Editor: Joseph Sung
9. Enteroscopy and capsule endoscopy
The length and tortuous nature of the small intestine has constituted a considerable challenge for endoscopic practice. However,
certain techniques are now well established. Three methods have dominated the field since the first enteroscopes were developed
more than 30 years ago.
- Sonde enteroscopy (a thin floppy scope with a balloon tip)
- Push enteroscopy (a long standard endoscope)
- Intraoperative enteroscopy (endoscopy during surgery)
Recently, the field has been revolutionized by the development of wireless capsule endoscopy.
We here review technical developments, diagnostic results, and the outcomes of therapeutic interventions, particularly in
patients with obscure gastrointestinal bleeding. Important new information on the clinical application and early results for
capsule endoscopy are now available, and are certain to stimulate further research in this dynamic field.
The Sonde endoscopy method is now mainly of historical interest, but it is worth reviewing, not least because there are important
lessons for gastroenterologists now working with the capsule.
The sonde enteroscope is long (2.7 m), and thin (0.5 cm in diameter), with an inflatable balloon at the tip . It is usually passed through the nose, and advances by the passive propulsive effects of small bowel peristalsis (Fig. 1). The jejunum and ileum are examined on withdrawal, but the method has significant problems. It takes several hours, and
is often poorly tolerated. Visualization is limited due to lack of tip deflection, and the uncontrolled nature of withdrawal
results in incomplete visualization. For these reasons, Sonde enteroscopy never established a place in routine clinical practice,
other than in a few units with a particular interest in patients with obscure bleeding. Nevertheless, the technique did show
that endoscopic examination of the small bowel was possible, and indeed clinically desirable. Reports of diagnostic yields
superior to conventional radiological techniques emphasized the importance of diseases of the jejunum and ileum, and the need
to develop more reliable methods for diagnosis and therapy [5,6].
Push enteroscopy is well established in clinical practice. Enteroscopes are essentially long floppy forward-viewing scopes,
2.22.5 m in length. Initial experience was reported using colonoscopes passed orally . Preparation and sedation are the same as for standard upper endoscopy. Once the tip of the scope is in the descending duodenum,
a stiffening overtube can be deployed to reduce gastric looping, which is a major factor limiting the duct through insertion.
Even so, the tip of the endoscope rarely reaches beyond the first 5070 cm beyond the pylorus. Usually, antispasmodic agents are avoided until the withdrawal/inspection phase of the examination.
Depth of insertion
Using a longer enteroscope does not seem to increase the insertion depth predictably. A stiffening overtube can help, but
the overall value of this technique is still in dispute, not least because its use has resulted in significant complications
Newer methods to improve the intubation depth include utilizing a double balloon method to create a concertina effect. Total
small bowel intubation can be achieved and the ability to biopsy or deliver therapy are likely to be of particular interest
as an alternative to operation in patients with small bowel lesions found at capsule endoscopy [20,21]
Accurate measurement of the insertion depth is challenging. We simply pull the enteroscope back until the tip starts to withdraw.
This gives a reasonably reliable measurement, which is used to guide subsequent therapy.
Routine biopsy is recommended when examining patients with suspected small bowel disease because there is a significant yield
even with negative macroscopic views [22,23].
The small bowel can be examined during laparotomy, using either a sterilized colonoscope passed through an enterotomy, or
a push enteroscope passed through the mouth . The surgeon 'milks' the intestine over the endoscope. Encouraging diagnostic yields have been observed, but the procedure is not without risk.
Complications have been reported in up to a quarter of these procedures, including serosal tears, prolonged ileus, even an
enterovaginal fistula [29,30,31]. Intraoperative enteroscopy has usually been employed as an intervention of last resort in patients with significant ongoing
GI bleeding after full investigations, including push enteroscopy. The recurrent nature of bleeding from arteriovenous malformations
in particular was a major disincentive to intraoperative interventions, especially segmental resections.
Laparoscopic-assisted enteroscopy 
This technique uses the peroral passage of a long push enteroscope or colonoscope, or even a Sonde enteroscope. The surgeon
performs a standard diagnostic laparoscopy, and then uses laparoscopic instruments to help the endoscopist advance the enteroscope.
Intubation of the terminal ileum has been described by this technique, but previous surgery and adhesions may interfere, and
postoperative ileus has occurred .
Lack of predictable deep insertion has led to the combining of push enteroscopy with colonoscopy and ileoscopy and combining
enteroscopy with enteroclysis [33,34].
This new technique involves the patient swallowing a wireless capsule camera which is 11 × 30 mm in length and consists of complimentary metal oxide silicon sensors (CMOS), an application specific integrated circuit
(ASIC) device and white light emitting diode (LED) illumination(Fig. 2) No specific bowel preparation other than the overnight fast is needed. Some reports even suggest that capsule progression
through the small intestine may be delayed by large bowel preparation (Fig. 3). The capsule images are transmitted at the rate of 2 per s to aerials positioned across the abdomen and stored in a recorder
for subsequent analysis. The entire examination may obtain up to 50 000 images and battery life permits transmission for up to 68 h, during which patients are ambulant and independent . Images are analyzed on a computer workstation. Problems with this technique include: the small risk of capsule impaction
(in patients with unsuspected strictures); incomplete examination of the small bowel due to limited battery life in patients
with prolonged small bowel transit (in up to 15% of patients); and the length of time it takes to review and analyze the recorded
data (at least an hour in experienced hands).
Clinical applications of enteroscopy and capsule endoscopy
Enteroscopy and capsule techniques have been used for the investigation of patients with obscure gastrointestinal bleeding,
suspected inflammatory bowel disease, malabsorption syndromes, and some rarities such as small bowel transplantation.
Obscure gastrointestinal bleeding
Definitions and prevalence
Gastrointestinal bleeding is defined as 'obscure' when patients continue to bleed despite normal upper and lower endoscopy examinations. This is not uncommon. Studies have
shown that endoscopy and colonoscopy together reveal lesions in only just over one half of patients with documented iron deficiency
anaemia [36,37]. The result was no higher in patients who also had positive fecal occult blood tests .
Multiple guidelines are available suggesting algorithms for the evaluation of this problem and defining the potential role
of enteroscopy [39,40]. Patients with obscure gastrointestinal bleeding may be subdivided into those with overt (blood loss noticed by patient)
and occult (unnoticed by patients) bleeding. Although such subdivision may seem arbitrary with inevitable overlaps, the appreciation
that the rate of blood loss may influence diagnostic yield of enteroscopy will influence the enthusiasm for enteroscopy in
Historical estimates of the prevalence of small bowel lesions to account for blood loss have varied from 3% to 5% but these
are undoubtedly underestimates resulting from lack of appropriate methods to evaluate the small bowel mucosa.
Alternative diagnostic procedures in obscure bleeding
Small bowel radiology, isotope-labeled red cell studies, and angiography have all been used in this context, but the diagnostic
yield is low . Newer imaging modalities such as helical CT angiography might improve the yield, but availability is currently limited .
When to use enteroscopy in obscure bleeding
Some clinicians question the need for further evaluation when endoscopy and colonoscopy are negative, since a number of series
attest to the benign outcome of anaemia in this context . This attitude fails to recognize the negative healthcare impact on the patient, and the significant resource implications
of subsequent management . It is our view that patients with more than a single unexplained episode of iron deficiency anaemia should undergo evaluation
by enteroscopy or capsule endoscopy [50,51].
Pathology of obscure bleeding
Angiodysplasia and small bowel tumors are the commonest identified causes of obscure gastrointestinal bleeding (Fig. 4). Predominant tumor types are gastrointestinal stromal tumors (GIST), adenocarcinomas, and lymphomas (Figs 5 and 6). Secondary spread to the bowel from melanoma and lung cancer in particular can present as obscure gastrointestinal bleeding
. Whilst it is asserted that tumors frequently present in younger patients, our experience, particularly with a large population
of patients with celiac disease, is that tumors are found equally in all age groups (Fig. 7). The superficial nature of angiodysplasia explains the disappointingly low diagnostic yield from non-endoscopic diagnostic
methods. In approaching the management of a patient thought to be bleeding from angiodysplasia it is important to understand
the likely geographic distributions, limited non-endoscopic treatment options and recurrent nature of these lesions, even
if successfully treated initially by endoscopic methods or segmental resections. Angiodysplasias are most frequently found
in the proximal jejunum and right colon and increase in frequency with age. The factors predisposing to this distribution
are unknown, but suggestions include bowel wall surface tension. Recent data suggests that bleeding from angiodysplasia in
some cases may be related to a deficiency of Von Willebrand factor, as these multimers promote hemostasis at very high shear
conditions experienced in the gut wall related to vascular abnormalities . Even if these lesions are treated, the persisting pathophysiological abnormalities mean that recurrence is almost inevitable.
Clinicians should develop an expectation that further therapy may become necessary in the future. In attempting to allow objective
assessment and comparison of treatment outcomes the European Club of Enteroscopy has proposed a classification of angiodysplasia
which may be helpful in future studies .
Medical therapy for angiodysplasia
Non-endoscopic therapy of a diffuse and recurring disease would seem to have some theoretical advantages. Early reports of
successful hormone therapy (estrogen/progesterone) in inherited vascular disorders  seemed to encourage more widespread use and some non-randomised cohort studies supported the use of hormone therapy in acquired
angiodysplasia . However, a significant number of patients on hormone therapy have to discontinue the medication due to unacceptable side-effects.
Other reports of the use of vasoactive drugs such as Octreotide seemed equally encouraging [60,61] but in clinical practice non-endoscopic therapy has remained disappointing. In a recent important study from Spain no benefit
of the use of hormone therapy to prevent bleeding from angiodysplasia was observed in a controlled study. At present hormone
therapy cannot be recommended for acquired vascular malformations of the gut .
Diagnostic yield and outcomes of enteroscopic techniques in bleeding
In patients with obscure gastrointestinal bleeding/unexplained anaemia, three studies show remarkably similar diagnostic yield for sonde enteroscopy2630% [6,63,64]. New diseases have been identified, for example NSAID enteropathy, occurring in 47% of patients with unexplained anaemia
receiving these drugs . The rate of blood loss is a factor determining the diagnostic yield, which increases from 27% in patients with anaemia to
37% in those with acute bleeding . Although the push examination is limited to the proximal jejunum, several series confirm the superior diagnostic yield of
this procedure, compared with sonde enteroscopy, with diagnostic rates ranging from 30% to 64% depending on case selection
. This is probably a reflection of improved mucosal inspection as a result of a more controlled examination technique. Only
one study has evaluated the combined diagnostic potential of push and sonde enteroscopy in the same patients giving a combined
yield of 58% overall, with sonde enteroscopy adding an additional 26% of patients with a diagnosis achieved. This data confirms
that depth of intubation is a key factor determining diagnostic yield of enteroscopy .
Comparing capsule and push enteroscopy
Comparisons of the capsule technique with standard push enteroscopy have (not surprisingly) shown increased yields from the
capsule, not least because push enteroscopy rarely examines more than half of the small intestine. One study involved sewing
colored beads into the small intestine of dogs. Sensitivities for push enteroscopy and capsule endoscopy were 37% and 64%,
respectively. There is now a plethora of clinical studies indicating significant diagnostic yields in patients with obscure
bleeding. However, the effect on clinical outcomes awaits further evaluation [74,75].
Diagnostic yields of 55% and 68% for the capsule examination are impressive . However, the low diagnostic yield of push enteroscopy in comparative studies to date might reflect selection bias, as some
patients already had a negative push enteroscopy .
Repeat standard endoscopies before enteroscopy?
Most studies of enteroscopy indicate that lesions are often found within the reach of standard upper endoscopy, bringing into
question the quality of the initial endoscopic procedures . This has led to the suggested strategy of using push enteroscopy as the first (upper) examination in patients with unexplained
anaemia . Unfortunately, lack of access and experience with push enteroscopy will make application of this strategy unlikely for most
Unusual causes of obscure bleeding
The growing use of push enteroscopy in patients with bleeding has yielded many unusual diagnoses, including worm infestation,
jejunal varices, ulceration related to Henoch Schonlein purpura, and bleeding from aortic graft fistula .
Enteroscopic therapy for bleeding
The push enteroscope allows delivery of endoscopic therapy, primarily through cauterization of arteriovenous malformations.
Whilst retrospective studies show encouraging results, only one prospective study has addressed the impact of heater probe
ablation in this clinical setting . We found complete resolution of bleeding in 83% of patients with a significant improvement in hemoglobin levels . Due to the thin small bowel wall we recommend a maximum of three 10 J applications of the heater probe to each arteriovenous
malformation. Following initial ablation bleeding is often seen (Figs 810). Whilst the reduction of blood loss was confirmed in subsequent studies, an interesting effect on improved quality of life
has also been demonstrated, probably as a result of reduced transfusion and hospitalization . Interest in the long-term outcome of patients having investigation and treatment by push enteroscopy has revealed important
insights into the perceived benefit of the procedure. Although enteroscopy was perceived by clinicians to have positively
influenced patient management in three studies, in one of these studies only one third of the patients felt it was beneficial
. This discrepancy probably reflects the lack of impact to an individual patient of not achieving a diagnosis after enteroscopy
although once again these studies demonstrated reduced hospitalization in patients in whom a diagnosis was achieved. Rebleeding
occurs in approximately one third of all patients with obscure bleeding. The risk is less on long-term follow-up patients
who have undergone negative push enteroscopy . Patients should be counselled about the risk of rebleeding, and the potential need for further investigation and treatment.
Intraoperative enteroscopy for obscure bleeding
This procedure is normally reserved for those patients in whom bleeding persists despite negative push enteroscopy. In this
highly selected group, studies using a colonoscope passed orally or via enterotomies reveal a diagnostic yield approaching
7080% of patients . The ability to examine the whole small bowel has led to the perception that intraoperative enteroscopy should be regarded
as the gold standard for small bowel evaluation. The only study which has compared enteroscopy with intraoperative enteroscopy
found that both procedures missed lesions, but that intraoperative enteroscopy had a higher sensitivity . Most experts now use a push enteroscope through the mouth for intraoperative enteroscopy, not least because it obviates
the need for opening the bowel.
Push enteroscopy or capsule endoscopy for bleeding?
The problem for the clinician nowadays is to decide whether to use capsule endoscopy as the next step following negative upper
endoscopy and colonoscopy, or whether to use push enteroscopy first. The latter would be advantageous only if lesions were
found and treated at enteroscopy. Although data from diagnostic yield would seem to favor the capsule no studies are yet available
to definitely answer this question. As stated in a recent ASGE technical review, patient factors and local availability will
be major determinants in this process .
Small intestinal mucosal diseases
Celiac disease is usually diagnosed (and excluded) by standard endoscopic biopsy from the distal duodenum. Enteroscopy is
rarely required for diagnosis, although two studies did suggest an increased yield over standard duodenal biopsy [102,103]. Push enteroscopy should be restricted for diagnostic purposes when there is strong suspicion, or when the disease is refractory
to treatment. Under these circumstances enteroscopy allows detection of macroscopic abnormalities such as ulceration and lymphoma,
and the ability to obtain biopsies for immunopathological analysis [104,105]. Identifying patients at particular risk for developing lymphoma is an exciting prospect. Several studies have reported on
an abnormal immunophenotype in which intraepithelial lymphocytes in patients with refractory celiac disease express on intracytoplasmic
CD3 positive CD8 negative staining pattern. The majority also had clonal intestinal TCR gamma gene rearrangements . These findings were found to be highly suggestive of subsequent development of enteropathy-associated lymphoma in the latter
study whereas those without these patterns had good responses to steroid and gluten withdrawal.
Enteroscopy is of value in selected patients with negative investigations when there is a high index of suspicion of Crohn's
disease. Abnormalities and supporting histology have been reported in up to 50% of such patients . Remarkably similar results are also observed in patients examined by capsule enteroscopy . Therapeutic enteroscopy (e.g. balloon dilatation of strictures) has also been used successfully in patients with proximal
Crohn's disease . Enteroscopy has also been used during surgery for complications of Crohn's disease, and has often shown a high frequency
of metachronous lesions . However, these findings have not affected the outcome, but the situation might change with newer immunomodulating therapies.
Small bowel tumors
Tumors of the small intestine are relatively uncommon. They account for less than 2% of tumors of the gastrointestinal tract
and can be very difficult to identify . Many present with obscure bleeding, and patients undergo repeated investigations prior to definitive diagnosis. Malignant
tumors, particularly adenocarcinoma, present early with weight loss, pain, perforation, or obstruction . Sonde enteroscopy revealed tumors in about 5% of 258 patients investigated for obscure bleeding . This frequency reflects the over-representation of tumor patients in a series of patients with no diagnosis by other diagnostic
modalities. However it emphasizes the fact that serious diseases occur in this patient group and that enteroscopy should be
considered an important addition to non-endoscopic methods of evaluation [117, 118]. A further role of enteroscopy has recently been defined in patients with small bowel polyps in PeutzJeghers syndrome. Using push enteroscopy and intraoperative enteroscopy successful surveillance and polypectomy have been
performed, avoiding the need for emergency surgery for intestinal obstruction. Although relatively small numbers of patients
have been reported, these early results provide encouragement for future development of a screening and monitoring role for
Capsule endoscopy has not proven useful in evaluating unexplained abdominal pain . Images from the transient passage through the esophagus were found in a recent study to be insufficient to evaluate for
esophagitis or Barrett's esophagus . It is clear that future enthusiasm for capsule endoscopy will lead to its evaluation in many novel diseases or anatomical
Small bowel endoscopy has been developed and evaluated extensively over the past two decades. The techniques, diagnostic yield,
and clinical outcomes have been defined. Initial scepticism over the need for endoscopic examination of the small intestine
has been replaced by a recognition of the potential role that this technique fulfills in the management of patients with obscure
bleeding, small intestinal mucosal diseases, and tumors. Newer techniques have improved diagnostic yield and patient tolerance
and now it is important to acknowledge that complete endoscopic examination of the gastrointestinal tract is a clinical reality.
As our methods become more reliable, enteroscopy research will move from defining the process of the techniques to evaluating
their role in disease management. Capsule endoscopy has added substantial impetus to this process.
Outstanding issues and future trends
Capsule endoscopy heralds a new era for structural evaluation of the gastrointestinal tract.
Important questions that will need to be clarified are: refining techniques to maximize mucosal views; studies to define inter-
and intraobserver variability; who should most appropriately read capsule studies; and outcomes for individual patient groups.
Although currently limited to examination of the small bowel, we should expect that modifications of capsule technology will
lend themselves to total gastrointestinal visualization, perhaps by a steerable capsule.
Simple changes to capsule function including blood indicators which are in evolution will probably be supplemented by other
abilities such as measuring physiological conditions including pH and motility.
These devices will revolutionize our approach to patients with mucosal disease and be used to monitor disease progress, outcomes
of therapy (and possibly delivery of it) and be an ideal screening tool. It is likely that contrast radiology will become
obsolete and diagnostic endoscopic procedures may be gradually replaced. Increased demand for therapy or biopsy of lesions
detected by capsule will, for the present, maintain significant need for push enteroscopy.
1 Tada, M, Akasaka, Y, Misaki, F & Kawai, K. Clinical evaluation of a sonde-type small intestinal fibrescope. Endoscopy, 1977; 8: 338.
2 Tada, M & Kawai, K. Small bowel endoscopy. Scand J Gastroenterol, 1984; 19: 3952.
3 Lewis, BS & Waye, JD. Total small bowel enteroscopy. Gastrointest Endosc, 1987; 33 (6): 4358. PubMed
4 Waye, JD. Small bowel examination by the Sonde enteroscope. Acta Endoscopica, 1996; 26: 27791.
5 Lewis, BS, Kornbluth, A & Waye, JD. Small bowel tumors: yield of enteroscopy. Gut, 1991; 32: 7635. PubMed
6 Morris, AJ, Wasson, LA & MacKenzie, J. Small bowel enteroscopy in undiagnosed gastrointestinal blood loss. Gut, 1992; 33: 8879. PubMed
7 Parker, HW & Agayoff, JD. Enteroscopy and small bowel biopsy utilizing a peroral colonoscope (letter). Gastrointest Endosc, 1983; 29: 13940. PubMed
8 Foutch, PG, Sawyer, R & Sanowski, RA. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc, 1990; 36: 33741. PubMed
9 Dabezies, MA, Fisher, RS & Krevsky, B. Video small bowel enteroscopy: early experience with a prototype instrument. Gastrointest Endosc, 1991; 37: 602. PubMed
10 Shimizu, S, Masahiro, T & Kuwai, K. Development of a new insertion technique in push-type enteroscopy. Am J Gastroenterol, 1987; 82: 8447. PubMed
11 Barkin, J, Lewis, B, Reiner, D, Waye, J, Goldberg, R & Phillips, R. Diagnostic and therapeutic jejunoscopy with a new, longer enteroscope. Gastrointest Endosc, 1992; 38: 558. PubMed
12 Harris, A, Dabezies, M, Catalano, M & Krevsky, B. Early experience with a video push enteroscope. Gastrointest Endosc, 1994; 40: 624. PubMed
13 Barkin, JS, Chong, J & Reiner, JK. First generation video enteroscope: fourth generation push-type small bowel enteroscopy utilizing an overtube. Gastrointest Endosc, 1995; 40: 7437.
14 Benz, C, Jakobs, R & Riemann, JF. Does the insertion depth in push enteroscopy depend on the working length of the enteroscope? Endoscopy, 2002; 34 (7): 5435. PubMed
15 Taylor, AC & Chen, RY, Desmond PV. Use of an overtube for enteroscopy does it increase depth of insertion? A prospective study of enteroscopy with and without an overtube. Endoscopy, 2001; 33 (3): 22730. PubMed
16 Benz, C, Jakobs, R & Riemann, JF. Do we need the overtube for push-enteroscopy? Endoscopy, 2001; 33 (8): 65861. PubMed
17 Bures, J & Rejchrt, S. Use of an overtube for enteroscopy: depth of insertion. Endoscopy, 2002; 34 (4): 347. PubMed
18 Yang, R & Laine, L. Mucosal stripping: a complication of push enteroscopy. Gastrointest Endosc, 1995; 41: 1568. PubMed
19 Landi, B, Cellier, C & Fayemendy, L et al. Duodenal perforation occurring during push enteroscopy. Gastrointest Endosc, 1996; 43: 631. PubMed
20 Yamamoto, H, Sekine, Y, Sato, Y, Higashizawa, T, Miyata, T, Lino, S, Ido, K & Sugano, K. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc, 2001; 53 (2): 21620. PubMed
21 Bouhnik, Y, Bitour, A, Coffin, B, Moussaoui, R, Oudghiri, A & Rambaud, JC. Two way push videoenteroscopy in investigation of small bowel disease. Gut, 1998; 43: 2804. PubMed
22 Barkin, JS, Schonfeld, W, Thomsen, S, Manten, HD & Rogers, AI. Enteroscopy and small bowel biopsy an improved technique for the diagnosis of small bowel disease. Gastrointest Endosc, 1985; 31: 2157. PubMed
23 Van Bergeijkl, JD, Fockens, P, Mulder, CJJ & Tytgat, GNJ. Enteroscopy for unexplained iron deficiency anemia: take enough biopsies. Gastrointest Endosc, 1994; 40: 1135. PubMed
24 Desa, LA, Ohri, SK, Hutton, KAR, Lee, H & Spencer, J. Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin. Br J Surg, 1991; 78: 1925. PubMed
25 Apelgren, KN, Vargish, T & Al-Kawas, F. Principles for use of intraoperative enteroscopy for hemorrhage from the small bowel. Am Surg, 1988; 54: 858. PubMed
26 Lala, AK, Sitaram, V & Perakath, B et al. Intraoperative enteroscopy in obscure gastrointestinal hemorrhage. Hepatogastroenterology, 1998; 45: 597602. PubMed
27 Lau, WY, Fau, ST & Chu, KW et al. Intraoperative fibreoptic enteroscopy for bleeding lesions of the small intestine. Br J Surg, 1986; 73: 2178. PubMed
28 Lau, WY. Intraoperative enteroscopy indications and limitations. Gastrointest Endosc, 1990; 36: 26871. PubMed
29 Krishnan, RS & Kent, RB III Enterovaginal fistula as a complication of intraoperative small bowel endoscopy. Surg laparosc Endosc, 1998; 8: 3889. PubMed
30 Lopez, MJ, Cooley, JS, Petros, JG, Sullivan, JG & Cave, DR. Complete intraoperative small bowel endoscopy in the evaluation of occult gastrointestinal bleeding using the sonde enteroscope. Arch Surg, 1996; 131: 2727. PubMed
31 Matsushita , M, Hajiro, K & Takakuwa, T. Laparoscopically assisted panenteroscopy for gastrointestinal bleeding of obscure origin. . Gastrointest Endosc, 1997; 46: 4745. PubMed
32 Stuart, RC, Knapple, W, Carter, RC, MacKenzie, JF & Morris, AJ. Laparoscopy assisted push enteroscopy: a novel technique for evaluating patients with obscure gastrointestinal bleeding. Gut, 1999; 44 Suppl. 1 (Abstr.) T75.
33 Aliperti, G, Zuckerman, GR, Willis, JR & Brink, J. Enteroscopy with enteroclysis. Gastrointest Endosc Clin N Am, 1996; 6: 80310. PubMed
34 Cohen, M & Barkin, JS. Enteroscopy and enteroclysis: the combined procedure. Am J Gastroenterol, 1989; 84: 14135. PubMed
35 Iddan, G, Meron, G, Glukhovsky, A & Swain, P. Wireless capsule endoscopy. Nature, 2000; 405: 417. PubMed
36 Rockey, DC & Cello, JP. Evaluation of the gastrointestinal tract in patients with iron deficiency anaemia. N Engl J Med, 1993; 329: 16915. PubMed
37 Zuckerman, G & Benitez, J. A prospective study of bi-directional endoscopy (colonoscopy and upper endoscopy) in the evaluation of patient with occult
gastrointestinal bleeding. Am J Gastroenterol, 1992; 87: 626. PubMed
38 Rockey, DC, Koch, J, Cello, JP, Sanders, LL & McQuaid, K. Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult blood tests. N Engl J Med, 1998; 339: 1539. PubMed
39 American Gastroenterological Association medical position statement Evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology, 2000; 118 (1): 197201. PubMed
40 Eisen, GM, Dominitz, JA, Faigel, DO, Goldstein, JL, Kalloo, AN, Petersen, BT, Raddawi, HM, Ryan, ME, Vargo, JJ, Young, HS, Fanelli, RD & Hyman, NH, Wheeler-Harbaugh Standard Practice Committee Enteroscopy. J. Am Soc Gastrointest Endosc, 2001; 53 (7): 8713.
41 Rex, DK, Lappas, JC & Maglinte, DT. Enterolysis in the evaluation of suspected small intestinal bleeding. Gastroenterol, 1989; 97: 5860.
42 Voeller, GR, Bunch, G & Britt, LG. Use of Technetium labeled red cell scintigraphy in the detection and management of gastrointestinal hemorrhage. Surgery, 1991; 110 (4): 799804. PubMed
43 Fioritos, J, Brandt, L, Kozicky, O, Grosman, I & Sprayragen, S. The diagnostic yield of superior mesenteric angiography: correlation with the pattern of gastrointestinal bleeding. Am J Gastroent, 1989; 84 (8): 87881. PubMed
44 Morris, AJ. Small bowel investigation in occult gastrointestinal bleeding. Sem Gastrointest Dis, 1999; 10: 6570.
45 Ettorre, G, Francioso, G & Garribba, A et al. Helical CT angiography in gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol 1997; 168: 72730. PubMed
46 Sayer, JM & Long, RG. A perspective on iron deficiency anaemia. Gut, 1993; 34: 12979. PubMed
47 Sahay, R & Scott, BB. Iron deficiency anaemia how far to investigate? Gut, 1993; 34: 14278. PubMed
48 McIntyre, AS & Long, RG. Prospective evaluation of investigations in outpatients referred with iron deficiency anaemia. Gut, 1993; 34: 11027. PubMed
49 Lucas, CA, Logan, ECM & Logan, RFA. Audit of the investigations and outcomes of iron deficiency anaemia in one health district. J R Coll Physicians Lond, 1996; 30 (1): 335. PubMed
50 Cellier, C, Tkoub, M & Gaudric, M. et al. Comparison of push-type endoscopy and barium transit study of the small intestine in digestive bleeding and unexplained iron
deficiency anemia. Gastroenterol Clin Biol, 1998; 22: 4914. PubMed
51 Lewis, B. Radiology versus endoscopy of the small bowel. Endoscopy, 1998; 30: 4125. PubMed
52 Ashley, S & Wells, S. Tumors of the small intestine. Sem Oncol 1988; 15: 11628.
53 Priest, M & Morris, AJ. Detection of small bowel neoplasia at push enteroscopy. Gut 2001; 48: . (Abstr.): O45.
54 Veyradier, A, Balian, A & Wolf, M et al. Abnormal Von Willebrands factor in bleeding angiodysplasias of the digestive tract. Gastroenterology 2001; 120: 34653. PubMed
55 Proposal for an endoscopic classification of digestive angiodysplasias for therapeutic trials (The European Club of Enteroscopy)
(letter). Gastrointest Endosc. 1998; 48: 659.
56 Van Cutsem, E, Rutgeerts, P & Vantrappen, G. Treatment of bleeding gastrointestinal vascular malformations with estrogen-progesterone. Lancet, 1990; 335: 9535. PubMed
57 Lewis, BS, Salomon, P, Rivera-MacMurray, S, Kornbluth, AA, Wenger, J & Waye, JD. Does hormonal therapy have any benefit for bleeding angiodysplasia? J Clin Gastroenterol, 1992; 15: 99103. PubMed
58 Barkin, JS & Ross, BS. Medical therapy for chronic gastrointestinal bleeding of obscure origin. Am J Gastroenterol, 1998; 93: 12504. PubMed
59 Askin, M & Lewis, B. Long term follow-up of 83 patients with bleeding small intestinal angiodysplasia. Gastrointest Endosc, 1996; 43: 5803. PubMed
60 Rossini, FP, Arrigoni, A & Pennazio, M. Octreotide in the treatment of bleeding due to angiodysplasia of the small intestine. Am J Gastroenterol, 1993; 88: 14247. PubMed
61 Nordquist, LT & Wallach, PM. Octreotide for gastrointestinal bleeding of obscure origin in an anticoagulated patient. Dig Dis Sci, 2002; 47 (7): 15145. PubMed
62 Junquerra, F, Feu, F, Papo, M, Videla, S, Armengol, JR & Bordes, JM. A multicenter, randomised, clinical trial of hormone therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. Gastroenterology, 2001; 121: 10739. PubMed
63 Gastout, CJ, Shroeder, KW & Burton, DD. Small bowel enteroscopy: an early experience in gastrointestinal bleeding of unknown origin. Gastrointest Endosc, 1991; 37 (1): 58. PubMed
64 Lewis, BS & Waye, JD. Chronic gastrointestinal bleeding of obscure origin: role of small bowel enteroscopy. Gastroenterology, 1988; 94: 111720. PubMed
65 Morris, A, Madhok, R & Sturrock, R et al. Enteroscopic diagnosis of small bowel ulceration in patients receiving non-steroidal anti-inflammatory drugs. Lancet, 1991; 337: 520. PubMed
66 Davies, GR, Benson, MJ & Gertner, DJ et al. Diagnostic and therapeutic push type enteroscopy in clinical use. Gut, 1995; 37: 34652. PubMed
67 Pennazio, M, Arrigoni, A, Risio, M, Spandre, M & Rossini, FP. Clinical evaluation of push type enteroscopy. Endoscopy, 1995; 27: 16470. PubMed
68 O'Mahoney, S, Morris, AJ, Straiton, M, Murray, L & MacKenzie, JF. Push enteroscopy in the investigation of small intestinal disease. QJM, 1996; 89 (9): 68590. PubMed
69 Davies, G, Benson, M, Gertner, D, Van Someren, R, Rampton, D & Swain, C. Diagnostic and therapeutic push type enteroscopy in clinical use. Gut, 1995; 37: 34652. PubMed
70 Chong, J, Tagle, M, Barkin, J & Reiner, D. Small bowel push-type fibreoptic enteroscopy for patient with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol, 1994; 89: 2436.
71 Berner, J, Mauer, K & Lewis, B. Push and sonde enteroscopy for the diagnosis of obscure gastrointestinal bleeding. Am J Gastroenterol, 1994; 89: 213942. PubMed
72 Landi, B, Tkoub, M & Gaudric, M et al. Diagnostic yield of push-type enteroscopy in relation to indication. Gut, 1998; 42: 4215. PubMed
73 Chak, AC, Koehler, MK & Sundaram, SN. et al. Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings. Gastrointest Endosc, 1998; 47: 1822. PubMed
74 Fleischer, DE. Capsule Endoscopy: The voyage is fantastic will it change what we do? Gastrointest Endosc, 2002; 56 (3): 4526. PubMed
75 Lewis, BS. Enteroscopy: endangered by the capsule? Endoscopy, 2002; 34 (5): 4167. PubMed
76 Lewis, BS & Swain, P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: Results of a pilot study. Gastrointest Endosc, 2002; 56 (3): 34953. PubMed
77 Ell, C, Remke, S, May, A, Helou, L, Henrich, R & Mayer, G. The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal
bleeding. Endoscopy, 2002; 34 (9): 6859. PubMed
78 Mylonaki, M, Fritscher-Ravens, A & Swain, P. Wireless capsule endoscopy: a comparison with push enteroscopy in patient with gastroscopy and colonoscopy negative gastrointestinal
bleeding. Gut, 2003; 52: 11226. PubMed
79 Saurin, JC, Delvaux, M, Gaudin, JL, Fassler, I, Villarejo, J, Vahedi, K, Bitoun, A, Canard, JM, Souquet, JC, Ponchon, T, Florent, C & Gay, G. Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding. Bilateral comparison with video push enteroscopy. Endoscopy, 2003; 35: 57684. PubMed
80 Zaman, A & Katon, RM. Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard
endoscope. Gastrointest Endosc, 1998; 47: 3726. PubMed
81 Chak, AC, Cooper, GS & Canto, MI et al. Enteroscopy for the initial evaluation of iron deficiency. Gastrointest Endosc, 1998; 47: 1448. PubMed
82 Sharma, BS, Bhasin, DK, Bhatti, HS, Das, G & Singh, K. Gastrointestinal bleeding due to worm infestation with negative upper gastrointestinal endoscopy findings: impact of enteroscopy. Endoscopy, 2000; 32 (4): 3146. PubMed
83 Tang, SJ, Jutabha, R & Jensen, DM. Push enteroscopy for recurrent gastrointestinal hemorrhage due to jejunal anastomotic varices: a case report and review of
the literature. Endoscopy, 2002; 34 (9): 7357. PubMed
84 Taylor, AC, Allen, RM & Buttigieg, RJ. Jejunal ulceration and push enteroscopy. Lancet, 2000; 356 (9248): 21923. PubMed
85 Loehry, J & Winwood, PJ. A bleeding aortic graft enteric fistula diagnosed by push enteroscopy. Postgrad Med J, 2002; 78 (920): 372. PubMed
86 Askin, M & Lewis, B. Push enteroscopic cauterization: long-term follow-up in 83 patients with bleeding small intestinal angiodysplasia. Gastrointest Endosc, 1996; 43: 4503.
87 Schmit, A, Gay, F, Adler, M, Cremer, M & Van Gossum, A. Diagnostic efficacy of push enteroscopy and long term follow-up of patients with small bowel angiodysplasia. Dig Dis Sci, 1996; 41: 234852. PubMed
88 Morris, AJ, Mokhashi, M, Straiton, M, Murray, L & MacKenzie, JF. Push enteroscopy and heater probe therapy for small bowel bleeding. Gastrointest Endosc, 1996; 44: 3947. PubMed
89 Vakil, N, Huilgol, V & Khan, I. Effect of push enteroscopy on transfusion requirements and quality of life in patients with unexplained gastrointestinal bleeding. Am J Gastroenterol, 1997; 92: 4258. PubMed
90 Hayat, M, Axon, AT & O'Mahoney, S. Diagnostic yield and effect on clinical outcomes of push enteroscopy in suspected small bowel bleeding. Endoscopy, 2000; 32 (5): 36972. PubMed
91 Adrain, AL, Dabezies, MA & Krevsky, B. Enteroscopy improves clinical outcome in patients with obscure gastrointestinal bleeding. J Laparoendosc Adv Surg Tech A. 1998; 8 (5): 27983. PubMed
92 Taylor, ACF, Buttigeig, RJ, McDonald, IG & Desmond, PV. Prospective Assessment of the diagnostic and therapeutic impact of small bowel push enteroscopy. Endoscopy, 2003; 35 (11): 9516. PubMed
93 Landi, B, Cellier, C, Gaudric, M, Demont, H, Guimbaud, R, Cuillerier, E, Couturier, D, Barbier, JP & Marteau, P. Long-term outcome of patients with gastrointestinal bleeding of obscure origin explored by push enteroscopy. Endoscopy, 2002; 34 (5): 3559. PubMed
94 Ress, AM, Benacci, JC & Sarr, MG. Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent occult gastrointestinal bleeding. Am J Surg, 1992; 163: 949. PubMed
95 Scott-Conner, CE & Subarmony, C. Localization of small intestinal bleeding: the role of intraoperative endoscopy. Surg Endosc, 1994; 8: 9157. PubMed
96 Desa, LA, Ohri, SK, Hutton, KAR, Lee, H & Spencer, J. Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin. Br J Surg, 1991; 78: 1925. PubMed
97 Kendrick, ML, Buttar, NS, Anderson, MA, Lutzke, LS, Peia, D, Wang, KK & Sarr, MG. Contribution of intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. J Gastrointest Surg, 2001; 5 (2): 1627. PubMed
98 Douard, R, Wind, P, Panis, Y, Marteau, P, Bouhnik, Y, Cellier, C, Cugnenc, P & Valleur, P. Intraoperative enteroscopy for diagnosis and management of unexplained gastrointestinal bleeding. Am J Surg, 2000; 180 (3): 1814. PubMed
99 Zaman, A, Sheppard, B & Katon, RM. Total peroal intraoperative enteroscopy for obscure GI bleeding using a dedicated push enteroscope: diagnostic yield and outcome. Gastrointest Endosc, 1999; 50: 50610. PubMed
100 Lewis, BS, Wenger, JS & Waye, JD. Small bowel enteroscopy and intraoperative enteroscopy for obscure gastrointestinal bleeding. Am J Gastroenterol, 1991; 86: 1714. PubMed
101 Leighton, JA, Goldstein, J & Hirota, W, et al. American Society for Gastrointestinal Endoscopy Technical review: obscure gastrointestinal bleeding. Gastrointest. Endosc. 2003; 58 (5): 6515.
102 Pennazio, M, Arrigoni, A & Rossini, FP. Push enteroscopy for evaluating patient with diarrhoea or malabsorption. Acta Endoscopica, 1996; 26 (4): 24954.
103 Cuillerier, E, Landi, B & Cellier, C. Is push enteroscopy useful in patients with malabsorption of unclear origin. Am J Gastroenterol, 2001; 96 (7): 21036. PubMed
104 Green, JA, Barkin, JS, Gregg, PA & Kohen, K. Ulcerative jejunitis in refractory coeliac disease: enteroscopic visualization. Gastrointest Endosc, 1993; 9 (4): 5845.
105 Cellier, C, Cuillerier, E & Patey-Mariaud de Sere, N, et al. Push enteroscopy in coeliac sprue and refractory sprue. Gastrointest Endosc, 1999; 50 (5): 6137. PubMed
106 Patey-Mariaud De Serre, N, Cellier, C, Jabri, B, Delabesse, E, Verkarre, V, Roche, B, Lavergne, A, Briere, J, Mauvieux, L, Leborgne, M, Barbier, JP, Modigliani, R, Matuchansky, C, MacIntyre, E, Cerf-Bensussan, N & Brousse, N. Distinction between coeliac disease and refractory sprue: a simple immuno-histochemical method. Histopathology, 2000; 37 (1): 707. PubMed
107 Daum, S, Weiss, D, Hummel, M, Ulrich, R, Heise, W, Stein, H, Riecken, EO & Foss, HD. Frequency of clonal intraepithelial T lymphocyte proliferations in enteropathy-type intestinal T cell lymphoma, coeliac disease
and refractory sprue. Gut, 2001; 49 (6): 80412. PubMed
108 Cellier, C, Delabesse, E & Helmer, C et al. Refractory sprue, coeliac disease and enteropathy assisted T-cell lymphoma. Lancet, 2000; 356: 2038. PubMed
109 Perez Cuadrado Macenile, R & Iglesias, J et al. Usefulness of oral video push enteroscopy in Crohn's disease. Endoscopy, 1997; 29: 7457. PubMed
110 Herrerias, JM, Caunedo, A, Rodriguez, M, Pellicer, F & Herrerias, JM Jr Capsule endoscopy in patient with suspected Crohn's disease and negative endoscopy. Endoscopy, 2003; 35 (7): 5648. PubMed
111 Couckuyt H, Gevers, AM & Coremans, G. Efficacy and safety of hydrostatic balloon dilatation of ileoclonic structures: a prospective long-term analysis. Gut, 1995; 36: 57780. PubMed
112 Perez-Cuadrado, E & Molina Perez, E. Multiple strictures in jejunal Crohn's disease: push enteroscopy dilatation. Endoscopy, 2001; 33 (2): 194. PubMed
113 Lescut, D, Vanco, D & Bonniere, P. Perioperative endoscopy of the whole small bowel in Crohn's disease. Gut, 1993; 34: 6499.
114 Esaki, M, Matsumoto, T, Hizawi, K, Mibu, R, Iiida, M & Fujishima, M. Intraoperative enteroscopy detects more lesions but is not predictive of postoperative recurrence in Crohn's disease. Surg Endosc, 2001; 15 (5): 4559. PubMed
115 North, JH & Pack, MS. Malignant tumors of the small intestine. Am Surgeon, 2000; 66 (1): 4651. PubMed
116 Ciresi, DL & Scholten, DJ. The continuing clinical dilemma of primary tumors of the small intestine. Am Surgeon, 1995; 61 (8): 698703. PubMed
117 Pennazio, M. Push enteroscopy for small bowel tumors. Gastrointest Endosc, 1995; 41: 5245. PubMed
118 Arrigoni, A, Pennazio, M & Rossini., FP. Enteroscopy in small bowel neoplastic pathology. Acta Endoscopica, 1996; 26: 25562.
119 Iida, M, Matsui, T, Itoh, H, Mibu, R & Fujishima, M. The value of push-type jejunal endoscopy in familial adenomatosis coli/Gardner's syndrome. Am J Gastroenterol, 1990; 85: 13468. PubMed
120 Bertoni, G, Sassatelli, R, Tasini, P, Ricci, E, Conigliaro, R & Bedogni, G. Jejunal polyps in familial adenomatous polyposis assessed by push-type endoscopy. J Clin Gastroenterol, 1993; 17: 3437. PubMed
121 Rodriguez-Bigas, MA, Penetrante, RB, Herrera, L & Petreilli, NJ. Intraoperative small bowel enteroscopy in familial adenomatous and familial juvenile polyposis. Gastrointest Endosc, 1995; 42: 5604. PubMed
122 Pennazio, M & Rossini, FP. Small bowel polyps in PeutzJeghers syndrome: management by combined push enteroscopy and intraoperative enteroscopy. Gastrointest Endosc, 2000; 51: 3048. PubMed
123 Bardan, F, Nadler, M, Chowers, Y, Fidder, H & Bar Meir, S. Capsule endoscopy for the evaluation of patients with chronic abdominal pain. Endoscopy, 2003; 35 (8): 6889. PubMed
124 Neu, B, Wettschureck, E & Rosch, T. Is oesophageal capsule endoscopy feasible? Results of a pilot study. Endoscopy, 2003; 35 (11): 95761. PubMed
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