diagnostic yield. Longterm outcome data in patients with OGIB is limited, but is most promising for capsule endoscopy. This article reviews the current literature and provides an overview of the clinical evaluation of patients with OGIB, available diagnostic and therapeutic modalities and longterm clinical outcomes.

Small-bowel mucosal injuries in low-dose aspirin users with obscure gastrointestinal bleeding

AIM: To investigate the clinical differences between small intestinal injuries in low-dose aspirin (LDA) users and in non-steroidal anti-inflammatory drug (NSAID) users who were examined by capsule endoscopy (CE) for obscure gastrointestinal bleeding (OGIB).

Efficacy of computed image modification of capsule endoscopy in patients with obscure gastrointestinal bleeding

AIM:To investigate whether flexible spectral color enhancement(FICE) improves diagnostic yields of capsule endoscopy(CE) for obscure gastro-intestinal bleeding(OGIB).METHODS:The study subjects consisted of 81 patients.Using FICE,there were three different sets with different wavelengths.Using randomly selected sets of FICE,images of CE were evaluated again by two individuals who were not shown the conventional CE reports and findings.The difference between FICE and conventional imaging was examined.RESULTS:The overall diagnostic yields in FICE sets 1,2,3 and conventional imaging(48.1%) were 51.9%,40.7%,51.9% and 48.1%,respectively,which showed no statistical difference compared to conventional imaging.The total numbers of detected lesions per examination in FICE imaging and conventional imaging were 2.5 ± 2.1 and 1.8 ± 1.7,respectively,which showed a significant difference(P = 0.01).CONCLUSION:The diagnostic yield for OGIB is not improved by FICE.However,FICE can detect significantly more small bowel lesions compared to conventional imaging.

Evaluation of Fujinon intelligent chromo endoscopy-assisted capsule endoscopy in patients with obscure gastroenterology bleeding

AIM:To investigate the potential benef it of Fujinon in-telligent chromo endoscopy(FICE)-assisted small bowel capsule endoscopy(SBCE)for detection and character-ization of small bowel lesions in patients with obscure gastroenterology bleeding(OGIB).METHODS:The SBCE examinations(Pillcam SB2,Giv-en Imaging Ltd)were retrospectively analyzed by two GI fellows(observers)with and without FICE enhance-ment.Randomization was such that a fellow did not assess the same examination with and without FICE enhancement.The senior consultant described f indings as P0,P1 and P2 lesions(non-pathological,intermedi-ate bleed potential,high bleed potential),which were considered as reference f indings.Main outcome mea-surements:Inter-observer correlation was calculated using kappa statistics.Sensitivity and specif icity for P2 lesions was calculated for FICE and white light SBCE.RESULTS:In 60 patients,the intra-class kappa cor-relations between the observers and reference f indings were 0.88 and 0.92(P2),0.61 and 0.79(P1),for SBCE using FICE and white light,respectively.Overall 157 le-sions were diagnosed using FICE as compared to 114 with white light SBCE(P = 0.15).For P2 lesions,the sensitivity was 94% vs 97% and specif icity was 95% vs 96% for FICE and white light,respectively.Five(P2 le-sions)out of 55 arterio-venous malformations could be better characterized by FICE as compared to white light SBCE.Significantly more P0 lesions were diagnosed when FICE was used as compared to white light(39 vs 8,P < 0.001).CONCLUSION:FICE was not better than white light for diagnosing and characterizing signif icant lesions on SBCE for OGIB.FICE detected signif icantly more non-pathological lesions.Nevertheless,some vascular le-sions could be more accurately characterized with FICE as compared to white light SBCE.

Diagnosis of obscure gastrointestinal bleeding by intraoperative enteroscopy in 81 consecutive patients

AIM： To analyze the results and complications of intraoperative enteroscopy （IOE） by investigating a series of selected patients with bleeding suspected to originate from the small intestine. METHODS： Eighty-one patients （mean age： 65 years） including 40 males （49.4%） and 41 females （50.6%） with obscure gastrointestinal bleeding underwent IOE between 1990 and 2004. The patients were identified from a database and data were selected from the patients＇ charts retrospectively. All the patients had undergone at least one non-diagnostic esophagogastroduodenoscopy, colonoscopy, standard enteroscopy and a negative abdominal ultrasound scan before IOE. RESULTS： The median minimal hemoglobin level in the patients was 59＋15g/L and 72.8% of the patients required transfusion of packed erythrOoltes previously. A bleeding source was detected in 68 （84%） of the patients during IOE. Angiodysplasiae were found in 44 patients （54.3%） and 9 patients （11.1%） were affected by ulcers in the small intestine. A tumor in the small intestine was detected in another 6 patients. The treatment consisted of argon-plasma-coagulation, surgical suture or limited resection in most of the patients. CONCLUSION： Intra-operative enteroscopy is still used for the diagnosis of suspected small bowel bleeding. Recent developments such as wireless capsule endoscopy and double balloon enteroscopy, may lead to the replacement of IOE in the future.

Outcome of patients who have undergone total enteroscopy for obscure gastrointestinal bleeding

AIM： To assess the diagnostic success and outcome among patients with obscure gastrointestinal bleeding who underwent total enteroscopy with double-balloon endoscopy.

Small bowel Dieulafoy lesions: An uncommon cause of obscure bleeding in cirrhosis

Dieulafoy lesions(DLs) are an uncommon cause of gastrointestinal bleeding, accounting for up to 2% of cases overall. They are largely under recognised and difficult to treat. Up to 95% occur in the stomach, and only case reports document their occurrence in the small bowel(SB). Little is known about their pathophysiology, although there have been associations made previously with chronic liver disease, thought to be due to the erosive effects of alcohol on the mucosa overlying the abnormally dilated vessels. We present a case series of 4 patients with a long duration of obscure gastrointestinal bleeding, who were diagnosed with small intestinal DLs and incidentally diagnosed with chronic liver disease. The histories describe the challenges in both diagnosis and treatment of small intestinal DLs. Our case series suggest a previously unreported link between chronic liver disease and SB DLs which may be due to anatomical vasculature changes or a shift in angiogenic factors as a consequence of portal hypertension or liver cirrhosis.

Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding

The diagnosis and management of obscure gastrointestinal bleeding(OGIB) have changed dramatically since the introduction of video capsule endoscopy(VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.

Case of obscure-overt gastrointestinal bleeding after pediatric liver transplantation explained by endoscopic ultrasound

Portal hypertension,which is a common finding in children awaiting liver transplantation,is also found after transplantation.It's reported the case of a 6-year-old girl,transplanted for biliary atresia,who had a severe obscure-overt bleeding presenting with melena.An esophagogastroduodenoscopy showed several duodenal small,bulging lesions,with some red signs.Near the lesions,a depressed area of 2cm,covered with mixed hyperemic and white mucosa,was observed.To better evaluate these lesions,we performed an endoscopic ultrasonography(EUS) that showed multiple,round hypoechoic areas 0.5-5mm in diameter,compatible with duodenal varices,and several periduodenal anechoic lesions compatible with collaterals.A consecutive computed tomography scan showed a stenosis of the portal vein anastomosis confirmed with a transhepatic portography,which was successfully treated with balloon angioplasty.No further episodes of bleeding were observed during the follow-up.This case report suggests that EUS is safe and feasible in young children when using echoendoscopes designed for use in adults.However further studies are needed to validate the employment of this technique in the management and follow-up of pediatric portal hypertension.

Assessment of multi-modality evaluations of obscure gastrointestinal bleeding

AIMTo determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.METHODSRetrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1st, 2002 to June 30th, 2013 at a single tertiary center.RESULTSFour hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging vs 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, P = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, P < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.CONCLUSIONDBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.

Role of balloon enteroscopy for obscure gastrointestinal bleeding in those with surgically altered anatomy: A systematic review

BACKGROUND Obscure gastrointestinal(GI)bleeding is defined as persistent bleeding despite negative evaluation with both esophagogastroduodenoscopy and colonoscopy and can be secondary to small intestinal pathology.Standard endoscopy as well as push endoscopy can be a challenge in those with altered anatomy given inaccessible areas as well as perforation risk.Single and double balloon enteroscopy can be warranted in this patient population in instances of obscure GI bleed.AIM To assess the safety and diagnostic efficacy of balloon enteroscopy for obscure GI bleeding in patients with surgically altered anatomy.METHODS A search was conducted through PubMed,MEDLINE,Google Scholar,Scopus,and Embase with the key words“enteroscopy,”“obscure bleeding,”and“altered anatomy,”to identify relevant articles in English with no restricted time frame.A search within the Reference Citation Analysis database was conducted to ensure inclusion of the latest high impact articles.Study types included in the review were prospective and retrospective reviews,case series,and case reports.The reference lists of these papers were also reviewed to find further papers that were applicable.The authors extracted the data from the studies that fit inclusion criteria.Data of interest included type of study,type of procedure,and type of altered anatomy,as well as the number of patients with any diagnostic or therapeutic intervention.Data was also recorded on procedure tolerance and complications.The data was analyzed with descriptive statistics.RESULTS Our literature search yielded 14 studies that were included.There were 68 procedures performed with 61 unique patients subjected to these procedures.Forty-four(65%)of the procedures were double balloon,21(31%)were single balloon,and 3(4%)were classified as through the scope balloon assisted.The most common altered anatomy types included Gastric Bypass Roux-en-Y,Pylorus Sparing Whipple,Orthotopic Liver Transplantation with Roux-en-Y,and Gastrojejunostomy Roux-en-Y.The procedures were successfully performed in each patient.There were 5(7%)procedures that were complicated by perforation.Amongst the available data,the diagnostic yield was 48/59(81%)and a therapeutic yield of 39/59(66%).One patient was recommended surgical revision of their altered anatomy following enteroscopy.CONCLUSION Balloon enteroscopy is a useful diagnostic modality in investigating obscure GI bleeding within those with surgically altered anatomy;however,precautions must be taken as this population may have increased perforation risk.