| Small bowel bleeding(SBB)refers to the hemorrhage between the duodenal papilla and the ileocecal valve,which is also known as middle gastrointestinal bleeding.Small bowel bleeding is insidious,accounting for about 5%-10%of patients with gastrointestinal bleeding.Due to the complex anatomical structure of the small intestine,the diagnosis and treatment of small intestinal bleeding have become a difficult clinical problem.In recent years,the diagnosis and treatment of small bowel bleeding has become possible with the clinical application and promotion of Balloon assisted enteroscopy(BAE),including Double Balloon enteroscopy(DBE),Single Balloon enteroscopy(SBE),Capsule endoscopy(CE),and small bowel radiography.Studies have shown that the disease detection rate of DBE in patients with small bowel bleeding is 60%-80%,and in the clinic,even after bilateral DBE examination,about 20%-40%of patients with small bowel bleeding cannot be identified as the cause of bleeding.How to improve the diagnosis and treatment efficiency of DBE in patients with small bowel bleeding is a difficult problem that urgently needs to be discussed in the clinic.The clinical information was collected of underwent DBE for suspected small bowel bleeding at Air Force Medical Center from January 2015 to October 2020.The purpose of this study is how to improve the diagnosis and treatment efficiency of DBE for patients with small intestinal hemorrhage by studying the timing of endoscopy,the choice of approach,and endoscopic treatment,etc.1.The study of time limit of double balloon enteroscopy in small bowel bleedingIn this part,we discussed the diagnostic value of emergency DBE in patients with small bowel bleeding.The clinical information was collected from 328 patients who underwent DBE for suspected small bowel bleeding at Air Force Medical Center from January 2015 to October 2020.After inclusion and exclusion criteria,282 patients were finally included.The 282patients included were divided into emergence DBE group and non-emergence DBE group according to the timing of the DBE examination.The overall detection rate of lesions,disease types,and adverse reactions were compared between the two groups.The research findings show among 282patients,224 patients had identified the causes of bleeding,and the overall lesion detection rate was 79.43%(224/282).Of the 103 patients in the emergency DBE group,89 patients have identified the cause of bleeding,and the lesion detection rate was 86.41%(89/103).Among 179 patients in the non-emergence DBE group,135 patients have identified the cause of bleeding,and the lesion detection rate was 75.42%(135/179).The detection rate of the emergence DBE group was higher than that of the non-emergence DBE group,and the difference was statistically significant(P<0.05).Comparing the disease composition ratio between the two groups,it was found that small intestinal vascular diseases in the emergence DBE group were significantly higher than those in the non-emergence DBE group[35.92%(37/103)vs 16.76%(30/179),P<0.05].There was no difference between the two groups in intestinal diverticulum,small intestinal tumor,small intestinal inflammatory disease,NSAIDS-related intestinal disease,or other diseases.The above results indicated that the emergence DBE can improve the detection rate of patients with small bowel bleeding(especially intestinal vascular diseases).2.The study of double balloon enteroscopy on the choice of approach in patients with small bowel bleedingTo evaluate the value of blood urea nitrogen(BUN)/creatinine(Cr)ratio for guiding the access route of double-balloon endoscopy(DBE)for small intestinal bleeding.The clinical information was collected from 105 patients who underwent DBE for small bowel bleeding at Air Force Medical Center from January 2015 to October 2019.Patients were divided into the elevated group(n=52)and the normal BUN/Cr group(n=53),with a cut-off value of 81.The comparison was made for the detection rate of lesions between the oral route and anal route separately in the two groups using the chi-square test.The results show that among the 105 patients with suspected small bowel bleeding,definite causes of bleeding were identified in 79 patients by DBE,and the overall lesion detection rate was 75.24%(79/105).In the elevated BUN/CR group,the overall lesion detection rate was 76.92%(40/52),among which 79.49%(31/39)was through oral and 47.37%(9/19)through anal endoscopy In the normal BUN/CR group,the overall lesion detection rate was 73.58%(39/53)and 63/64%(21/33)was transoral,and 51.43%(18/35)transanal.The lesion detection rate of transoral endoscopy in the elevated group was significantly higher than that in the normal group(c~2=6.576,P<0.05).There was no significant difference in the lesion detection rate of transanal endoscopy between the two groups(c~2=2.230,P>0.05).The sensitivity,specificity,positive predictive value,and negative predictive value of BUN/Cr ratio>81 were 86.96%(20/23),73.68%(14/19),80.00%(20/25)and 82.35%(14/17)for transoral endoscopy.The above results suggest that BUN/Cr(within 48h of active bleeding)>81is an effective indicator to guide transoral endoscopy in patients with potential small bowel bleeding3.Effect analysis of double balloon endoscopy in the treatment of small intestinal vascular diseasesTo explore the efficacy of endoscopic therapy via double-balloon endoscopy(DBE)for small intestinal vascular lesions and to explore risk factors associated with rebleeding in small intestinal vascular lesions.Clinical information was retrospectively collected for 67 patients of suspected small intestinal vascular lesions at our center.They were divided into the DBE treatment group[Different methods of endoscopic treatment were selected according to different modes of bleeding.According to Yano-Yamamoto classification,APC was used type 1a and 1b.Yano2 and Yano3were mainly arterial lesions,and titanium-clamps combined with submucosal injection of lauromacrogol hardener were selected]and non-DBE treatment group.They were closely followed up until bleeding recurrent or the last follow-up date(January 31,2021).The median duration of follow-up was 13.00 months(range 1.00-70.00 months).Risk factors analyses were performed by the multi-factors Logistic Regression Model based on the results of univariate analyses.The research findings show forty-seven patients showed the DBE treatment group included single vascular lesions of thirty patients and multiple vascular lesions of seventeen patients.Twenty patients showed the non-DBE treatment group,which are single vascular lesions.The recurrence rate of hemorrhage in the DBE treated single vascular lesions group was lower than that non-DBE treated single vascular lesions group(20.00%vs 70.00%P<0.05).The recurrence rate of hemorrhage in the DBE treated single vascular lesions group was lower than that of DBE treatment of multiple vascular lesions group(20.00%vs 52.94%,P<0.05).Multivariate Logistic regression analysis was performed in 29patients with recurrent hemorrhage identified that transfusion(P<0.05,OR=3.748,95%CI:0.997-14.093)and valvular heart disease(P<0.05,OR:0.162,95%CI:0.042-0.622)were an independent predictor of rebleeding.DBE treatment was a protective factor for recurrent bleeding(P<0.05,OR=0.214,95%CI:0.057-0.808)The result prove that endoscopic therapy via DBE is an effective method for small intestinal vascular lesions.Patients with transfusion and valvular heart disease are more likely to rebleed.In summary,this experiment concluded that emergency DBE examination can improve the detection rate of small bowel bleeding.In patients with potential small bowel bleeding.serum BUN/Cr>81 within 48hours of active bleeding is an effective indicator to guide transoral endoscopy examination.Endoscopic treatment of small intestinal vascular lesions is effective,especially for patients with single vascular lesions.Valvular heart disease and blood transfusion during the course of the disease were independent risk factors for recurrent bleeding in small intestinal vascular lesions.This study suggests that the timing of DBE examination,the selection of endoscopic approach and endoscopic treatment can improve the diagnosis and treatment efficiency of double-balloon endoscopy for small bowel bleeding. |
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