Which Direction is Best for Enteroscopy?

Antegrade is better than retrograde enteroscopy in diagnosis and treatment of patients with small bowel disease, according to the August issue of Clinical Gastroenterology and Hepatology.

Single and double balloon-assisted enteroscopy (SBE and DBE), and spiral enteroscopy (which uses a screw-like overtube), are used to evaluate and treat patients with small-bowel mucosal diseases.

The most commonly used approach is the antegrade approach, via the mouth. Retrograde enteroscopy, performed through the rectum, allows the endoscopist to view the distal small intestine. However, the retrograde procedure is technically more challenging—21% of DBEs fail at terminal ileal intubation. Depths of insertion into the small bowel from retrograde DBE and SBE are also much lower than those of antegrade procedures.

Madhusudhan R. Sanaka et al. compared the efficacy of antegrade vs retrograde approaches for the different enteroscopy systems, based on diagnosis and treatment of suspected small-bowel disease.

They found that the diagnostic and therapeutic yields were significantly greater for antegrade than retrograde enteroscopy.

Diagnostic and therapeutic yields of antegrade and retrograde enteroscopy.

Furthermore, antegrade procedures were of shorter duration than retrograde enteroscopy (an average of 44.3 vs 58.9 minutes), and the mean depth of maximal insertion was significantly greater with antegrade endoscopy (an average of 231.8 vs 103.4 cm). There were no significant differences in complications.

The most common indication for small-bowel endoscopy among patients in this study was obscure gastrointestinal bleeding. In an editorial that accompanies the article, Klaus Mönkemüller says that this makes the findings especially relevant to daily clinical practice.

Sanaka et al. conclude that antegrade enteroscopy should be used as the initial approach for suspected small-bowel disease, and that retrograde enteroscopy be considered when findings are not clear or if the abnormalities identified are unlikely to account for the patient’s symptoms.

Mönkemüller says this conclusion applies for conditions that occur most frequently in the proximal jejunum, but this does not mean that clinicians should always take the “easier route” (antegrade)—all information should be considered when selecting the route for entrance into the small bowel.

He warns that retrograde enteroscopy could be best for patients with hematochezia and history of pelvic radiation, who are likely to have radiation ileitis, rather than jejunitis. Retrograde enteroscopy also should be considered if capsule endoscopy or radiologic imaging studies clearly indicate defects in the distal small-bowel, such as in patients with suspected Crohn’s disease. For this reason Mönkemüller proposes dividing small diseases into those that mostly affect the jejunum, the ileum, or both.

Because this was a retrospective analysis, prospective randomized studies are needed to compare the efficacy of these approaches.

Read the article online.
Sanaka MR, Navaneethan U, Kosuru B, et al. Antegrade is more effective than retrograde enteroscopy for evaluation and management of suspected small-bowel disease. Clin Gastroenterol Hepatol 2012;10:910-916.

Read the accompanying editorial.
Mönkemüller K. Should we illuminate the black box of the small bowel mucosa from above or below? Clin Gastroenterol Hepatol 2012;10:917-919.

About Kristine Novak, PhD, Science Editor

Dr. Kristine Novak is the science editor for Gastroenterology and Clinical Gastroenterology and Hepatology, both published by the American Gastroenterological Association. She has worked as an editor at biomedical research journals and as a science writer for more than 12 years, covering advances in gastroenterology, hepatology, cancer, immunology, biotechnology, molecular genetics, and clinical trials. She has a PhD in cell biology and an interest in all areas of medical research.
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