Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

Abstract

Obscure gastrointestinal bleeding has long been a diagnostic challenge because of the relative inaccessibility of small bowel to standard endoscopic evaluation. Intraoperative enteroscopy indications have been reduced by the development of deep enteroscopy techniques and video capsule endoscopy. In light of the current advances, this review aimed at evaluating the intraoperative enteroscopy technical aspects, study results and an ongoing role for intraoperative enteroscopy in obscure gastrointestinal bleeding management. Intraoperative enteroscopy allows complete small bowel exploration in 57–100% of cases. A bleeding source can be identified in 80% of cases. Main causes are vascular lesions (61%) and benign ulcers (19%). When a lesion is found, intraoperative enteroscopy allows successful and recurrence-free management of gastrointestinal bleeding in 76% of cases. The reported mortality is 5% and morbidity is 17%. The recurrence of bleeding is observed in 13–52% of cases. With the recent development of deep enteroscopy techniques, intraoperative enteroscopy remains indicated when small bowel lesions (i) have been identified by a preoperative work-up, (ii) cannot be definitively managed by angiographic embolization, endoscopic treatment or when surgery is required and (iii) cannot be localized by external examination during surgical explorations. Surgeons and endoscopists must exercise caution with intraoperative enteroscopy to avoid the use of a low yield, highly morbid procedure.

Introduction

Obscure gastrointestinal bleeding is defined as persistent or recurrent bleeding from the gastrointestinal tract for which no definite source has been identified by upper and lower tract endoscopy, conventional barium contrast studies or enteroclysis [1], [2]. This is an uncommon event since bleeding source fails to be detected by both upper and lower conventional endoscopy in approximately 5% of cases of all gastrointestinal bleeding [3]. When bleeding from oesophagus, stomach or colon has not been identified at initial endoscopic work-up, obscure gastrointestinal bleeding is found to arise from small bowel lesions in 45–75% of cases [1], [4], [5]. The clinical presentation may be ongoing obscure overt bleeding with continuous flow of visible blood, or obscure occult bleeding with no visible blood but signs of iron deficiency anaemia from a gastrointestinal source.

In obscure gastrointestinal bleeding cases, exploration of the jejunum and the ileum has been a diagnostic challenge because of relative inaccessibility with standard endoscopic methods. Improvements in computed tomography, magnetic resonance [6], angiography [7], [8] and endoscopic techniques including video capsule endoscopy, deep enteroscopy (push-enteroscopy, balloon-assisted endoscopy [9], [10], [11], balloon-guided enteroscopy and spiral enteroscopy [12], [13]) identify small intestine bleeding sites that were not previously approachable. Balloon-assisted endoscopy (single and double balloon endoscopy) uses specific endoscopes comprising one or two balloons to allow the endoscope advancement into the small bowel. Balloon-guided endoscopy uses the advancement of a balloon at the end of a catheter to guide the introduction of the endoscope. With the advent of these techniques, particularly the deep enteroscopy techniques, exploration of the entire small bowel and complete endoscopic treatment of the discovered lesions are increasingly feasible. However, when small bowel lesions have not been localized and/or cannot be endoscopically treated, intraoperative enteroscopy (IOE) must be considered after multidisciplinary discussion.

In light of the current advances, the objectives of this review were to evaluate the IOE study results and examine an ongoing role for IOE in obscure bleeding management.