Emerging From Obscurity

Central China may accelerate development due to favorable policies An old Chinese proverb says, "Those who control central China control China." The region that is comprised ’of Shanxi, Henan, Anhui, Jiangxi,

Three cases of jejunal tumors detected by standard upper gastrointestinal endoscopy:A case series

BACKGROUND In patients with obscure gastrointestinal bleeding,re-examination with standard upper endoscopes by experienced physicians will identify culprit lesions in a substantial proportion of patients.A common practice is to insert an adult-sized forward-viewing endoscope into the second part of the duodenum.When the endoscope tip enters after the papilla,which is a marker for the descending part of the duodenum,it is difficult to endoscopically judge how far the duodenum has been traversed beyond the second part.CASE SUMMARY We experienced three cases of proximal jejunal masses that were diagnosed by standard upper gastrointestinal endoscopy and confirmed with surgery.The patients visited the hospital with a history of melena;during the initial upper gastrointestinal endoscopy and colonoscopy,the bleeding site was not confirmed.Upper gastrointestinal bleeding was suspected;thus,according to guidelines,upper endoscopy was performed again.A hemorrhagic mass was discovered in the small intestine.The lesion of the first patient was thought to be located in the duodenum when considering the general insertion depth of a typical upper gastrointestinal endoscope;however,during surgery,it was confirmed that it was in the jejunum.After the first case,lesions in the second and third patients were detected at the jejunum by inserting the standard upper endoscope as deep as possible.CONCLUSION The deep insertion of standard endoscopes is useful for the diagnosis of obscure gastrointestinal bleeding.

Prediction models for recurrence in patients with small bowel bleeding

Obscure gastrointestinal bleeding(OGIB)has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy.OGIB can present as overt bleeding or occult bleeding,and small bowel lesions are the most common causes.The small bowel can be evaluated using capsule endoscopy,device-assisted enteroscopy,computed tomography enterography,or magnetic resonance enterography.Once the cause of smallbowel bleeding is identified and targeted therapeutic intervention is completed,the patient can be managed with routine visits.However,diagnostic tests may produce negative results,and some patients with small bowel bleeding,regardless of diagnostic findings,may experience rebleeding.Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans.Several studies have identified different factors associated with rebleeding,and a limited number of studies have attempted to create prediction models for recurrence.This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding.These models may aid clinicians in forming tailored patient management and surveillance.

An Unusual Cause of Obscure Gastrointestinal Bleeding Using an Abdominal CT Scan with Contrast: A Case Report of Small Intestinal GIST at the Duodenojejunal Junction

Background/Aim: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. However, they only constitute approximately 1% of all primary GI tumors. GISTs are most commonly found in the stomach (60% - 70%) and small intestine (20% - 30%). Colorectal (5%) and esophageal (Presentation of Clinical Case: A 33-year-old male, presented to the emergency department for melena and dizziness in January 2023. He was hospitalized several times for anemia with multiple blood transfusions since 2017 and never made a final diagnosis. From 2017 to 2019 he underwent esophagogastroduodenoscopy (EGD) and ileocolonoscopy 3 times which always gave a negative result. At this time, laboratory results showed microcytic anemia with hemoglobin 7 g/dl. We performed an EGD and ileocolonoscopy again but still showed negative then we did an abdominal CT scan with contrast with demonstrated a solid exophytic hypervascular mass measuring 62 × 38 × 73 mm that appeared to arise from the duodenojejunal junction. The surgeon decided to proceed with surgical resection of the mass and the histopathologist confirmed the diagnosis of GISTs. The patients were discharged in stable condition after the surgery and followed up every 3 - 6 months with the oncologist. Conclusion: The presentation of chronic GI bleeding with negative results in EGD and ileocolonoscopy, and abdominal CT scan with contrast could provide useful information in order to obtain a diagnosis of bleeding GISTS. Teamwork is the cornerstone in the management of the case. After the resection of the mass by the surgeon, the histopathologist allowed us to establish the definitive diagnosis and the oncologist will follow up with this patient in order to prevent the relapse of symptoms.

不明原因消化道出血诊断进展

不明原因消化道出血（ obscure gastrotintestinal bleeding，OGIB）发病率约占消化道出血的5％，由于诊断的困难，曾使临床医生面临巨大挑战。近年来，由于内镜诊疗水平和放射学技术的飞速发展，OGIB诊疗水平有了很大提高。本文对 OGIB 的诊治进展做一综述。

Sue Bridehead:The Girl of the Period in Thomas Hardy's Jude the Obscure

Jude the Obscure was Thomas Hardy’s last novel creation,and he spent eight year from preparation to publication.Although this novel received a lot of criticisms instead of praises when it came out,it also can be considered as Thomas Hardy’s classical works.The theme of this novel is so brave to explore the existing women’s living circumstances in that time.With the industrial revolution in England,new thoughts and ideas sprang out.Women were no longer belonging to husband and family,and they began to be aware of their social roles and reconsider their identity in society and marriage.The aim of the paper is to analyze this novel from the feministic perspective and re-read the character of Sue Bridehead in the light of the theory"the girl of the period".

主要营养素源组合对暗纹东方鲀生长、消化吸收和水环境的效应

为探讨主要营养素源组合对暗纹东方鲀（Takifugu obscures）（172.87g±6.71g）生长、消化吸收和水环境的影响和效应,作者采用3×2×2三因素设计,蛋白质水平—43%、40%、37%,分别以P43、P40、P37表示,脂肪水平——10%、7%,分别以L10、L7表示;蛋白源鱼粉水平——高鱼粉（49%～55%）、低鱼粉（39%～45%）,分别以FH、FL表示,形成12种试验处理组（1#-12#）饲粮。试验期77 d。结果表明：1#（P43L10FH）、9#（P40L10FL）增质量率和饲料系数最优,显著或明显优于较好的3#（P40L10FH）、11#（P37L10FL）和7#（P43L10FL）,9#饲料系数较3#显著降低28.3%;低鱼粉组（9#、11#、7#）显著提高胰蛋白酶和肠脂肪酶活性,9#其活性较1#分别显著提高21.09%、14.39%;高脂肪极显著提高吸收酶活力（P〈0.01）,且具有增强多数消化酶活力的趋势;高鱼粉组和低鱼粉高蛋白组的氨氮、亚硝酸氮、磷酸盐相对浓度变化呈现普遍高于其他低鱼粉组的趋势或特征,以11#、9#、7#、1#相对较低,11#、9#氨氮浓度较3#分别显著降低73.97%、58.75%;9#、11#、1#亚硝酸氮、磷酸盐浓度不同程度极显著降低（P〈0.01）;高脂肪有降低磷酸盐和COD的趋势。总之,本研究值得关注的新发现是：低鱼粉组9#、11#、7#饲粮分别显著或明显提高生长、消化性能,并显著改善水生态环境,营养素源组合正效应突出,不仅节约鱼粉资源,且饲粮组成更经济,具有重要理论和应用价值。

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.

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.

Different roles of capsule endoscopy and double-balloon enteroscopy in obscure small intestinal diseases

AIM: To compare the roles of capsule endoscopy(CE)and double-balloon enteroscopy(DBE) in the diagnosis of obscure small bowel diseases.METHODS: From June 2009 to December 2014, 88 patients were included in this study; the patients had undergone gastroscopy, colonoscopy, radiological small intestinal barium meal, abdominal computed tomography or magnetic resonance imaging scan and mesenteric angiography, but their diagnoses were still unclear. The patients with gastrointestinal obstructions,fistulas, strictures, or cardiac pacemakers, as well as pregnant women, and individuals who could not accept the capsule-retention or capsule-removal surgery were excluded. Patients with heart, lung and other vital organ failure diseases were also excluded. Everyone involved in this study had undergone CE and DBE. The results were divided into:(1) the definite diagnosis(the diagnosis was confirmed at least by one of the biopsy,surgery, pathology or the drug treatment effects with follow-up for at least 3 mo);(2) the possible diagnosis(a possible diagnosis was suggested by CE or DBE,but not confirmed by the biopsy, surgery or follow-up drug treatment effects); and(3) the unclear diagnosis(no exact causes were provided by CE and DBE for the disease). The detection rate and the diagnostic yield of the two methods were compared. The differencein the etiologies between CE and DBE was estimated,and the different possible etiologies caused by the age groups were also investigated.RESULTS: CE exhibited a better trend than DBE for diagnosing scattered small ulcers(P = 0.242, Fisher's test), and small vascular malformations(χ 2 = 1.810,P = 0.179, Pearson χ 2 test), but with no significant differences, possible due to few cases. However,DBE was better than CE for larger tumors(P =0.018, Fisher's test) and for diverticular lesions with bleeding ulcers(P = 0.005, Fisher's test). All three hemangioma cases diagnosed by DBE in this study(including sponge hemangioma, venous hemangioma,and hemangioma with hamartoma lesions) were all confirmed by biopsy. Two parasite cases were found by CE, but were negative by DBE. This study revealed no obvious differences in the detection rates(DR) of CE(60.0%, 53/88) and DBE(59.1%, 52/88). However,the etiological diagnostic yield(DY) difference was apparent. The CE diagnostic yield was 42.0%(37/88),and the DBE diagnostic yield was 51.1%(45/88).Furthermore, there were differences among the age groups(χ 2 = 22.146, P = 0.008, Kruskal Wallis Test). Small intestinal cancer(5/6 cases), vascular malformations(22/29 cases), and active bleeding(3/4cases) appeared more commonly in the patients over50 years old, but diverticula with bleeding ulcers were usually found in the 15-25-year group(4/7cases). The over-25-year group accounted for the stromal tumors(10/12 cases).CONCLUSION: CE and DBE each have their own advantages and disadvantages. The appropriate choice depends on the patient's age, tolerance, and clinical manifestations. Sometimes CE followed by DBE is necessary.

Comparison of the diagnostic yield and outcomes between standard 8 h capsule endoscopy and the new 12 h capsule endoscopy for investigating small bowel pathology

AIM: To evaluate the completion rate and diagnostic yield of the Pill Cam SB2-ex in comparison to the Pill Cam SB2.METHODS:Two hundred cases using the 8-h Pill Cam SB2 were retrospectively compared to 200 cases using the 12 h Pill Cam SB2-ex at a tertiary academic center.Endoscopically placed capsules were excluded from the study.Demographic information,indications for capsule endoscopy,capsule type,study length,completion of exam,clinically significant findings,timestamp of most distant finding,and significant findings beyond 8 h were recorded.RESULTS:The 8 and 12 h capsule groups were well matched respectively for both age(70.90±14.19vs 71.93±13.80,P=0.46)and gender(45.5%vs48%male,P=0.69).The most common indications for the procedure in both groups were anemia and obscure gastrointestinal bleeding.Pill Cam SB2-ex had a significantly higher completion rate than Pill Cam SB2(88%vs 79.5%,P=0.03).Overall,the diagnostic yield was greater for the 8 h capsule(48.5%for SB2vs 35%for SB2-ex,P=0.01).In 4/70(5.7%)of abnormal SB2-ex exams the clinically significant findingwas noted in the small bowel beyond the 8 h mark.CONCLUSION:In our study,we found the Pill Cam SB2-ex to have a significantly increased completion rate,though without any improvement in diagnostic yield compared to the Pill Cam SB2.

Fields of applications,diagnostic yields and findings of OMOM capsule endoscopy in 2400 Chinese patients

AIM:To retrospectively analyze the fields of application,diagnostic yields and findings of OMOM capsule endoscopy in Chinese patients.METHODS:A database including 2400 Chinese patients who received OMOM capsule endoscopy in 27 endoscopy centers in China was retrieved from the Jianshan Science and Technology Ltd.OMOM capsule endoscopy database.The patient's age,gender,fields of application,the potentially relevant findings,pyloric transit time(PTT),small bowel transit time(SBTT),and complete small-bowel examination rate(CSER) were recorded and analyzed.RESULTS:Two thousand four hundred patients aged 9-91 years(mean,49 years),of whom 1510 were males(62.9%),underwent 2400 OMOM capsule endoscopy procedures.One thousand two hundred and thirty two(51.3%) were referred with obscure gastrointestinal bleeding(OGIB),642(26.8%) with abdominal pain,and 223(9.3%) with chronic diarrhea.The overall diagnostic yield was 47.7%(1144/2400).The diagnostic yield of OMOM capsule endoscopy in OGIB subgroup was much higher than in the non-OGIB subgroup(62.4% vs 32.1%,P<0.001).The most common findings of the small bowel in Chinese patients with OGIB were arteriovenous malformation(28.1%) and tumors(18.9%).There was no significant difference in the diagnostic yield between the male and female patients with OGIB.However,the diagnostic yield in patients aged more than 60 was higher than in patients aged less than 60(69.8% vs 58.9%,P<0.001).The median PTT was 41 min(range:1-544 min) and the mean SBTT was 247.2 ± 88.9 min.The overall CSER was 86.8%.CONCLUSION:The OMOM capsule endoscopy is a valuable tool for small bowel evaluation with good overall diagnostic yield and CSER.

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.

Capsule endoscopy:Present status and future expectation

Video capsule endoscopy(CE)since its introduction 13years back,has revolutionized our approach to small intestinal diseases.Obscure gastrointestinal bleed(OGIB)continues to be the most important indication for CE with a high sensitivity,specificity as well as positive and negative predictive values.It is best performed during ongoing bleed or immediately thereafter.Overt OGIB has a higher diagnostic yield than occult OGIB.However,even in iron deficiency anemia,CE is emerging as important investigation after initial negative work up.In suspected Crohn’s disease(CD),CE has been shown superior to traditional imaging and endoscopic technique and should be considered after a negative ileocolonoscopy.Although CE has also been used for evaluating established CD,a high capsule retention rate precludes its use ahead of cross-sectional imaging.Celiac disease,particularly where gastro-duodenoscopy cannot be performed or is normal,can also be investigated by CE.Small bowel tumor,hereditary polyposis syndrome,and non-steroidal anti-inflammatory drugs induced intestinal damage are other indications for CE.Capsule retention is the only significant adverse outcome of CE and occurs mostly in presence of intestinal obstruction.This can be prevented by use of Patency capsule prior to CE examination.Presence of cardiac pacemaker and intracardiac devices continue to be relative contraindications for CE,though data do not suggest interference of CE with these devices.Major limitations of CE today include failure to control its movement from outside,inability of CE to acquire tissue for diagnosis,and lack of therapeutic help.With ongoing interesting and exciting developments taking place in these areas,these issues would be solved in all probability in near future.CE has the potential to become one of the most important tools in diagnostic and possibly in the therapeutic field of gastrointestinal disorder.

Emergent single-balloon enteroscopy for overt bleeding of small intestinal vascular malformation

A 28-year-old man presented with anemia symptoms and intermittent tarry stool passage for three days. No stigmata of hemorrhage were identified using esophagogastroduodenoscopy, ileocolonoscopy, and contrast-enhanced computed tomography. He then developed massive tarry stool passage with profound hypovolemic shock and hypoxic respiratory failure. Emergent angiography revealed active bleeder, probably from the jejunal branches of the superior mesenteric artery, but embolization was not performed due to possible subsequent extensive bowel ischemia. His airway was secured via endotracheal intubation with ventilator support, and emergent antegrade singleballoon enteroscopy was performed at 8 h after clinical overt bleeding occurrence; the procedure revealed a 2-cm pulsating subepithelial tumor with a protrudingblood plug at the distal jejunum. Laparoscopic segmental resection of the jejunum with end-to-end anastomosis was performed after emergent endoscopic tattooing localization. Pathological examination revealed a vascular malformation in the submucosa with an organizing thrombus. He was uneventfully discharged 5 d later. This case report highlights the benefit of early deep enteroscopy for the treatment of small intestinal bleeding.

Bleeding Dieulafoy's-like lesions of the gut identified by capsule endoscopy

Dieulafoy's-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.

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.

Diagnosis and therapeutic strategies for small bowel vascular lesions

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions;therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding:A systematic review and metaanalysis

AIM To compare the diagnostic accuracy of video capsule endoscopy(VCE) and double-balloon enteroscopy(DBE) in cases of obscure gastrointestinal bleeding(OGIB) of vascular origin.METHODS MEDLINE(via PubMed), LILACS(via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables(sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.RESULTS In the per-patient analysis, 17 studies(1477 lesions) were included. We identified3150 exams(1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864(58.5%) were diagnosed by VCE, and 613(41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84%(95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was92%(95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29(95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20(95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to90%.CONCLUSION The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.