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  • Pennazio
  • Pennazio
  • Pennazio
  • Diese 5% sind es, die den Endoskopikern am meisten Kopfzerbrechen machen, denn der Dünndarm ist mit endoskopischen Methoden traditioneller Weise schwerer evaluierbar als der Rest des GI-Traktes. Aber eben hier haben sich in den letzten Jahren die Methoden neu entwickelt und darüber möchte ich hier referieren. Welches Armentarium haben wir zur Dünndarmdiagnostik an der Hand ?
  • Pennazio
  • Pennazio
  • Pennazio

R.marmo l. l'enteroscopia R.marmo l. l'enteroscopia Presentation Transcript

  • Forum Nazionale di Gastroenterologia “AIGO 2010” L’enteroscopia R. Marmo Roma, Palazzo della Cancelleria , 14 -15 Maggio 2010
  • Publications Number – Assisted Enteroscopy 2001 - 2009
  • Prospective Multicenter Trial Comparing Push-and- Pull Enteroscopy With the Single- and Double-Balloon Techniques in Patients With Small-Bowel Disorders Andrea May et al .Am J Gastroenterol 2010; 105:575–581 Double Balloon Single balloon p Complete enteroscopy ( n , % ) 33 / 50 (66 % ) 11 / 50 (22 % ) <0.0001 Therapeutic yield ( n , % ) 36 / 50 (72 % ) 24 / 50 (48 % ) <0.025
  • Prospective Multicenter Trial Comparing Push-and- Pull Enteroscopy With the Single- and Double-Balloon Techniques in Patients With Small-Bowel Disorders Andrea May et al .Am J Gastroenterol 2010; 105:575–581 Double Balloon Single balloon p Complete enteroscopy ( n , % ) 33 / 50 (66 % ) 11 / 50 (22 % ) <0.0001 Therapeutic yield ( n , % ) 36 / 50 (72 % ) 24 / 50 (48 % ) <0.025
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  • Diagnostic gain CE vs DB Marmo R et al DLD sept 2007
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  • MAJOR LIMITS V.C.E : ORIENTATION BIOPSY CLEANING
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  • Controindication to Capsule enteroscopy Pohl J et al. Current status of DBE…Endoscopy 2008; 40: 156 -160
  • CE SHOWING ONLY BLOOD OR CLOTS IN THE LUMEN WHAT TO DO? Courtesy dr. Pennazio
  • DBE clarified the origin of bleeding in 2/3 of patients with CE showing only blood or clots in the lumen
  •  
  • Lesions of mid gastrointestinal tract and treatment Bleeding lesions Polyps, tumors Stenosis Foreign bodies Polypectomy EMR Dilation, stent Extraction Injection, thermal, mechanical therapy PEG, PEJ ERCP
  • Indications for DBE
    • No. (%)
    • OGIB 98 (62.8%)
    • Obstruction 14 (8.9%)
    • Tumor 13 (8.3%)
    • Inflammatory bowel disease 10 (6.4%)
    • Investigation for postoperative GI tract 9 (5.8%)
    • Further evaluation SBD 3 (1.9%)
    • Foreign body 2 (1.3%)
    • Miscellaneous 14 (8.9%)
    • Total 163 (100%)
  • Bleeding lesions - Angiodysplasias
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  •  
  • Rebleeding-free interval after first DBE for 50 patients with OGIB N.Ohmiya et al. Gastrointest. Endosc 2007;66:S72-7.
  • DB Endoscopic treatment Occult Overt Bleeding Pennazio M. Gastrointest Endosc Clin N Am 2009
  • 59% 24% 18% Outcomes data at 30-month follow-up after DBE (n=85)
    • Patients with AVMs or normal examinations to the depth of insertion are most likely to report recurrent hemorrhage.
  • Marmo et al.Endoscopy 2009, 41: 587-592 Capsule Endoscopy Double Balloon Endoscopy No lesion detected 18/193 (9.3%) No lesion detected 61/193 (31.6%) Negative also on DBE 11/18 Negative also on CE 11/61 Positive findings on DBE Vascular lesion Ulcer(s) Jejunal diverticula Neoplasia 7 2 (10.51%) 2 (10.5%) 2 (10.5%) 1(5.5%) Positive findings on CE Vascular lesion Mass n eoplasia Polyp(s) Ulcer(s) Blood or clots in the lumen Other 50 13 (2.3%) 8 (13.1%) 7 (11.5%) 6 (9.8%) 12 (19.7%) 4 (7.2%)
  • Mehdizadeh GIE 2006 Kaffes GIE 2006 Marmo Endoscopy 2009 M ö nkem ü ller Endoscopy 2006 Heine Endoscopy 2006 May GIE 2005 Yamamoto CGH 2004 0% 5% 8% 20% 35% 42% 45% 86% Zhong Endoscopy 2007 56% Eenteroscopia in 2 sessioni (%) 61% Ohmiya GIE 2007 Occidente Oriente Gross GIE 2008 Total enteroscopy DB
  • Endoscopic treatment failure
    • The use of hormonal therapy is highly controversial;
    • ineffective in a randomized controlled trial.
    • The somatostatin analogue octreotide has been examined as a therapy for diffuse vascular ectasia bleeding. However, controlled studies have not been
    • performed. .
    Rockey, D. C. Nat. Rev. Gastroenterol. Hepatol. May 7, 265–279;2010
  • Endoscopic treatment failure
    • The use of hormonal therapy is highly controversial;
    • ineffective in a randomized controlled trial.
    • The somatostatin analogue octreotide has been examined as a therapy for diffuse vascular ectasia bleeding. However, controlled studies have not been
    • performed. .
    Rockey, D. C. Nat. Rev. Gastroenterol. Hepatol. May 7, 265–279;2010
  • Octreotide for mid-GI-bleeding
    • 12 papers (4 on LAR) mainly case reports and not controlled studies
    • The results are positive and the effect seems to remain even after drug suspension
    • A sigle controlled (not randomized) study:
      • 32 vs 38 patients
      • Recurrence of bleeding in 23% vs 48%
      • 77- 68% vs 55-36% free of bleeding at 1 and 2 yrs
      • No difference in nr of bleeding and blood transfusions
    Junquera et al, Am J Gastroenterol 2007
  •  
    • 17 /114 DBE emergency < 24 hrs
    • (9 oral ; 8 anal )
    • 10 pts mean age 68
    • Mean Hb 7.4 g/dL, range 4.2–8.4.
    • ASA median (American Society of Anesthesiologists) 2
    Endoscopy 2009; 41: 715–717
  • Diagnosis and treatment 9/10 pts ongoing bleeding
    • Neoplasia n = 4
    • Dieulafoy n = 2
    • Vascular lesion n = 2
    • Crohn’s disease n = 1
    • 13 / 108
    • Mean age 61 years
    • Mean Hb gr/dl 7.2 ± 2.8
    Gastrointest Endosc 2008;68:683-91
    • Neoplasia n = 6
    • Vascular lesion n = 6 (1 Surgery)
    • Crohn’s disease n = 1
    Diagnosis and treatment 13/13 pts ongoing bleeding
  •  
  • Endoscopic Interventions in the Small Bowel Using Double Balloon Enteroscopy A. May et al. Am J Gastroenterol 2007;102:527–535
  • Outcome after double balloon dilatation H. Tochigi Gastrointest Endosc 2007;66:S108-12 Surgery Relapse Long term success Crohn’s disease 23 pts 2 (8.7%) 4 (17.4%) 17 (73.9%)
  • Failure Double Balloon Enteroscopy
    • 9 cases (4.6 %)
    • 1) 7 terminal ileum not explored
    • 2 duodenum not explored
    • 1 tongue 1 pylorus stricture
    R. Marmo , Endoscopy. 2009 ;41(7):587-92
    • 6/178 (3.4%)
    • Polipectomy (N = 2)
    • Dilation (N = 3)
    • Stenting (N = 1)
    • Anatomical or technical reasons
    May A - Am J Gastroenterol - 01-MAR-2007; 102(3): 527-35 Failure on intention treatment Double Balloon Enteroscopy
  • Therapeutic enteroscopy complications
    • 2367 procedures
    • 4.3 % therapeutics (bleeding, perforation APC , dilation, polipectomy)
    Mensik P GE 2007 May et al AJG 2007
    • 2476 patients
    Pancreatitis 6 (0.2%), 1 anal route Bleeding 4 (0.2%) Perforation 11 (0.4%), L. B. GERSON et al. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009; Enteroscopy diagnostic Patients with normal anatomy
  • Complications Perforation
    • Previous surgery 8/ 219 (3.6%) vs
    • Normal anatomy 11/ 2476 (0.4%)
    • O.R. 7.4 [C.L. 95% 2.4 – 21.1]
    • p <.005
  • Forum Nazionale di Gastroenterologia “AIGO 2010” L’enteroscopia R. Marmo Roma, Palazzo della Cancelleria , 14 -15 Maggio 2010 Grazie dell’attenzione
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  • Publications Number – Assisted Enteroscopy 2001 - 2009
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  •