Transparent cap improves single balloon enteroscopy for examining GI bleeds

WASHINGTON — Using a transparent cap during single balloon enteroscopy improved the examination of obscure GI bleeding, according to new research presented here.

Perspective from John R. Saltzman, MD, FACP, FACG, FASGE, AGAF

Specifically, the cap increased the diagnostic yield of clinically important arteriovenous malformations (AVMs) and depth of small bowel insertion, Stephen Hasak, MD, of Washington University School of Medicine in St. Louis, Missouri, said during his presentation.

“Video capsule endoscopy (VBE) and balloon assisted enteroscopy (BAE) allow visualization of and access to most of the small bowel,” Hasak said during his presentation. “Despite these modalities, 40% to 50% of patients with OGIB experience continued GI blood loss following endoscopy. The use of a transparent cap at the tip of the endoscope in EGD and colonoscopy can improve diagnostic yield and therapeutic success, but has not been evaluated formally in BAE.”

Hasak and colleagues randomly assigned 91 patients to undergo anterograde single balloon enteroscopy (SBE) with or without the cap for evaluation of obscure GI bleeding or iron deficiency anemia. Identification of P2 lesions at high-risk for bleeding served as the primary endpoint.

Significantly more high-risk AVMs were identified in patients who underwent the procedure with the transparent cap (14.8% vs. 0%; P = .02), and there was a trend toward a higher diagnostic yield of high-risk lesions in the small bowel of the group for whom the cap was used (20.4% vs. 8.8%).

Additionally, using the cap resulted in significantly greater depth of small bowel insertion (191.9 cm vs. 147.5 cm; P = .01). There were no adverse events in the cap group, and three in the group for whom the cap was not used.

“To summarize, using a transparent cap significantly increased the diagnostic yield of AVMs at high risk of bleeding, increased the diagnostic yield of all lesions, and increased the depth of insertion,” Hasak said. “The use of a transparent cap also led to no adverse events.” – by Adam Leitenberger

Reference:

Hasak S, et al. Abstract 175. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.

Disclosures: Hasak reports no relevant financial disclosures. Please see the DDW faculty disclosure index for a list of all other authors’ relevant financial disclosures.

Perspective

John R. Saltzman, MD, FACP, FACG, FASGE, AGAF

This study is fascinating because these investigators used a very simple, cheap, widely available tool, a transparent cap, attached to the end of their endoscope, but in a new and potentially very useful manner. The transparent cap is available to all endoscopists and is used in other procedures, particularly in the colon, but has not been used much in the upper GI tract and very little in the small bowel. It has the advantage of flattening out folds and potentially expanding one’s view in areas that are difficult to visualize, which certainly the small bowel is one of those.

The authors studied the use of a cap in a rigorous way in this randomized trial and showed several benefits. It is interesting that they found more high-risk bleeding lesions and AVMs as well as obtained deeper insertion. Both those benefits are reasonable to expect, but I find the results are almost too good to be true. There was a 0% yield of high-risk AVMs in those patients without a transparent cap, so it puts into question whether the study size was large enough or if there was some unintended bias.

Nevertheless, yield of high-risk lesions and AVMs was higher with the transparent cap and it is a simple intervention to improve diagnostic yield for physicians who perform balloon-assisted enteroscopy.

John R. Saltzman, MD, FACP, FACG, FASGE, AGAF

Professor of Medicine

Harvard Medical School

Brigham and Women's Hospital

Disclosures: Saltzman reports no relevant financial disclosures.