BACKGROUND AND AIMS:Video capsule endoscopy (VCE) is valuable for assessing conditions like GI bleeding, anemia, and inflammatory bowel disease. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are prescribed for diabetes and weight loss, with their pharmacologic effects including delayed gastric emptying. This study investigates the impact of GLP-1RA use on VCE outcomes in patients with diabetes. METHODS:This retrospective cohort study involves patients with diabetes undergoing VCE while on GLP-1RAs matched in a 1:1 ratio with control subjects, who are not on GLP-1RAs, based on demographics and diabetes-related factors. The primary outcome was gastric transit time in VCE studies, whereas secondary outcomes were incomplete small-bowel evaluation and small-bowel transit time. RESULTS:In the GLP-1RA cohort with 68 patients, 5 (7%) experienced failure to pass the video capsule through the stomach; all control subjects passed the video capsule successfully (P = .06). GLP-1RA patients had a longer gastric transit time (99.3 ± 134.2 minutes) compared with control subjects (25.3 ± 31.6 minutes, P < .001). Multivariate analysis revealed GLP-1RA use was associated with an increased gastric transit time by 74.5 minutes (95% confidence interval, 33.8-115.2; P < .001) compared with control subjects, after adjusting for relevant factors. Sixteen GLP-1RA patients (23.5%) experienced incomplete passage of the video capsule through the small intestine, a significantly higher rate compared with 3 patients in the control group (4.4%, P < .01). CONCLUSIONS:GLP-1RA use is associated with a prolonged gastric transit time and a higher rate of incomplete small-bowel evaluation during VCE. Future studies may be crucial for evaluating strategies to mitigate these effects.

Double balloon enteroscopy remains a resource and time-intensive procedure that is not available in many endoscopy units. We aimed to identify variables impacting the speed and completion of double balloon enteroscopy. We retrospectively reviewed 550 patients. Using a mean time and distance for both the antegrade and retrograde approach, we determined the procedure speed and assessed factors that influenced it. In addition, we assessed the factors that contributed to a complete double balloon enteroscopy. A total of 386 antegrade and 164 retrograde double balloon enteroscopies were performed. Greater than 10 AVMs requiring treatment was a negative predictor (AOR 0.25, CI 0.11–0.51, p < 0.001), whereas age greater than 60 years (AOR 2.66, CI 1.18–6.65, p = 0.025) was a positive predictor of a fast antegrade enteroscopy. For retrograde, prior abdominal surgery was the only factor that trended to significance (AOR 0.38, CI 0.14–0.99, p = 0.052). A total of 120 combined procedures were performed. Female gender (AOR 2.62, CI 1.16–6.24, p = 0.02), history of prior abdominal surgery (AOR 0.31, CI 0.13–0.70, p = 0.006) and Boston bowel pre-preparation score of greater than 6 (AOR 4.50, CI 1.59–14.30, p = 0.006) were the only significant predictors of a complete procedure. By applying double balloon enteroscopy speed, a novel method of measuring procedure efficiency, we were able to more reliably identify the factors that will negatively impact the speed and success of the procedure.

Background and study aims Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P = 0.12) or 1 year (19.9 % vs 15.7 %, P = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.

BACKGROUND:The diagnosis of isolated small bowel Crohn's disease (CD) can be challenging. Symptoms are non-specific and both imaging and capsule endoscopy (CE) may be misleading as several diseases may mimic CD. Double balloon enteroscopy (DBE) allows a more extensive endoscopic and histologic evaluation of the small bowel. Our aim was to describe the diagnostic utility and impact of DBE on management of patients with known CD and in patients with suspected/rule-out CD.METHODS:Retrospective review of our institution's DBE database from February 2009 to May 2013. Adult patients referred for DBE for further evaluation of known or suspected CD (due to symptoms, abnormal imaging and/or CE) were included. Patient demographics, clinical characteristics, imaging and CE results, prior DBE, indication for DBE, DBE findings, DBE adverse events, pathology findings, final diagnosis, treatment prior and post DBE and follow-up DBE were abstracted from the electronic medical record.RESULTS:A total of 108 patients were included, 61 (56%) females, mean age 52 years (range 20-83). Indications for DBE included: disease activity assessment/therapeutic in 10 patients with established diagnosis of CD and for diagnostic purposes in 98 patients with suspected CD (31 patients due to abnormal imaging, 29 due to abnormal CE and 26 due to both abnormal imaging and CE). Upper, lower, bidirectional upper and lower, and stomal DBE were performed in 21, 24, 62 and 1 patients, respectively. DBE revealed active disease in 8/10 patients with known CD with one patient undergoing dilation of a stricture. Changes in management were recommended for all patients with active disease - start thiopurine (2), optimize thiopurine dose (1), start biologics (3) change biologics (1), systemic steroids (1) and budesonide (1). The patient who underwent stricture dilation ultimately required surgery. A definitive diagnosis of CD (both endoscopic and histologic) was reached in only 39/98 (40%) patients who were referred for suspected CD. Changes in management were recommended in 32/39 (82%) patients. Interestingly, 24/98 patients had been diagnosed with CD at outside institutions and were recommended to initiate therapy for CD. Of these, CD was confirmed in only 15/24 (63%) patients. Adverse events included perforation in 1 patient (1%) who required surgical management and mouth swelling/abrasion in 3 patients (3%). Follow-up DBE to re-assess disease activity was performed in 10/49 (20%) patients with definitive diagnosis of CD, average time between procedures 4.5 years (range 0.7-11.6). One patient with CD was diagnosed with lymphoma 2.4 years after initial DBE. Changes in management were recommended in 6 patients: de-escalation of therapy (3, two underwent surgery), start thiopurine and/or biologic (2) and switch biologics (1). No complications were seen at follow-up DBE.CONCLUSION:DBE is a useful technique to confirm a diagnosis in patients who have suspected CD and can help establish a diagnosis of several diseases that may mimic CD on CT scan or CE. Additionally, DBE in patients with established diagnosis of small bowel CD is an effective tool to assess disease activity and guide therapy. Serious complications are infrequent.

Double balloon enteroscopy (DBE) allows the diagnosis and therapy of small bowel disorders with a low complication rate, however it remains a resource-intensive procedure that is not available in many endoscopy units, with equipment, expertise and the duration of the procedure remaining a frequent concern. In this study we attempt to identify procedure, operator and patient variables impacting the duration of the procedure.

Learning Objectives: Obscure gastrointestinal (GI) bleeding is a challenging entity frequently encountered in critical care practice. The associated mortality and morbidity are high despite advancements in diagnostic tools and treatment. Localizing the source of bleeding is crucial but can be difficult. Here we present a rare case of a bleed from an unusual source after pancreas transplantation. Methods: N/A Results: A 60-year-old male with a past medical history of endstage renal disease related to diabetic nephropathy and hypertension with a failed combined kidney and pancreas transplantation in 2002 transferred to our tertiary referral center for further evaluation of an obscure GI bleed. He initially presented to another facility 12 days prior to transfer with bright red blood per rectum. During that hospital course, he received a total transfusion volume of 25 units of packed red blood cells and underwent two upper/lower endoscopies and two tagged RBC nuclear scans, all with negative findings. Upon transfer, patient was hemodynamically unstable requiring vasoactive support with two agents and multiple units of blood transfusions. Double balloon enteroscopy performed at our facility identified a large adherent fibrin clot at the duodenojejunostomy of the previous pancreas allograft along with large varices at the anastomotic scar, which were unable to be treated endoscopically. Patient was taken to the operating room and underwent an allograft pancreatectomy with resection of the small bowel and enteroenterostomy. The bleeding was subsequently controlled, but his hospital course was complicated by respiratory failure, sepsis from an intra-abdominal source, and delirium which all improved. Conclusions: This case exemplifies the challenges in diagnosing small intestinal bleeds given the intermittent nature of the hemorrhage. In up to 5% of cases, thorough investigation fails to find a definitive source. GI bleeding is a well-known complication of pancreas transplants, especially at the site of the duodeno-jejunal anastomosis. However, hemorrhage in this setting is usually an early complication within the first 3 months post-surgery due to ulcer formation. Delayed hemorrhage, especially after 16 years as in this patient, is rare. Thus, it is important to recognize this late complication of a combined kidney-pancreas transplant while evaluating obscure GI bleeds.

Patients undergoing double balloon enteroscopy (DBE) are often anticoagulated and/or use antiplatelet therapy. Current ASGE guidelines do not explicitly recommend continuation or discontinuation of these agents prior DBE.

Deciding to perform antegrade or retrograde double-balloon enteroscopy (DBE) accordingly to identify findings on video capsule endoscopy (VCE) can be challenging. We ought to develop a model to facilitate the decision making process on the DBE approach according to VCE findings and other possible pertinent factors, like intake of opioid and prior bowel surgery.

Video capsule endoscopy (VCE) is an important test when evaluating obscure gastrointestinal bleeding (OGIB). Historically, VCE has higher diagnostic yield in patients with overt OGIB, particularly when performed within less than a week from the bleeding episode. However, VCE may miss lesions which are then visualized on repeat VCE or during subsequent enteroscopy.

A 29-year-old woman was referred to our facility because of a 2-year history of relapsing abdominal pain associated with melena, diarrhea, chronic arthralgia, and new onset of lower extremity edema. Previous workup in an outside center included negative results for HLA B-27 testing without radiologic features of spondyloarthropathy. Capsule endoscopy revealed erosions, circular ulcers, and concentric stenosis in the proximal jejunum and ileum (A, B). An abdominal CT scan revealed nonobstructing dilatated and stenotic segments within the ileum (C). She was empirically treated for Crohn’s disease with mesalamine and budesonide but with no improvement. A thorough medication history disclosed long-term use of lysine clonixinate (nonsteroidal anti-inflammatory drug [NSAID] derived from nicotinic acid) and metamizole (active NSAID breakdown products). Physical examination revealed bilateral lower extremity pitting edema (3+) and left-sided abdominal tenderness. Noteworthy laboratory findings included the following: anemia (Hb 8.0 g/dL), low albumin (1.9 g/dL), low immunoglobulin G (377 mg/dL), negative autoimmune and celiac panels, and normal renal function. Double-balloon enteroscopy showed 2 diaphragm-like stenotic lesions with circular ulcerations in the distal ileum (D, E). Mild architectural distortion, inflammation, and villous injury without granulomas was found in histopathology (F). With the diagnosis of NSAID-induced enteropathy, NSAIDs were discontinued, and her symptoms gradually improved in 3 weeks. Although NSAID-induced upper GI adverse events have been well described, the small-intestinal manifestations (circular ulcers and diaphragm-like stenosis) remain not well recognized by clinicians.

Introduction: Portal hypertensive polypoid enteropathy is an under recognized complication of portal hypertension. It is a rare manifestation of portal hypertensive enteropathy (PHE), polypoid lesions are seen in about 0.3% cases in the small intestine. Endoscopic findings of portal hypertension may or may not be present. Case description: A 60 year-old female with a history of liver cirrhosis from NAFLD and chronic GI bleeding was referred for evaluation of transfusion-dependent anemia requiring IV iron and packed red blood cells. Encephalopathy was her only known complication from cirrhosis. Previous work-up revealed a polypoid lesion in the duodenum which was removed (histology: chronic active duodenitis with ulceration, polypoid inflamed granulation tissue). EGD did not show varices, GAVE, or portal hypertensive gastropathy. She also had a history of large internal hemorrhoids and diverticulosis which were previously treated. Despite management of suspected lesions, anemia persisted with hem occult positive stools. VCE was performed using PillCam system which showed a 6-8mm villous polyp with surface erosion without bleeding in the proximal duodenum. Clusters of erythema and red villi were noted in small intestine which did not appear to be discrete angiodysplasias. At mid-small intestine (57% transit) 1cm sessile polypoid lesion with active bleeding was noted that appeared to be an inflammatory polyp or granulation tissue. Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM (Figure 1). Small inflammatory polyps were removed from duodenum. Histopathology showed benign inflammatory polyp c/w portal enteropathy. Lower DBE revealed a 1 cm sessile polyp in mid- ileum (40 cm upstream of colon) which matched the lesion seen on VCE. Polyp was removed with hot snare. Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations (Figure 2, 3). The findings were suggestive of polypoid portal hypertensive enteropathy.Figure: Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.Discussion: Introduction of VCE and deep enteroscopy has enabled us to perform diagnostic and therapeutic evaluation of small bowel in PHE. Portal hypertensive polypoid enteropathy should be kept high in the differential in patient s with liver cirrhosis presenting with occult GI blood loss. Management of PHE is yet to be standardized, individualized approach should be sought.

Double balloon enteroscopy (DBE) allows endoscopic evaluation of the entire small bowel, which is termed total enteroscopy. DBE can also be performed to evaluate particular small bowel sections with abnormal findings on previous imaging, termed targeted enteroscopy. At times, total and targeted enteroscopy are technically not feasible. In such situations, the length of the remaining unevaluated small bowel is unclear, which raises concern for missed lesions.

Acquired von Willebrand factor deficiency (aWFD) is associated with the formation of angioectasia. It has been shown that patients with overt obscure gastrointestinal bleeding (OGIB) and underlying aWFD have a marginally higher risk of rebleeding following therapeutic double balloon enteroscopy (DBE). Of more importance is the impact of aWFD in patients with occult OGIB, which is a common presentation of angioectasia.

The etiology of symptomatic recurrent partial small bowel obstruction (pSBO) is often unclear. Imaging can provide information about the location of suspected culprit lesions, however tissue sampling and direct visualization are required for exact diagnosis. We investigated the outcome of consecutive patients undergoing diagnostic double balloon enteroscopy (DBE) for symptomatic recurrent pSBO with and without abnormal imaging. A total of 50 patients were identified who underwent DBE for workup of pSBO between 2/2009 and 6/2014. Symptoms leading to DBE indication were recurrent abdominal pain with nausea, vomiting and abdominal distention in all cases. Demographics, comorbidities, NSAID use, contrast enhanced cross-sectional imaging, video capsule endoscopy (VCE), DBE findings, pathology reports and long-term outcomes were abstracted by retrospective chart review. Primary outcome was to identify the etiology of recurrent pSBO and secondary outcome to define predictors for culprit lesions on DBE. Fifty patients (mean age 60.1 years, SD 14, 70% female) underwent 73 DBE (42 upper DBE and 31 lower DBE), with total enteroscopy achieved in 64% of attempted cases. pSBO symptoms were present over a mean of 61 months (SD 94). All previous EGD (n=30) and colonoscopies (n=38) were unrevealing. VCE showed strictures and ulcers in 74%. Cross-sectional imaging was performed 103 days (mean) prior to DBE and showed normal results in 33%. The remaining results were unspecific small bowel dilation in 55% whereas strictures were present only in 5% of cases. A culprit for pSBO was identified by DBE in 78% of patients: non-specific ulcerated strictures (16%), suspected adhesions (16%), NSAID strictures (10%), radiation induced changes (10%), anastomotic strictures (8%), suspected motility disorder (8%), lymphoma (2%) and other (8%). Overall, strictures were found in 21 patients (42%), with dilation performed in 10 patients to allow passage of DBE scope. On univariate analysis, only odds ratio (OR) of VCE findings (40.6) significantly predicted DBE findings, whereas cross-sectional imaging, duration of symptoms, presence of weight loss or anemia, underlying surgery or inflammatory bowel disease, radiation therapy and NSAID use did not. None of the factors predicted DBE findings independently on multivariate analysis. Of patients with available follow up (n=31), most patients (74%) had no improvement following DBE and eventually required surgical resection for the identified culprit lesion. None of the patients followed up after normal DBE required surgery. The yield of DBE was 78% identifying a culprit lesion in patients with long standing pSBO. CT, MRI, VCE findings, amongst other laboratory values did not predict independently the presence of small bowel pathology. Most patients eventually required surgical resection for small bowel pathology identified on DBE.

Background Small bowel strictures are common in gastroenterology practice. We report diagnostic and therapeutic yield of double-balloon enteroscopy for small bowel strictures. Methods Retrospective study of 71 consecutive patients who were found to have small bowel stricture at the time of double-balloon enteroscopy. Results During double-balloon enteroscopy, stricture identification and tissue sampling were possible in all 71 cases. Surgical pathology reported aetiology as non-steroidal anti-inflammatory drugs (32%), non-specific (21%), Crohn's disease (21%), radiation-induced (9%), tumour (10%), anastomotic (4%), celiac disease (1%), and surgical adhesions (1%). Sixteen patients (23%) underwent balloon dilation. Sensitivity of abdominal computed-tomography and video-capsule endoscopy for strictures based on double balloon enteroscopy findings was 61% and 43%, respectively. Conclusion Double-balloon enteroscopy was safe and effective to access small bowel stricture with direct visualization and tissue sampling or for therapeutic balloon dilation. Given low sensitivity with conventional computed-tomography and/or video-capsule endoscopy for small bowel stricture, double-balloon enteroscopy can be considered if clinical suspicion is high.

Degraded by shear stress, loss of high-molecular-weight multimers of von Willebrand factor (VWF) correlates strongly with pressure gradient in aortic stenosis (AS) and obstructive hypertrophic cardiomyopathy (HC). We assessed VWF tests before and after interventions in HC and contrasted the severity of abnormalities in HC to patients with AS, mitral regurgitation, and left ventricular assist devices. Ninety patients with median (interquartile range) age 66 (53 to 72) years, 51% men, with HC had assessments of 3 VWF parameters and B-type natriuretic peptide before and after 26 discreet medical/pacing interventions, 22 alcohol septal ablations, and 28 ventricular septal myectomies. VWF multimers were abnormal in 87% of patients with obstructive HC versus 48% of patients with latent obstruction (p = 0.0001). VWF measurements correlated with peak instantaneous left ventricular outflow tract gradient, Spearman p 0.51 to 0.61, p <0.0001. For B-type natriuretic peptide, correlation with left ventricular outflow tract gradient was weaker, p = 0.37, p = 0.0005, but stronger with septal thickness or mitral E/e'. In pre-/post-medical treatment of HC, VWF multimers were abnormal in 73%/68% of patients, p = 0.74; pre-/postseptal ablation 74%/26%, p = 0.0035; and pre-/post-septal myectomy 75%/0%, p <0.0001. In obstructive HC, the degree VWF multimer loss was greater than in severe AS or severe mitral regurgitation and overlapped that seen in left ventricular assist devices. In conclusion, VWF activity indexes were predictably abnormal in patients with HC with resting obstruction to a degree where bleeding could be anticipated, accurately reflected gradient changes after intervention, and demonstrated complete normalization after septal myectomy. (C) 2016 Elsevier Inc. All rights reserved.

Introduction: Intestinal epithelioid angiosarcomas are extremely rare and aggressive vascular tumors, with a very limited number of cases reported in the literature. We report a case of this malignancy presenting with small bowel overt bleeding. Case Presentation: A 77-year-old male with recurrent maroon-colored stools and anemia was transferred to our hospital for tertiary care. Past medical history was significant for coronary artery disease status post bypass x 6. He was on daily aspirin 81 mg and denied NSAID use. He initially presented with melena and an EGD discovered a non-bleeding duodenum ulcer. Two weeks later, he was evaluated again for hematochezia and persistent anemia. An EGD was repeated with same findings. A colonoscopy showed a 1cm polyp with an arteriovenous malformation (AVM) in the rectum. This was treated with hot snare polypectomy. On video capsule endoscopy (VCE), there were multiple bleeding ulcers throughout the visualized small bowel. At our hospital, an upper double-balloon enteroscopy (DBE) revealed bleeding erosion on a polyp in distal duodenum which was treated with argon plasma coagulation. There were several blue-purple polypoid lesions on top of focal ulcers on jejunal mucosa (Image1). Biopsies of these polypoid lesions in both distal duodenum and jejunum had histological features consistent with epithelioid angiosarcoma. Immunostains were positive for CD31 and keratin (Image2-3), but negative for S-100 and melan A. Further review of pathology from the previous polypectomy of the rectum also confirmed the diagnosis. Staging imaging study did not show evidence of extraintestinal disease. Chemotherapy with paclitaxel 135 mg/m2 every 3 weeks were recommended. Unfortunately, the patient died 6 weeks later due to complications of infection and respiratory failure. Discussion: Suspected small intestinal bleeding should be investigated promptly with VCE to look for rarer causes. This may be followed by DBE for a tissue biopsy and intervention. Epithelioid angiosarcoma is a highly aggressive endothelial cell malignancy, most commonly arising in the deep soft tissues but rare in the small intestine. The prognosis is very poor and most patients die within 1 year of diagnosis, therefore, it is important for endoscopists to be aware of this disorder to obtain an early diagnosis. Treatment usually involves surgical resection of the bleeding lesions, chemotherapy, radiotherapy, and transfusions for symptom alleviation.Figure 1