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GE Portuguese Journal of Gastroenterology logoLink to GE Portuguese Journal of Gastroenterology
. 2019 Jun 21;27(1):18–28. doi: 10.1159/000499678

Enteroscopy in the Elderly: Review of Procedural Aspects, Indications, Yield, and Safety

Enteroscopia nos idosos: revisão de aspetos processuais, indicações, rentabilidade e segurança

Ana Catarina Ribeiro Gomes 1,*, Rolando Pinho 1, Adélia Rodrigues 1, Ana Ponte 1, João Carvalho 1
PMCID: PMC6959112  PMID: 31970236

Abstract

Background

As human longevity continues to increase, age-related diseases are more common, which leads to a higher use of gastroenterology services. Endoscopic procedures are generally considered to be of higher risk in the elderly with multiple comorbidities. However, some endoscopic techniques have already been proved to be well tolerated in the elderly.

Summary

<underline></underline>Enteroscopy enables the nonsurgical diagnosis and therapeutic management of a wide variety of small bowel diseases. Although it has been shown to be safe and effective, with high diagnostic yield and therapeutic success rate in the general population, its safety and efficacy in the elderly is largely unknown, and there are still some concerns about its use in these patients.

Key Messages

This review will focus on enteroscopy in elderly people, taking into account patient and procedure characteristics, indications, findings, yield, and complication rate.

Keywords: Enteroscopy, Elderly, Safety, Efficacy, Yield

Introduction

The small bowel (SB) has been a relatively difficult area to examine until the beginning of this millennium. The introduction of capsule endoscopy (CE) in 2000 allowed an easier and more effective diagnostic approach to the SB, being the first-line noninvasive SB investigative modality [1]. Enteroscopy enables the nonsurgical diagnosis and therapeutic management of a wide variety of diseases of the SB [2], and it is divided into push, deep, and intraoperative enteroscopy. Push enteroscopy is a rapid technique, but only allows limited access to the proximal SB [3]. Intraoperative enteroscopy used to be a modality to investigate and treat the SB; however, it requires general anesthesia and is associated with a higher morbidity and mortality rate [4]. Nonetheless, it continues to have an important role in limited indications [5]. Deep enteroscopy (DE) uses specialized platforms to pleat the bowel over the scope in order to increase insertion depth and permit SB visualization.

DE is the technique of choice for obtaining mucosal biopsies and performing therapeutic interventions in the SB [2]. The commercially available platforms for DE include single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), and spiral enteroscopy (SE). Balloon enteroscopy (SBE and DBE) follows the push-and-pull technique to advance deeper into the SB, whereas the SE principle uses rotating motion to gather the SB [6]. DBE was first introduced in Japan by Yamamoto in 2001 and in Western countries by May in 2003. SBE was introduced in 2007, as a simplified balloon enteroscopy system because the preparation and handling of the DBE were complex. Spiral enteroscopy was first introduced in 2006, and in addition to the advantage of a shorter small-bowel examination time, it is more stable within the bowel, thus allowing controlled examination of the intestinal mucosa and therapy [6]. Compared to SBE and DBE, SE is the least studied and utilized DE platform.

Age cutoffs of older than 65 and older than 80 years have been used to designate elderly status and advanced age, respectively [7]. As human longevity continues to increase, age-related diseases grow, and in this patient population there is a higher prevalence of comorbidities, specifically anemia and obscure gastrointestinal bleeding (OGIB), which leads to a higher use of gastroenterology services [8, 9].

Endoscopic procedures are generally considered to be of higher risk in the elderly with multiple comorbidities [8]. Some endoscopic techniques, mainly upper endoscopy [10, 11, 12], colonoscopy [10, 12, 13, 14] and endoscopic retrograde cholangiopancreatography [12, 15, 16, 17, 18] have already been proved to be well tolerated in the elderly. Although DE has been shown to be safe and effective, with high diagnostic yield and therapeutic success rate in the general population [19], the safety and efficacy of DE in the elderly are largely unknown, and there are still some concerns about its use [8]. Because of procedural complexity and extended procedure time, certain providers may be discouraged from using DE. This issue is important, as in one multicenter survey evaluating 1,411 DE procedures (DBE, SBE, and SE), over 40% were elderly patients. In this paper, we review enteroscopy series focusing in elderly patients (Table 1), taking into account patient and procedure characteristics (Table 2), indications (Table 2), findings (Table 3), diagnostic and therapeutic yield (Table 3), and complication rate (Table 3).

Table 1.

Characteristics of the different studies

Study Country Year Study methodology Type of enteroscopy Patients, n Procedures, n Time evaluated Cohort age, years
Hegde et al. [23] USA 2010 Retrospective DBE 170 (110 younger, 60 elderly) 216 (137 younger, 79 elderly) 1 year (August 2007–August 2008) <75 and ≥75
He et al. [20] China 2012 Retrospective DBE 59 (only 1 patient ≥80 years) 81 8 years and 6 months (January 2003–July 2011) All ≥65
Byeon et al. [21] USA 2012 Retrospective DBE 167 (22 >85 years); prior to inclusion, in 4 patients DBE was canceled because of poor medical conditions, in 2 patients it was canceled because of inadequate indications 214 5 years and 10 months (November 2004–September 2010) All ≥75
Sidhu et al. [27] UK 2013 Prospective DBE 111 (NA number of patients in each group) 148 (108 younger, 40 elderly) 6 years and 4 months (July 2006–November 2012) <70 and ≥70
Choi et al. [24] Republic of Korea 2014 Retrospective DBE 158 (124 younger, 34 elderly) 218 (177 younger, 41 elderly) 9 years and 11 months (September 2003–August 2013) <65 and ≥65
Cangemi et al. [22] USA 2015 Retrospective DBE 130 215 6 years and 7 months (January 2006–September 2012) All ≥80
Chen et al. [34] China 2016 Retrospective DBE 674 (308 younger, 272 middle-aged, 94 elderly) 729 (NA number of procedures in each group) 8 years and 10 months (January 2007–November 2015) 11–44, 45–65 and 66–88
Davis- Yadley et al. [25] USA 2016 Retrospective SBE 366 (101 ≥75 years, 119 65–74 years, 90 55–64 years, 118 <55 years) 428 (NA number of procedures in each group) ±4 years (2010–2014) ≥75 65–74 55–64 <55
Chang et al. [26] Taiwan 2017 Retrospective SBE 168 (112 younger, 56 elderly) 265 6 years and 10 months (December 2009–October 2016) <65 and ≥65
Pinho et al. [19] Portugal 2016 Multicentric retrospective DAE – 1,411: (16 pediatric, 828 adults, 567 elderly) 10 years <18 18–65 ≥65
Lin et al. [35] Taiwan 2016 Retrospective SBE 128 200 5 years and 3 months (September 2009–December 2014) <30 30–65 >65
Pattni et al. [28] UK 2017 Retrospective DAE 202 215 6 years and 2 months (September 2008–November 2014) <75 and ≥75
Tao et al. [36] China 2017 Retrospective SBE 186 196 5 years and 11 months (January 2009–December 2014) 14–45 46–59 60–74 75–89 >90
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NA, not available; DBE, double-balloon enteroscopy; SBE, single-balloon enteroscopy.

Table 2.

Patient characteristics, indications, and type of procedure in the different studies

Study Patient characteristics Indications Procedure
Hedge et al. [23] Cardiac disease: elderly − 46.7%; younger − 28.2% (p = 0.02)
Anticoagulation therapy: elderly − 26.7%; younger − 11.8% (p = 0.02)		 Main indication − OGIB: all − 85%; elderly − 96%; younger − 79.6% (p = 0.0008)
Abnormal findings on a previous radiologic imaging study: elderly − 3.8%; younger − 14.6% (p = 0.01)		 No significant differences in the mean number of procedures per patient, the percentage of upper/lower DBE procedures, procedure time, and depth of enteroscope insertion between the 2 age groups
He et al. [20] Age-related diseases − 50%
49.2% (n = 29) had blood transfusion		 Main indication − overt OGIB (36/51)
Others: abdominal pain (15/51), diarrhea (3/51)
Byeon et al. [21] Significant chronic diseases such as ischemic heart disease or COPD − 97.2%
ASA class III − 70.6%
Anticoagulants or antiplatelet − 42.1%		 Main indication − OGIB (82.7%) Mean DBE procedure time − 131 ± 51 min
Sidhu et al. [27] Median dose of midazolam: elderly − 4.5 mg; younger − 6 mg (p < 0.001)
Median dose of fentanyl: elderly − 50 µg; younger − 75 µg (p = 0.02)
Transfusion requirements (number of patients): 10 (<70) vs. 22 (≥70)		 The only indications were OGIB (74% occult and 26% overt)
Occult OGIB was the most frequent indication in both groups		 Procedure time was not significantly different between the groups (p = 0.45)
Choi et al. [24] Comorbidities: elderly − 67,6%; younger − 33,9% (p = 0.001)
ASA class III: elderly − 20.6%; younger − 2.4% (p = 0.001)
NSAID, anticoagulant, or antiplatelet agent use: elderly − 29.4%; younger − 11.3% (p = 0.015)
Mean midazolam dose: elderly − 2.61 mg; younger 3.85 mg (p < 0.001)		 Main indication − OGIB: all − 56.3%; elderly − 67.6%; younger − 56.3% (p = 0.17) No difference in mean total procedure time
Cangemi et al. [22] Comorbidities − 89.2%
ASA class III or IV − 90.8%		 Main indication: OGIB (94.9%) Mean procedure time − 81.1 ± 29.7 min
Chen et al. [34] Main indication − OGIB (36.6%)
Next common indication − abdominal pain (29.7%)
(NA data of each group)
Davis-Yadley et al. [25] ASA class III: all − 80.9%; ≥75 − 69.3%; 65–74 − 66.4%; 55–64 − 68.9%; <55 − 72% (NA statistical significance)
CCI: Progressive increase with all older age groups compared with the younger group (p < 0.01)
Aspirin and anticoagulant use: all − 41.5%; ≥75 years − 47.6%; 65–74 − 48.8%; 55–64 − 38.9%; <55 − 9.3% (between all older groups and the youngest group, p < 0.05)
Transfusion requirements comparing to the <55 group with 22% → 55–64 33.3% (p = 0.04);
65–74 26.1% (p = 0.37) and ≥75 19.1% (p = 0.95)		 Main indication − OGIB: all − 96.4%; ≥75 − 94.1%; 65–74 − 90.8%; 55–64 − 90%; <55 − 58.5% (between all older groups and the youngest group, p < 0.01)
Other indications: all − 20.5%; ≥75 years − 5.9%; 65–74 − 9.2%; 55–64 − 10%; <55 − 41.5% (between all older groups and the youngest group, p < 0.001)		 Anterograde SBE: older patients 93–96%; younger − 83.1% (p < 0.05)
Retrograde SBE: older patients 5–8.9%; younger − 22% (p < 0.05)
Chang et al. [26] Comorbidities and ASA class III higher in elderly patients (p < 0.05)
Elderly patients tended to undergo SBE within 24 h of presentation (emergency setting) (p < 0.05)		 Main indication − OGIB: all − 52.4%; elderly patients − 83.9%; younger − 36.6% (p < 0.001)
Unexplained abdominal pain: all − 26.8%; elderly − 8.9%; younger − 35.7% (p < 0.001)
Suspicious small-bowel tumor: all − 12.5; elderly − 3.6%; younger − 17% (p = 0.01)		 Anterograde SBE: elderly − 33.9%; younger − 17.0% (p = 0.01)
Both approaches: elderly − 46.4%; younger − 63.4% (p = 0.04)
Complete SB evaluation: elderly − 45%; younger − 56.5% (p = 0.37)
Pinho et al. [19] Main indication − OGIB (43.3%)
(NA data of each group)
Lin et al. [35] Main indication − OGIB (62.5%)
(NA data of each group)
Pattni et al. [28] Mean midazolam dose: elderly − between 3.7–5.5; younger − 4.6–6.1 (p < 0.001) Main indication − OGIB (63.8%)
(NA data of each group) 		Completion rates did not vary across different ages of patient (p = 0.238)
Tao et al. [36] Main indication − OGIB (34.4%)
(NA data of each group)
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NA, not available; SB, small bowel; DBE, double-balloon enteroscopy; SBE, single-balloon enteroscopy; OGIB, obscure gastrointestinal bleeding; ASA, American Society of Anesthesiologists CCI, Charlson Comorbidity Index; NSAID, nonsteroidal anti-inflammatory drug.

Table 3.

Findings, diagnostic and therapeutic yield, and complications in the different studies

Study Findings Diagnostic yield Therapeutic yield Complications
Hedge et al. [23] Main finding − angiodysplasia: all − 28.7%; elderly − 39%. younger − 23% (p = 0.01)
Polyps/mass lesions were the next most common finding (13.1%), then small-bowel erosions/ulcers (11.7%); no significant differences between groups		 All: 53.2%; elderly − 55.7%; younger − 51.8%
(p = 0.8)		 Endoscopic therapy: all − 35.7%; elderly − 46.8%; younger − 29.2%
(p = 0.01)
Therapeutic success: all − 85.7%; elderly − 86.5; younger − 85% (p > 0.5)		 Immediately after the procedure and on the basis of follow-up telephone calls 24–48 h after the procedure
Complication rate: all − 0.9%; elderly − 0%; younger − 1.4% with transient hypoxia or arrhythmia (p = 0.5)
No deaths were observed
He et al. [20] Main finding − primary or metastatic tumors (15/51)
Others: diverticula − 7/51; single ulcer − 5/51; angiodysplasias − 4/51; erosions − 2/51
 		 64.4% DY for SB diseases of 60.8% TY = 34% (endoscopic therapy in 20 patients)
Surgical in 23 and intra-operative enteroscopy in 1		 Severe complications were not found during and after DBE Levels of systolic and diastolic blood pressure decreased slightly after DBE
Byeon et al. [21] Main finding − angiodysplasia (30.8%)
Next common findings − ulcer and/ or erosion of nonspecific etiology (7.0%)		 60.3% 38.8% Complication rate general − 3.7% Pancreatitis: 1.4%
Hypoxia after DBE procedures: 1.4%
Aspiration pneumonia: 0.9% and treated with antibiotics Small amount of peritoneal free air after DBE ERCP: 0.5%
No inadvertent perforation as a result of the DBE procedure Levels of systolic and diastolic blood pressure decreased slightly after DBE
Sidhu et al. [27] Main finding − angiodysplasia: all − 25.7%; elderly − 47.5%; younger − 17.6% (NA statistical significance)
Normal: all − 52.7%; elderly − 37.5%; younger − 58.3% (NA statistical significance)		 All: <I>NA</I>; elderly − 53%; younger − 35% (p = 0.06)
Increasing age (p = 0.008) and positive CE findings (p = 0.010) associated with a higher yield		 All: 45% treated vascular lesions (APC)
Management changed: all − 50%; elderly − 50%; younger − 28% (p = 0.01)
Increasing age (p = 0.006) and positive CE findings (p = 0.016) predicted a change in management		 Elderly: no complications or procedure-related deaths at 30 days Younger: respiratory arrest occurred in 1 patient in DPOC (type 2 respiratory failure)
(NA statistical significance)
Choi et al. [24] Most common diagnosis: all − mucosal lesions: elderly − 33.3%; younger − 60.9% (p = 0.002)
> The most common and detailed final diagnosis: elderly − drug-induced enteropathy younger − CD or tuberculosis Second common diagnosis all − tumor lesions; elderly − 30.8%; younger − 14.1%
(p = 0.005)		 All: <I>NA</I>; elderly − 92.3%; younger − 86.5%
(p = 0.422)		 Endoscopic therapy: all − 15.2%; elderly − 23.5%; younger − 12.9%
(p = 0.17)
Interventional therapy (endoscopic + surgery): all − 29.7%; elderly − 50%; younger − 24.2%
(p = 0.006)
Medical therapy: all − 70.3%; elderly − 50%; younger − 75.8%
(p = 0.006)
Therapeutic success: elderly − 100%; younger − 87.5%
(p > 0.05)		 Complication rate: all − 1.8%; elderly − 2.6%; younger − 1.8% (p = 0.548)
elderly − transient hypoxia 0.5%
younger − intervention-related bleeding 0.9%; pancreatitis 0.5% No perforations or deaths related to DBE were reported in both groups
Cangemi et al. [22] Main finding − nonbleeding angiodysplasia (43.7%)
Next common finding − bleeding angiodysplasia (17.2%)		 77.2%
Diagnostic yield for OGIB − 76.5%		 59.5%
APC − 99.2% of the therapeutic procedures and 59.1% of all procedures		 No immediate postprocedural complications noted within 48 h
Chen et al. [34] Main finding: all − Crohn's disease (33.4%); elderly − tumor (73.4%); younger − Crohn's disease (48%) (NA statistical significance)
Next common finding: all − tumor (18.8%); elderly − angiodysplasia (24.5%); younger − tumor (10.4%) (NA statistical significance)		 All: 70.9%. elderly: 78.6%; middle-aged: 71.2%; younger: 73%
(NA statistical significance) 		All − 8.23% (60/729)
hemostasis − 28.3%; polypectomy − 25%
(NA data of each group) 		Complication rate: all − 0.96% (3 patients with perforation, 2 patients with postprocedural hemorrhage, and 1 patient with aspiration pneumonia)
(NA data of each group)
Davis-Yadley et al. [25] Main finding − angiodysplasia: all − 34.7%; ≥75 y − 39.6%; 65–74 y − 37%; 55–64 y − 30%; <55 y − 13.6% (between all older groups and the youngest group p < 0.01)
Tumors: all − 3%; ≥75 y − 2%; 65–74 y − 0.8%; 55–64 y − 1.1%; <55 y − 5.9% (between all older groups and the youngest group p > 0.05)		 All − 67.5%; ≥75 years − 66.3%; 65–74 − 59.7%; 55–64 − 55.6%; <55 − 50% (only p < 0.05 between the oldest group and the youngest group) All − 44.2%; ≥75 years − 47.5%; 65–74 − 42%; 55–64 − 44.4%; <55 − 20.3% (between all older groups and the youngest group p < 0.05) Minor complications (bradycardia, supraventricular tachycardia and mild bleeding): all: 1.4%; ≥75 years − 1%; 65–74 − 0; 55–64 − 1.1%; <55 − 2.5% (between all older groups and the youngest group, p >0.05)
Major complications (hemodynamic instability, bowel perforation and balloon trauma):
all: 1.4%; ≥75 years − 2%; 65–74 − 2.5%; 55–64 − 1.1%; <55 − 0 (NA statistical significance)
Overall complication rate: all: 2.8%; ≥75 years − 2%; 65–74 − 2.5%; 55–64 − 2.2%; <55 − 2.5% (between all older groups and the youngest group, p >0.05)
Chang et al. [26] Main finding − Mucosal lesions: 41.7% Next finding tumor lesions: 36.9%
Angiodysplasia: all − 17.8%; elderly − 37.5%; younger − 8% (p < 0.001)
Diverticulum: all − 10.7%; elderly − 25%; younger − 3.6% (p < 0.001)
Ulcer/erosion: all − 36.9%; elderly − 23.2%; younger − 43.8% (p = 0.01)
IBD: all − 4.8%; elderly − 0; younger − 7.1% (p = 0.04)		 All − 59.5%; elderly − 75%; younger − 51.8%
(p = 0.004)		 All − 26.2%; elderly − 39.3%; younger − 16.9%
(p = 0.001)		 Complication rate: all − 3.6%; elderly − 5.4%; younger − 2.7% (p = 0.37)
Pinho et al. [19] Main finding − angiodysplasias (25.8%). Next common finding: tumor/polyps and Crohn's disease
(NA data of each group)		 Anesthetic complications requiring interruption of the procedures were reported in 9 (0.6%) patients, all under deep propofol sedation, 6 of them aged 65 or older (p > 0.05)
Lin et al. [35] Main finding: all − angiodysplasia (15.2%)
<30 years − Meckel's diverticulum (17.7%)
30–65 years − non-specific ulcer (26.9%) >65 years − angiodysplasia (27%)
(NA statistical significance)
Pattni et al. [28] Main finding: all − angiodysplasia (25.6%) Older patients were more likely to have an abnormal examination (mean age normal examination 60.3 vs. abnormal examination 67.9 years, p < 0.001) Elderly − 78.5%; younger − 37.9%
(p < 0.001)		 Procedure was better tolerated in older patients (p = 0.001)
0.4% complication rate related to sedation in an elderly patient (80 years)
Tao et al. [36] Main finding: all − mucosal lesions (17.2%)
elderly: vascular malformations younger (<45 y): small intestinal diseases except for lymphoma, protuberant lesions, vascular malformations, and undetermined bleeding
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NA, not available; DY, diagnostic yield; TY, therapeutic yield; CE, capsule endoscopy; DBE, double-balloon enteroscopy; SBE, single balloon enteroscopy; APC, argon plasma coagulation; CPOD, chronic pulmonary obstructive disease.

Patient Characteristics

In older patients, the proportion of patients with age-related diseases/comorbidities, class III of the American Society of Anesthesiologist (ASA), and with anticoagulation and antiplatelet agent use is significant [20, 21, 22]. This proportion could be higher than the younger counterpart, as has been seen in previous studies [23, 24, 25, 26]. According to Davis-Yadley et al. [25], with increasing age, there was a progressive increase in the Charlson Comorbidity Index (CCI) with all older age groups. In addition, according to one study, elderly patients tended to undergo enteroscopy within 24 h of presentation (emergency setting) more often than younger patients (p < 0.05) [26].

Procedure Characteristics

The procedure time was not significantly different between elderly and younger patients [23, 24, 27]. In some series, elderly patients were more likely to undergo the anterograde approach [25, 26], and in another series, the completion rate did not vary across different ages [28]. Hegde et al. [23] described no significant differences in the mean number of procedures per patient, the percentage of upper/lower DBE procedures, the procedure time, and the depth of enteroscope insertion between the age groups.

Indications

OGIB continues to be the main indication for DE [5, 29, 30, 31], although enteroscopy can be used for other indications such as the evaluation of SB obstruction and SB tumors, management of Peutz-Jeghers patients [32], and accessing the pancreaticobiliary system in patients with surgically altered anatomy [29, 31, 33].

OGIB was the most common indication, independent of the age group, in all series reported in Table 2[19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 34, 35, 36]. However, the proportion of patients performing enteroscopy for OGIB was significantly higher in elderly patients. Younger patients were more likely to undergo enteroscopy for other indications, such as abdominal pain, abnormal imaging, or suspicious small-bowel tumor [23, 25, 26]. This is in accordance with what has been established for CE [9].

Findings

The distribution of positive findings seems to be different between Eastern and Western countries. Inflammatory lesions and SB mass lesions are primarily found in the east, whereas in the west, vascular lesions are more often diagnosed (Fig. 1) [31, 37, 38, 39, 40].

Fig. 1.

Fig. 1

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Enteroscopy images of ulcerated stenosis (a), angioectasia (b), bleeding angioectasia (c), clip to control bleeding (d), bleeding controlled after 2 clips (e), scar after argon plasma coagulation (f), bleeding subepithelial lesion (g), subepithelial lesion (h), and neoplasia (i).

As reported previously, elderly patients are more likely to have vascular lesions than younger patients in CE [9, 41]. In these studies, vascular lesions were also the most common finding in the elderly in Western countries [19, 21, 22, 23, 25, 27, 28], and these patients were more likely to present vascular lesions compared to younger patients [23, 25, 26, 27, 35, 36, 42]. Despite that, Lin et al. [35], a group from Taiwan, reported that angiodysplasias were the main finding (contrary to what would be expected in an Asian population).

In Eastern series it seems that mass or mucosal lesions were the most common findings [20, 24, 26, 34, 36]. Mucosal lesions were more frequent in the younger group [24, 34, 35, 36] and tumor lesions in the older group [24, 34]. Choi et al. [24] reported that Crohn's disease or tuberculosis were the most common diagnoses in the younger group, with drug-induced enteropathy being the most common diagnosis in the elderly. Chen et al. [34] reported that associated with advancing age, the morbidity associated with tumors, angiodysplasias, tuberculosis, parasites, and nonsteroidal anti-inflammatory drugs, enteritis appeared to be increasing, and a decline occurred in the morbidity related to Crohn's disease, polyp, and Henoch-Schönlein purpura.

Diagnostic Yield

DBE has a diagnostic yield comparable with that of CE in the evaluation of small-bowel disease [43, 44]. According to a meta-analysis by Teshima et al. [45], the diagnostic yield of DBE performed after a previously positive CE is higher when compared to DBE performed after a negative CE. Furthermore, CE performed prior to SBE has been shown to improve both the diagnostic and therapeutic yields [46]. Despite that, in some cases, DE could detect lesions missed by CE [47, 48]. BE comprises both DBE and SBE, and according to recent meta-analyses they both have similar diagnostic yield [49, 50, 51], although there is some evidence that the DBE technique has a longer insertion depth [52]. A diagnostic yield of around 40–80% for DBE [19, 31, 43, 49, 50, 51, 53] and around 36–66% for SBE have been reported [19, 39, 49, 50, 51]. Baniya et al. [6] compared BE with SE and found no significant differences in the diagnostic yield. In a recent meta-analysis, the diagnostic yield for OGIB, the main indication for DE, was 62.5% [31]

In the elderly, the reported diagnostic yield varied between 53 and 92% [20, 21, 22, 23, 24, 25, 26, 27, 34], and when comparing with younger patients, it has a tendency to be higher in the elderly in some series [23, 24, 27, 34], being significantly higher in other series [25, 26]. Choi et al. [24] reported that increasing age and positive CE findings were found to be associated with a higher yield. Pattni et al. [28] observed that older patients were more likely to have an abnormal examination (mean age for normal examinations 60.3 years vs. mean age for abnormal examinations 67.9 years, p < 0.001). The superior diagnostic yield in the elderly was also found in CE studies (50.7 vs. 41.2%) [9].

Therapeutic Yield

According to recent evidence, SBE and DBE were similar in their ability to provide endoscopic therapy (Fig. 1) [50, 51], with therapeutic yields ranging from 4 to 48% for SBE [19, 39, 40, 49, 50, 51] and from 9 to 92% for DBE [19, 29, 49, 50, 51, 52, 54]. In the same meta-analysis of Baniya et al. [6], BE was similar to SE in the therapeutic yield reported.

The therapeutic yield in the elderly ranges between 23.5 and 59% [20, 21, 22, 23, 24, 25, 26, 27, 28]. Some studies reported that endoscopic therapy in the elderly was significantly higher [23, 25, 26, 28] than in younger patients, and endoscopic therapy and subsequent intervention after enteroscopy were more often applied in a significantly greater proportion of the former [24, 27]. On the other hand, medical therapy was administered to a higher percentage of younger patients than elderly patients [24]. Increasing age and positive CE findings were factors that predicted a change in management [27].

Complications and Safety

There is increasing data demonstrating that BE is safe, with low complication rates. The complication rates reported range from 0.4 to 5% for DBE [19, 29, 31, 49, 50, 51, 55] and from 0.6 to 5.5% for SBE [19, 39, 49, 50, 51, 56]; when comparing both techniques, they did not show significant differences [49, 50, 51]. Perforation, pancreatitis, bleeding, aspiration pneumonia, intussusception, paralytic ileus, and intestinal necrosis are the main complications in patients undergoing DE [19, 29, 31, 55, 57].

In the elderly, several physiologic changes including increased body fat content and compromised renal and hepatic clearance make the body have higher sensitivity and poorer tolerance for drug administration leading to prolonged recovery and greater risk of oversedation [8]. In these patients, the lowest cumulative dose of sedation is used to minimize complications [29, 58]. The dose of sedation used in the elderly has been significantly lower [24, 27, 28].

Geriatric patients have a reduction in pharyngeal sensitivity leading to a greater risk of aspiration [8], and hypoxia associated with endoscopic procedures under sedation was reported to be more common in these patients [59].

In our review, the highest complication rate reported in the elderly was up to 5.4% [26]. In two studies with only elderly patients, levels of systolic and diastolic blood pressure decreased slightly after DBE [21, 23]. Byeon et al. [21], when evaluating patients older than 75 years of age, reported a complication rate of 3.7%, including pancreatitis, hypoxia and aspiration and pneumonia. Davis-Yadley et al. [25] noted a major complication rate (hemodynamic instability, bowel perforation, and balloon trauma) of 2.25%, with no major complication in the younger group. Also, two other studies reported higher complication rates in the elderly patients, although not significantly different from the younger group [24, 26]. Pinho et al. [19] found that anesthetic complications requiring interruption of the procedures were reported in 9 (0.6%) patients, all under deep propofol sedation, where 6 of them were aged 65 or older (p > 0.05). Conversely, there were some series in which no severe complications were found [20, 23, 27, 34]. In another series, enteroscopy was better tolerated in older patients, despite the fact that the same authors describe only one complication related to sedation in an elderly patient (80 years of age) [28].

Conclusions

When comparing with a younger population, elderly patients usually have more comorbidities and higher use of anticoagulation and antiplatelet agents. Furthermore, they undergo enteroscopy within 24 h of presentation (emergency setting [60, 61]) more often. However, enteroscopy seems to be a safe procedure in this group of patients, with studies reporting a similar complication rate to the general population.

According to this review, the main indication in the elderly for performing enteroscopy was OGIB, as is the case in the general population, but elderly patients have a higher proportion of procedures performed for this indication. This could be explained by the fact that elderly patients more often present angiodysplasia as the main finding in enteroscopy procedures.

There is some evidence that the diagnostic yield and therapeutic success rate of enteroscopy are higher in older patients, which proves that this modality is important and effective in this patient group.

For all these reasons, enteroscopy seems to be a safe and useful procedure in elderly patients, and age, per se, should not be viewed as a limitation for its use.

Disclosure Statement

The authors declare no conflict of interest for this article.

References

  • 1.Ching HL, McAlindon ME, Sidhu R. An update on small bowel endoscopy. Curr Opin Gastroenterol. 2017 May;33((3)):181–8. doi: 10.1097/MOG.0000000000000346. [DOI] [PubMed] [Google Scholar]
  • 2.Pinho R. The Vanishing Frontiers of Therapeutic Enteroscopy. GE Port J Gastroenterol. 2015 Jul;22((4)):133–4. doi: 10.1016/j.jpge.2015.05.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Sidhu R, McAlindon ME, Kapur K, Hurlstone DP, Wheeldon MC, Sanders DS. Push enteroscopy in the era of capsule endoscopy. J Clin Gastroenterol. 2008 Jan;42((1)):54–8. doi: 10.1097/01.mcg.0000225655.85060.74. [DOI] [PubMed] [Google Scholar]
  • 4.Voron T, Rahmi G, Bonnet S, Malamut G, Wind P, Cellier C, et al. Intraoperative Enteroscopy: Is There Still a Role? Gastrointest Endosc Clin N Am. 2017 Jan;27((1)):153–70. doi: 10.1016/j.giec.2016.08.009. [DOI] [PubMed] [Google Scholar]
  • 5.Pennazio M, Spada C, Eliakim R, Keuchel M, May A, Mulder CJ, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2015 Apr;47((4)):352–76. doi: 10.1055/s-0034-1391855. [DOI] [PubMed] [Google Scholar]
  • 6.Baniya R, Upadhaya S, Subedi SC, Khan J, Sharma P, Mohammed TS, et al. Balloon enteroscopy versus spiral enteroscopy for small-bowel disorders: a systematic review and meta-analysis. Gastrointest Endosc. 2017 Dec;86((6)):997–1005. doi: 10.1016/j.gie.2017.06.015. [DOI] [PubMed] [Google Scholar]
  • 7.Qureshi WA, Zuckerman MJ, Adler DG, Davila RE, Egan JV, Gan SI, et al. Standards of Practice Committee, American Society for Gastrointestinal Endoscopy ASGE guideline: modifications in endoscopic practice for the elderly. Gastrointest Endosc. 2006 Apr;63((4)):566–9. doi: 10.1016/j.gie.2006.02.001. [DOI] [PubMed] [Google Scholar]
  • 8.Razavi F, Gross S, Katz S. Endoscopy in the elderly: risks, benefits, and yield of common endoscopic procedures. Clin Geriatr Med. 2014 Feb;30((1)):133–47. doi: 10.1016/j.cger.2013.10.010. [DOI] [PubMed] [Google Scholar]
  • 9.Pérez-Cuadrado-Robles E, Zamora-Nava LE, Jiménez-García VA, Pérez-Cuadrado-Martínez E. Indications for and diagnostic yield of capsule endoscopy in the elderly. Rev Gastroenterol Mex. 2018 Jul-Sep;83((3)):238–44. doi: 10.1016/j.rgmx.2017.08.004. [DOI] [PubMed] [Google Scholar]
  • 10.Clarke GA, Jacobson BC, Hammett RJ, Carr-Locke DL. The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort. Endoscopy. 2001 Jul;33((7)):580–4. doi: 10.1055/s-2001-15313. [DOI] [PubMed] [Google Scholar]
  • 11.Seinelä L, Ahvenainen J, Rönneikkö J, Haavisto M. Reasons for and outcome of upper gastrointestinal endoscopy in patients aged 85 years or more: retrospective study. BMJ. 1998 Aug;317((7158)):575–80. doi: 10.1136/bmj.317.7158.575. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Jafri SM, Monkemuller K, Lukens FJ. Endoscopy in the elderly: a review of the efficacy and safety of colonoscopy, esophagogastroduodenoscopy, and endoscopic retrograde cholangiopancreatography. J Clin Gastroenterol. 2010 Mar;44((3)):161–6. doi: 10.1097/MCG.0b013e3181c64d64. [DOI] [PubMed] [Google Scholar]
  • 13.Karajeh MA, Sanders DS, Hurlstone DP. Colonoscopy in elderly people is a safe procedure with a high diagnostic yield: a prospective comparative study of 2000 patients. Endoscopy. 2006 Mar;38((3)):226–30. doi: 10.1055/s-2005-921209. [DOI] [PubMed] [Google Scholar]
  • 14.Arora A, Singh P. Colonoscopy in patients 80 years of age and older is safe, with high success rate and diagnostic yield. Gastrointest Endosc. 2004 Sep;60((3)):408–13. doi: 10.1016/s0016-5107(04)01715-8. [DOI] [PubMed] [Google Scholar]
  • 15.Katsinelos P, Paroutoglou G, Kountouras J, Zavos C, Beltsis A, Tzovaras G. Efficacy and safety of therapeutic ERCP in patients 90 years of age and older. Gastrointest Endosc. 2006 Mar;63((3)):417–23. doi: 10.1016/j.gie.2005.09.051. [DOI] [PubMed] [Google Scholar]
  • 16.Katsinelos P, Kountouras J, Chatzimavroudis G, Zavos C, Terzoudis S, Pilpilidis I, et al. Outpatient therapeutic endoscopic retrograde cholangiopancreatography is safe in patients aged 80 years and older. Endoscopy. 2011 Feb;43((2)):128–33. doi: 10.1055/s-0030-1255934. [DOI] [PubMed] [Google Scholar]
  • 17.Sousa M, Pinho R, Proença L, Rodrigues J, Silva J, Gomes C, et al. Choledocholithiasis in elderly patients with gallbladder in situ - is ERCP sufficient? Scand J Gastroenterol. 2018 Oct-Nov;53((10-11)):1388–92. doi: 10.1080/00365521.2018.1524022. Epub ahead of print. [DOI] [PubMed] [Google Scholar]
  • 18.Sousa M, Pinho R, Proenca L, Rodrigues J, Silva J, Gomes C, Carvalho J. ASGE high-risk criteria for choledocholithiasis - Are they applicable in cholecystectomized patients? Digestive and liver disease: official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2018;51((1)):75–78. doi: 10.1016/j.dld.2018.09.029. [DOI] [PubMed] [Google Scholar]
  • 19.Pinho R, Mascarenhas-Saraiva M, Mão-de-Ferro S, Ferreira S, Almeida N, Figueiredo P, et al. Multicenter survey on the use of device-assisted enteroscopy in Portugal. United European Gastroenterol J. 2016 Apr;4((2)):264–74. doi: 10.1177/2050640615604775. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.He Q, Zhang Q, Li JD, Wang YD, Wan TM, Chen ZY, et al. Double balloon enteroscopy in the old: experience from China. World J Gastroenterol. 2012 Jun;18((22)):2859–66. doi: 10.3748/wjg.v18.i22.2859. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Byeon JS, Mann NK, Jamil LH, Lo SK. Double balloon enteroscopy can be safely done in elderly patients with significant co-morbidities. J Gastroenterol Hepatol. 2012 Dec;27((12)):1831–6. doi: 10.1111/j.1440-1746.2012.07284.x. [DOI] [PubMed] [Google Scholar]
  • 22.Cangemi DJ, Stark ME, Cangemi JR, Lukens FJ, Gómez V. Double-balloon enteroscopy and outcomes in patients older than 80. Age Ageing. 2015 May;44((3)):529–32. doi: 10.1093/ageing/afv003. [DOI] [PubMed] [Google Scholar]
  • 23.Hegde SR, Iffrig K, Li T, Downey S, Heller SJ, Tokar JL, et al. Double-balloon enteroscopy in the elderly: safety, findings, and diagnostic and therapeutic success. Gastrointest Endosc. 2010 May;71((6)):983–9. doi: 10.1016/j.gie.2009.10.054. [DOI] [PubMed] [Google Scholar]
  • 24.Choi DH, Jeon SR, Kim JO, Kim HG, Lee TH, Lee WC, et al. Double-balloon enteroscopy in elderly patients: is it safe and useful? Intest Res. 2014 Oct;12((4)):313–9. doi: 10.5217/ir.2014.12.4.313. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Davis-Yadley AH, Lipka S, Rodriguez AC, Nelson KK, Doraiswamy V, Rabbanifard R, et al. The safety and efficacy of single balloon enteroscopy in the elderly. Therap Adv Gastroenterol. 2016 Mar;9((2)):169–79. doi: 10.1177/1756283X15614517. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Chang CW, Chang CW, Lin WC, Wu CH, Wang HY, Wang TE, et al. Efficacy and Safety of Single-Balloon Enteroscopy in Elderly Patients. Int J Gerontol. 2017;11((3)):176–8. [Google Scholar]
  • 27.Sidhu R, Sanders DS. Double-balloon enteroscopy in the elderly with obscure gastrointestinal bleeding: safety and feasibility. Eur J Gastroenterol Hepatol. 2013 Oct;25((10)):1230–4. doi: 10.1097/MEG.0b013e3283630f1b. [DOI] [PubMed] [Google Scholar]
  • 28.Pattni V, Tate DJ, Terlevich A, Marden P, Hughes S. Device-assisted enteroscopy in the UK: description of a large tertiary case series under conscious sedation. Frontline Gastroenterol. 2018 Apr;9((2)):122–8. doi: 10.1136/flgastro-2017-100842. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Möschler O, May A, Müller MK, Ell C, German DBE Study Group Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy. 2011 Jun;43((6)):484–9. doi: 10.1055/s-0030-1256249. [DOI] [PubMed] [Google Scholar]
  • 30.Chauhan SS, Manfredi MA, Abu Dayyeh BK, Enestvedt BK, Fujii-Lau LL, Komanduri S, et al. ASGE Technology Committee Enteroscopy. Gastrointest Endosc. 2015 Dec;82((6)):975–90. doi: 10.1016/j.gie.2015.06.012. [DOI] [PubMed] [Google Scholar]
  • 31.Xin L, Liao Z, Jiang YP, Li ZS. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc. 2011 Sep;74((3)):563–70. doi: 10.1016/j.gie.2011.03.1239. [DOI] [PubMed] [Google Scholar]
  • 32.Serrano M, Mao-de-Ferro S, Pinho R, Marcos-Pinto R, Figueiredo P, Ferreira S, Claro I, Mascarenhas-Saraiva M, Dias-Pereira A. Double-balloon enteroscopy in the management of patients with Peutz-Jeghers syndrome: a retrospective cohort multicenter study. Revista espanola de enfermedades digestivas: organo oficial de la Sociedad Espanola de Patologia Digestiva. 2013;105:594–599. doi: 10.4321/s1130-01082013001000004. [DOI] [PubMed] [Google Scholar]
  • 33.May A. Double-Balloon Enteroscopy. Gastrointest Endosc Clin N Am. 2017 Jan;27((1)):113–22. doi: 10.1016/j.giec.2016.08.006. [DOI] [PubMed] [Google Scholar]
  • 34.Chen WG, Shan GD, Zhang H, Yang M, L L, Yue M, et al. Double-balloon enteroscopy in small bowel diseases: eight years single-center experience in China. Medicine (Baltimore) 2016 Oct;95((42)):e5104. doi: 10.1097/MD.0000000000005104. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Lin MC, Chen PJ, Shih YL, Huang HH, Chang WK, Hsieh TY, et al. Outcome and Safety of Anterograde and Retrograde Single-Balloon Enteroscopy: Clinical Experience at a Tertiary Medical Center in Taiwan. PLoS One. 2016 Aug;11((8)):e0161188. doi: 10.1371/journal.pone.0161188. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Tao Z, Liu GX, Cai L, Yu H, Min XJ, Gan HT, et al. Characteristics of Small Intestinal Diseases on Single-Balloon Enteroscopy: A Single-Center Study Conducted Over 6 Years in China. Medicine (Baltimore) 2015 Oct;94((42)):e1652. doi: 10.1097/MD.0000000000001652. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Di Caro S, May A, Heine DG, Fini L, Landi B, Petruzziello L, et al. DBE-European Study Group The European experience with double-balloon enteroscopy: indications, methodology, safety, and clinical impact. Gastrointest Endosc. 2005 Oct;62((4)):545–50. doi: 10.1016/j.gie.2005.04.029. [DOI] [PubMed] [Google Scholar]
  • 38.Sunada K, Yamamoto H. Double-balloon endoscopy: past, present, and future. J Gastroenterol. 2009;44((1)):1–12. doi: 10.1007/s00535-008-2292-4. [DOI] [PubMed] [Google Scholar]
  • 39.Upchurch BR, Sanaka MR, Lopez AR, Vargo JJ. The clinical utility of single-balloon enteroscopy: a single-center experience of 172 procedures. Gastrointest Endosc. 2010 Jun;71((7)):1218–23. doi: 10.1016/j.gie.2010.01.012. [DOI] [PubMed] [Google Scholar]
  • 40.Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Rao GV, et al. Diagnostic yield and therapeutic impact of single-balloon enteroscopy: series of 106 cases. J Gastroenterol Hepatol. 2009 Oct;24((10)):1631–8. doi: 10.1111/j.1440-1746.2009.05936.x. [DOI] [PubMed] [Google Scholar]
  • 41.Zhang BL, Chen CX, Li YM. Capsule endoscopy examination identifies different leading causes of obscure gastrointestinal bleeding in patients of different ages. The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology. 2012;23:220–225. doi: 10.4318/tjg.2012.0338. [DOI] [PubMed] [Google Scholar]
  • 42.Silva JC, Pinho R, Rodrigues A, Ponte A, Rodrigues JP, Sousa M, et al. Yield of capsule endoscopy in obscure gastrointestinal bleeding: A comparative study between premenopausal and menopausal women. World J Gastrointest Endosc. 2018 Oct;10((10)):301–7. doi: 10.4253/wjge.v10.i10.301. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Pasha SF, Leighton JA, Das A, Harrison ME, Decker GA, Fleischer DE, et al. Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis. Clin Gastroenterol Hepatol. 2008 Jun;6((6)):671–6. doi: 10.1016/j.cgh.2008.01.005. [DOI] [PubMed] [Google Scholar]
  • 44.Fukumoto A, Tanaka S, Shishido T, Takemura Y, Oka S, Chayama K. Comparison of detectability of small-bowel lesions between capsule endoscopy and double-balloon endoscopy for patients with suspected small-bowel disease. Gastrointest Endosc. 2009 Apr;69((4)):857–65. doi: 10.1016/j.gie.2008.06.007. [DOI] [PubMed] [Google Scholar]
  • 45.Teshima CW, Kuipers EJ, van Zanten SV, Mensink PB. Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis. J Gastroenterol Hepatol. 2011 May;26((5)):796–801. doi: 10.1111/j.1440-1746.2010.06530.x. [DOI] [PubMed] [Google Scholar]
  • 46.Sethi S, Cohen J, Thaker AM, Garud S, Sawhney MS, Chuttani R, et al. Prior capsule endoscopy improves the diagnostic and therapeutic yield of single-balloon enteroscopy. Dig Dis Sci. 2014 Oct;59((10)):2497–502. doi: 10.1007/s10620-014-3178-3. [DOI] [PubMed] [Google Scholar]
  • 47.Chong AK, Chin BW, Meredith CG. Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy. Gastrointest Endosc. 2006 Sep;64((3)):445–9. doi: 10.1016/j.gie.2006.04.007. [DOI] [PubMed] [Google Scholar]
  • 48.Louro-da-Ponte AI, Taveira-Pinho R, Rodrigues MA, Pinto-Pais MT, Pinho Fernandes CD, Ribeiro IC, Silva JI, Rodrigues-Carvalho J. Advances and pitfalls in the management of small bowel polyps in Peutz-Jeghers syndrome. Revista espanola de enfermedades digestivas: organo oficial de la Sociedad Espanola de Patologia Digestiva. 2015;107:390–391. [PubMed] [Google Scholar]
  • 49.Kim TJ, Kim ER, Chang DK, Kim YH, Hong SN. Comparison of the Efficacy and Safety of Single- versus Double-Balloon Enteroscopy Performed by Endoscopist Experts in Single-Balloon Enteroscopy: A Single-Center Experience and Meta-Analysis. Gut Liver. 2017 Jul;11((4)):520–7. doi: 10.5009/gnl16330. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Lipka S, Rabbanifard R, Kumar A, Brady P. Single versus double balloon enteroscopy for small bowel diagnostics: a systematic review and meta-analysis. J Clin Gastroenterol. 2015 Mar;49((3)):177–84. doi: 10.1097/MCG.0000000000000274. [DOI] [PubMed] [Google Scholar]
  • 51.Wadhwa V, Sethi S, Tewani S, Garg SK, Pleskow DK, Chuttani R, et al. A meta-analysis on efficacy and safety: single-balloon vs. double-balloon enteroscopy. Gastroenterol Rep (Oxf) 2015 May;3((2)):148–55. doi: 10.1093/gastro/gov003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.May A, Färber M, Aschmoneit I, Pohl J, Manner H, Lotterer E, et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol. 2010 Mar;105((3)):575–81. doi: 10.1038/ajg.2009.712. [DOI] [PubMed] [Google Scholar]
  • 53.Heine GD, Hadithi M, Groenen MJ, Kuipers EJ, Jacobs MA, Mulder CJ. Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease. Endoscopy. 2006 Jan;38((1)):42–8. doi: 10.1055/s-2005-921188. [DOI] [PubMed] [Google Scholar]
  • 54.Messer I, May A, Manner H, Ell C. Prospective, randomized, single-center trial comparing double-balloon enteroscopy and spiral enteroscopy in patients with suspected small-bowel disorders. Gastrointest Endosc. 2013 Feb;77((2)):241–9. doi: 10.1016/j.gie.2012.08.020. [DOI] [PubMed] [Google Scholar]
  • 55.Mensink PB, Haringsma J, Kucharzik T, Cellier C, Pérez-Cuadrado E, Mönkemüller K, et al. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy. 2007 Jul;39((7)):613–5. doi: 10.1055/s-2007-966444. [DOI] [PubMed] [Google Scholar]
  • 56.Aktas H, de Ridder L, Haringsma J, Kuipers EJ, Mensink PB. Complications of single-balloon enteroscopy: a prospective evaluation of 166 procedures. Endoscopy. 2010 May;42((5)):365–8. doi: 10.1055/s-0029-1243931. [DOI] [PubMed] [Google Scholar]
  • 57.Teshima CW. Small bowel endoscopy for obscure GI bleeding. Best Pract Res Clin Gastroenterol. 2012 Jun;26((3)):247–61. doi: 10.1016/j.bpg.2012.01.020. [DOI] [PubMed] [Google Scholar]
  • 58.Triantafillidis JK, Merikas E, Nikolakis D, Papalois AE. Sedation in gastrointestinal endoscopy: current issues. World J Gastroenterol. 2013 Jan;19((4)):463–81. doi: 10.3748/wjg.v19.i4.463. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Külling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary? Gastrointest Endosc. 2007 Sep;66((3)):443–9. doi: 10.1016/j.gie.2007.01.037. [DOI] [PubMed] [Google Scholar]
  • 60.Rodrigues JP, Pinho R, Rodrigues A, Sousa M, Silva JC, Gomes C, et al. Diagnostic and therapeutic yields of urgent balloon-assisted enteroscopy in overt obscure gastrointestinal bleeding. Eur J Gastroenterol Hepatol. 2018 Nov;30((11)):1304–8. doi: 10.1097/MEG.0000000000001244. [DOI] [PubMed] [Google Scholar]
  • 61.Pinto-Pais T, Pinho R, Rodrigues A, Fernandes C, Ribeiro I, Fraga J, et al. Emergency single-balloon enteroscopy in overt obscure gastrointestinal bleeding: efficacy and safety. United European Gastroenterol J. 2014 Dec;2((6)):490–6. doi: 10.1177/2050640614554850. [DOI] [PMC free article] [PubMed] [Google Scholar]

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