Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy

Background: Capsule endoscopy (CE) is increasingly being used to investigate the small bowel for various indications, including obscure GI bleeding (OGB). However, false negatives have been described. Double-balloon enteroscopy (DBE) is a new endoscopic technique developed to potentially view the entire small intestine while allowing therapeutic options to be carried out when appropriate. Objective: We described 4 patients with small-bowel pathology missed on CE but detected by DBE. Design: Descriptive retrospective study. All patients underwent CE followed by DBE. Setting: Single-center tertiary referral hospital. Patients: Four patients were included. Three patients had OGB that required blood transfusions. One patient with celiac disease, compliant on a strict gluten-free diet for 5 months, presented with persistent weight loss and abdominal pain. Interventions: DBE followed by surgical exploration and resection of small-bowel pathology. Main Outcome Measurements: Successful identification of pathology missed by CE. Definitive treatment of small-bowel pathology by surgical resection. Results: CE did not identify the small-bowel pathology in all 4 patients. The 3 patients with OGB had small-bowel masses found by DBE. Two of these were GI stromal tumors and one was an adenocarcinoma. The patient with celiac disease had a malignant ulcer, confirmed to be a lymphoma after surgical resection. Limitations: Retrospective study and small sample size. Conclusions: CE and DBE are complementary investigations. If there is a high index of suspicion of small-bowel pathology despite a negative CE, DBE should be performed.