Title: Small-bowel lesions detected by double-balloon enteroscopy performed after negative capsule endoscopy
Abstract: To the Editor: Postgate et al1Postgate A. Despott E. Burling D. et al.Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy.Gastrointest Endosc. 2008; 68: 1209-1214Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar described 5 cases of small-bowel lesions missed by capsule endoscopy (CE) but revealed by double-balloon enteroscopy (DBE), magnetic resonance imaging, or CT, a common occurrence, which outlines the technical limitations of CE, especially in the assessment of the jejunum. In our experience of 161 DBEs performed with various indications, we have seen at least 4 such cases (1 Crohn's ulcer, 2 angiodysplasias, and 1 tumor) in which the lesions missed by CE were identified by DBE. One case allows us to discuss some aspects of the problem: a 60-year-old patient with obscure GI bleeding who underwent, over a period of 2 years, 4 CE examinations that revealed nonspecific findings (rare jejunal erosions and a suspected angiodysplasia). DBE detected an ulcerated GI stromal tumor in the distal jejunum. The questions are these: why was CE unable to see the lesion, and how many CEs should we perform before deciding to switch to another kind of test? Postgate et al1Postgate A. Despott E. Burling D. et al.Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy.Gastrointest Endosc. 2008; 68: 1209-1214Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar report some limitations of CE (poor viewing quality, incomplete transit, and inadequate lumen distension), but we would suggest another explanation: some lesions, located immediately after a curve, may not be seen by CE that does not distend the lumen and has a limited angle of view. DBE, because of its flexibility and ability to straighten the bowel during retraction, may visualize such hidden lesions. The fact that, in this case, as well as in two others of jejunal angiodysplasia, the lesions were seen only during the retraction of the DBE scope and not during its introduction supports our hypothesis. Some investigators suggest that a negative CE should reassure2Lai L. Wong G. Chow D. et al.Long term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy.Am J Gastroenterol. 2006; 101: 1224-1228Crossref PubMed Scopus (154) Google Scholar and that repeated CE increases the diagnostic yield.3Jones B.H. Fleischer D.E. Sharma V.K. et al.Yield of repeat wireless video capsule endoscopy in patients with obscure gastrointestinal bleeding.Am J Gastroenterol. 2005; 100: 1058-1064Crossref PubMed Scopus (120) Google Scholar Our cases demonstrate the contrary: a second CE could theoretically discover a missed lesion, mainly in case of intermittent bleeding, but a hidden lesion can be seen only by a different method and, after a negative CE, DBE should be the next step in patients with suspected small-bowel disease and bleeding. ResponseGastrointestinal EndoscopyVol. 70Issue 4PreviewWe read with interest the experience with missed lesions with capsule endoscopy (CE), described by Manes et al.1 Various technical factors limit the sensitivity of current-generation capsule endoscopes for the detection of solitary mass lesions in the small bowel. As described in their letter, the inability to distend the bowel, as is possible with balloon enteroscopy or oral contrast magnetic resonance enterography (MRE), significantly impairs lesion detection in collapsed or angulated segments. Full-Text PDF