For more than a decade,1 capsule endoscopy (CE) has become the standard procedure for small bowel visualization,2 common enough that clinical fellows often are required to master CE during their training2 and effective enough to be considered a first-line diagnostic tool for conditions like obscure gastrointestinal (GI) bleeding.3,4 More recently, double balloon enteroscopy (DBE) also has offered complete small bowel visualization, but with control and treatment capabilities beyond CE.1,4 Although typically considered separately, using CE and DBE in tandem may provide particular benefit for GI clinicians and fellows seeking to confirm difficult diagnoses, as noted by several prominent gastroenterologists.

“In general, these are complementary rather than competing tools,” said Neel K. Mann, MD, MPH, associate director of small bowel enteroscopy in the Interventional Gastroenterology Program at Cedars-Sinai Medical Center in Los Angeles.

Dr. Mann explained that no other approach is able to provide a higher diagnostic yield than the sequential combination of CE and DBE. This result was demonstrated in a recent study of 62 patients who underwent CE followed by DBE. Among patients with obscure bleeding (n=33), the combination of both CE and DBE had a disease detection rate of 90% versus CE alone (78.8%; P>0.05).5 “In the setting of an obscure GI bleed, CE can localize the site of pathology, making later use of DBE more efficient and effective,” Dr. Mann added.

According to Daniel L. Raines, MD, chief of gastroenterology at Louisiana State University Health Sciences Center in New Orleans, “the advantage of using both CE and DBE is probably best illustrated when looking for the source of an overt or occult GI bleed. CE permits visualization of the whole bowel without sedation with a high diagnostic yield. DBE allows for better characterization of the lesion once it is located.”

When searching for specific pathologies, DBE allows for further inspection of the small bowel following positive CE; later DBE may be important if a high index of suspicion persists after a negative CE. Also, Dr. Raines noted CE is able to determine the approach of DBE (antegrade or retrograde). Thus, it may improve the precision of the commonly lengthy DBE procedure. Dr. Mann added that “as a rule, CE can successfully identify lesions, polyps, vascular lesions without the need for sedation5 that are then later validated by DBE. Therefore, CE can be used first and then followed up with DBE, if necessary.”4-6

Moshe Rubin, MD, director of the Gastroenterology Division and director of the Gastroenterology Fellowship Training Program at New York Hospital Queens in New York City, said that both CE and DBE provide advances over imaging and prior technology for examining the entire GI tract. “There are situations in which it makes sense to move directly to DBE, such as in follow-up after surgery in the small bowel, but the roles of CE and DBE are reasonably well defined at this point,” he said. “For evaluating an occult or overt bleed, which is one of the major indications for examining the small bowel, CE and DBE are most effective when used together.”

Dr. Mann pointed out that the timing of CE is also important. “There is evidence to suggest that CE should be performed within 24 hours of the sentinel obscure GI bleed because of the substantial increase in the diagnostic yield of CE within the first 24 to 72 hours,” she said. “This has not been previously appreciated, but some studies suggest the yield for diagnosing occult bleeding may increase by nearly 2-fold.”7

Both CE and DBE are relatively safe: The most significant adverse event associated with CE is retention, with a prevalence rate of approximately 1% in recent data8; serious complications are rare.4 Adverse events associated with DBE include bleeding and perforation, but both are uncommon9; pancreatitis has been reported with DBE with incidence of 1% to 2%.10 The sequential use of CE and DBE is evolving in the diagnosis of a broad variety of suspected pathology in the small bowel, such as inflammatory bowel disease,3 although DBE use is not as widespread as CE and mostly available in tertiary care centers.10

Although CE and DBE are major advances over previous modalities for evaluating the small bowel, the additive value is significant. “It is not necessary to use CE and DBE together in ever y situation, but I think there is a good appreciation for the strengths and limitations of these tools and a growing consensus about when one might be considered without the other as well as when they are best employed together,” Dr. Raines said.


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