Double-balloon enteroscopy and outcomes in patients older than 80.

BACKGROUND: double-balloon enteroscopy (DBE) is becoming more commonly used for investigation of small bowel pathology. Currently, there are limited data to describe its safety and efficacy in the population over age 65. AIM: to investigate the indications, findings and outcomes of DBE performed in patients older than 80, as well as the correlation between DBE and prior capsule endoscopy (CE) findings. METHODS: we retrospectively reviewed our large DBE database, including procedures from January 2006 to September 2012. Patients aged 80 or older at the time of DBE were included in the study. The indications, findings, outcomes and diagnostic yield of DBE were calculated by frequency analysis. RESULTS: two hundred and fifteen DBEs were performed in 130 patients aged 80 or older. The mean age was 83.6 ± 3.03 years (range: 80-94). Twelve patients (9.2%) were assigned an American Society of Anaesthesiologists score of II prior to procedure, 102 patients (78.4%) were assigned a score of III and 16 patients (12.3%) were given a score of IV. The most common indication for DBE was obscure gastrointestinal bleeding (N = 204, 94.9%). One hundred and fourteen patients (87.7%) underwent CE prior to DBE, and correlation between findings of CE and DBE occurred in 74.6% of these patients. The overall diagnostic yield of DBE was 77.2% (N = 166). There were no immediate post-procedural complications or failed procedures. CONCLUSION: DBE is a safe and effective technique for investigation of the small bowel in patients aged 80 and older. Age alone should not be a contraindication to performing DBE when clinically indicated.

Safety of capsule endoscopy in the octogenarian as compared with younger patients.

BACKGROUND: There has been an increased use of capsule endoscopy for the evaluation of small-intestine pathology in very elderly patients, yet the safety profile of this procedure has not been well-established. OBJECTIVE: To estimate the adverse event rate of capsule endoscopy in patients aged ≥80 years and to compare this rate with that of capsule endoscopy patients aged <80 years. DESIGN: Retrospective matched cohort study. SETTING: Single tertiary-care referral center. PATIENTS: All 195 patients aged ≥80 years who underwent capsule endoscopy between 2005 and 2011 were included, along with 585 capsule endoscopy patients aged <80 years who were matched by sex in a 1:3 fashion. INTERVENTION: All patients underwent capsule endoscopy and, in selected cases, double-balloon enteroscopy. MAIN OUTCOME MEASUREMENTS: Adverse event rate of capsule endoscopy, which was defined as capsule retention or aspiration. RESULTS: Adverse events occurred at a similar frequency in patients aged ≥80 years compared with those aged <80 years (1.03% vs 0.85%; P = 1.00), resulting in a difference of 0.2% (95% confidence interval, -1.8% to 2.1%). All adverse events were related to capsule retention, with no study patients experiencing aspiration. LIMITATIONS: This was a single-center, retrospective study. CONCLUSION: Adverse events resulting from capsule endoscopy occur at a similar rate in patients aged ≥80 years compared with those aged <80 years. Capsule endoscopy can be performed safely in the very elderly patient population.

Small bowel tumors discovered during double-balloon enteroscopy: analysis of a large prospectively collected single-center database.

BACKGROUND: The emergence of capsule endoscopy and double-balloon enteroscopy (DBE) has greatly enhanced the management of small bowel tumors (SBTs). DBE is particularly useful as a diagnostic modality because it allows for direct investigation of the gastrointestinal lumen, yet little data exist regarding its clinical efficacy. AIM: : To determine the diagnostic yield of DBE in detection of SBTs. METHODS: We restrospectively reviewed our large prospectively collected DBE database from September 2005 to May 2012. Patients who were diagnosed with SBTs by DBE were included in the study. The diagnostic yield of DBE in detection of SBTs was calculated by frequency analysis. RESULTS: A total of 1106 patients underwent 1652 DBE procedures. Of these patients, 134 (12.1%) were found to have an SBT. The majority (56.7%) of patients diagnosed with SBT were male, and the average age at the time of diagnosis was 64 years (SD±14 y). Indications for performing DBE included suspected mass lesion in 54.5% (73/134) of SBT patients, obscure gastrointestinal bleeding in 26.9% (36/134), and overt gastrointestinal bleeding in 14.9% (20/134). The most common SBTs identified were: carcinoid (26/134, 19.4%), hamartoma (14/134, 10.4%), inflammatory polyp (11/134, 8.2%), gastrointestinal stromal tumor (10/134, 7.5%), and lymphoma (10/134, 7.5%). CONCLUSIONS: DBE is a valuable tool in the evaluation of SBTs. The incidence of SBTs in our patient population was significantly higher than the generally accepted incidence for the overall population, but was comparable with other similar studies. Carcinoid tumor was the most common SBT identified, and was most often seen in the ileum.

Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett's Esophagus.

BACKGROUND & AIMS: High-resolution endoscopy with narrow band imaging (NBI) enhances the visualization of mucosal glandular and vascular structures. This study assessed whether narrow band targeted biopsies could detect advanced dysplasia using fewer biopsy samples compared with standard resolution endoscopy. METHODS: We conducted a prospective, blinded, tandem endoscopy study in a tertiary care center with 65 patients with Barrett's esophagus undergoing evaluation for previously detected dysplasia. Standard resolution endoscopy was used first to detect visible lesions. Narrow band endoscopy was then used by another gastroenterologist to detect and biopsy areas suspicious for dysplasia. The lesions initially detected by standard resolution endoscopy were then disclosed and biopsied, after biopsy of the lesions targeted with NBI. Finally, random 4-quadrant biopsies were taken throughout the segment of Barrett's mucosa. RESULTS: Higher grades of dysplasia were found by NBI in 12 patients (18%), compared with no cases (0%) in whom standard resolution white light endoscopy with random biopsy detected a higher grade of histology (P < .001). Correspondingly, narrow band directed biopsies detected dysplasia in more patients (n = 37; 57%) compared with biopsies taken using standard resolution endoscopy (n = 28; 43%). In addition, more biopsies were taken using standard resolution endoscopy with random biopsy compared with narrow band targeted biopsies (mean 8.5 versus 4.7; P < .001). CONCLUSIONS: In patients evaluated for Barrett's esophagus with dysplasia, NBI detected significantly more patients with dysplasia and higher grades of dysplasia with fewer biopsy samples compared with standard resolution endoscopy.

Investigation of the excluded stomach after Roux-en-Y gastric bypass: the role of percutaneous endoscopy.

Accessing the bypassed portion of the stomach via conventional endoscopy is difficult following Roux-en-Y gastric bypass surgery. However, endoscopic examination of the stomach and small bowel is possible through percutaneous access into the bypassed stomach (BS) with a combined radiologic and endoscopic technique. We present a case of obscure overt gastrointestinal (GI) bleeding where the source of bleeding was thought to be from the BS. After conventional endoscopic methods failed to examine the BS, percutaneous endoscopy (PE) was used as an alternative to surgical exploration.

Yield of double-balloon enteroscopy in the diagnosis and treatment of small bowel strictures.

BACKGROUND: Small bowel strictures are common in gastroenterology practice. We report diagnostic and therapeutic yield of double-balloon enteroscopy for small bowel strictures. METHODS: Retrospective study of 71 consecutive patients who were found to have small bowel stricture at the time of double-balloon enteroscopy. RESULTS: During double-balloon enteroscopy, stricture identification and tissue sampling were possible in all 71 cases. Surgical pathology reported aetiology as non-steroidal anti-inflammatory drugs (32%), non-specific (21%), Crohn's disease (21%), radiation-induced (9%), tumour (10%), anastomotic (4%), celiac disease (1%), and surgical adhesions (1%). Sixteen patients (23%) underwent balloon dilation. Sensitivity of abdominal computed-tomography and video-capsule endoscopy for strictures based on double balloon enteroscopy findings was 61% and 43%, respectively. CONCLUSION: Double-balloon enteroscopy was safe and effective to access small bowel stricture with direct visualization and tissue sampling or for therapeutic balloon dilation. Given low sensitivity with conventional computed-tomography and/or video-capsule endoscopy for small bowel stricture, double-balloon enteroscopy can be considered if clinical suspicion is high.

von Willebrand Factor Abnormalities and Heyde Syndrome in Dysfunctional Heart Valve Prostheses.

IMPORTANCE: Limited data suggest that von Willebrand factor (VWF) abnormalities may accompany the high-shear state associated with prosthetic valve dysfunction. If true, laboratory testing could add value in quantifying prosthesis dysfunction and could suggest a pathophysiological explanation for acquired bleeding in some patients. OBJECTIVES: To determine whether dysfunctional valve prostheses are associated with VWF abnormalities compared with normally functioning valve prostheses, to identify the severity of the VWF abnormality relative to other conditions, and to describe associated bleeding and the occurrence of gastrointestinal angiodysplasia. DESIGN, SETTING, AND PARTICIPANTS: Cohort study in a multispecialty practice setting from August 2010 through November 2015. To assess the severity of VWF dysfunction, data were compared with those from previously reported healthy controls and patients with aortic stenosis, mitral regurgitation, and left ventricular assist devices. Patients underwent assessment of multiple VWF laboratory tests and echocardiography. MAIN OUTCOMES AND MEASURES: Loss of high-molecular-weight multimers of VWF. RESULTS: A total of 136 patients were included in this study. During the study period, we assessed 26 patients with normally functioning surgical or transcatheter aortic valve replacement, 24 patients with dysfunctional aortic valve replacement, 36 patients with normally functioning mitral valve replacement or repair, 19 patients with dysfunctional mitral valve replacement or repair, and 31 patients with native aortic regurgitation without coexisting aortic stenosis. von Willebrand factor multimers were abnormal in 1 of 26 normal aortic valve replacements and in 2 of 36 normal mitral valve replacements or repairs but were abnormal in 20 of 24 dysfunctional aortic valve replacements and in 14 of 19 dysfunctional mitral valve replacements or repairs (P < .001 for both). Normal aortic valve replacement also had a higher VWF activity to antigen ratio, mean (range) 0.94 (0.84-0.99) compared to dysfunctional aortic valve replacement, 0.78 (0.73-0.87), P < .001, as did normal mitral valve replacement or repair, 0.90 (0.86-0.93) compared to dysfunctional mitral valve replacement or repair, 0.78 (0.70-0.90), P = .005. Platelet function analyzer closure times were lower with normal aortic valve replacement, mean (range) 92 (82-112) seconds compared to dysfunctional aortic valve replacement, 139 (122-177) seconds, P < .001, and also in normally functioning mitral valve replacement or repair, 85 (74-96) seconds compared to dysfunctional mitral valve replacement or repair, 143 (128-192) seconds, P < .001. Gastrointestinal bleeding was noted in 6 of 24 patients with aortic prosthesis dysfunction and in 5 of 19 patients with mitral prosthesis/repair dysfunction and was associated with a lower normalized VWF multimer ratio than in patients without bleeding. Gastrointestinal angiodysplasia was noted in 5 of 6 bleeding patients with dysfunctional aortic prostheses and in 3 of 5 bleeding patients with dysfunctional mitral prostheses/repair. CONCLUSIONS AND RELEVANCE: Acquired abnormalities of VWF multimers are associated with aortic and mitral prosthesis dysfunction, with occasional gastrointestinal bleeding and gastrointestinal angiodysplasia. Quantitative VWF tests may provide adjunctive value in the difficult assessment of prosthetic valve dysfunction.

Usefulness of Von Willebrand Factor Activity Indexes to Predict Therapeutic Response in Hypertrophic Cardiomyopathy.

Degraded by shear stress, loss of high-molecular-weight multimers of von Willebrand factor (VWF) correlates strongly with pressure gradient in aortic stenosis (AS) and obstructive hypertrophic cardiomyopathy (HC). We assessed VWF tests before and after interventions in HC and contrasted the severity of abnormalities in HC to patients with AS, mitral regurgitation, and left ventricular assist devices. Ninety patients with median (interquartile range) age 66 (53 to 72) years, 51% men, with HC had assessments of 3 VWF parameters and B-type natriuretic peptide before and after 26 discreet medical/pacing interventions, 22 alcohol septal ablations, and 28 ventricular septal myectomies. VWF multimers were abnormal in 87% of patients with obstructive HC versus 48% of patients with latent obstruction (p = 0.0001). VWF measurements correlated with peak instantaneous left ventricular outflow tract gradient, Spearman ρ 0.51 to 0.61, p <0.0001. For B-type natriuretic peptide, correlation with left ventricular outflow tract gradient was weaker, ρ = 0.37, p = 0.0005, but stronger with septal thickness or mitral E/e'. In pre-/post-medical treatment of HC, VWF multimers were abnormal in 73%/68% of patients, p = 0.74; pre-/post-septal ablation 74%/26%, p = 0.0035; and pre-/post-septal myectomy 75%/0%, p <0.0001. In obstructive HC, the degree VWF multimer loss was greater than in severe AS or severe mitral regurgitation and overlapped that seen in left ventricular assist devices. In conclusion, VWF activity indexes were predictably abnormal in patients with HC with resting obstruction to a degree where bleeding could be anticipated, accurately reflected gradient changes after intervention, and demonstrated complete normalization after septal myectomy.

Double balloon enteroscopy is a safe and effective procedure in removing entrapped foreign objects in the small bowel for up to 3 months.

Recent case series have shown that enteroscopy is safe and effective to remove entrapped small bowel foreign bodies. However, the optimal timing for the foreign body retrieval in terms of duration of entrapment and when to consider surgical intervention are unknown. In this case series, we report that antegrade and retrograde enteroscopy can be used safely to retrieve foreign bodies entrapped in the small bowel for longer than 70 days. In total, 20 patients (mean age, 48 years; 11 females) with entrapped foreign bodies in the small intestine underwent antegrade, retrograde, or combined double balloon enteroscopy for retrieval of objects. Symptoms prompted removal of entrapped, nonsharp objects in all patients and included abdominal pain, nausea, and vomiting. The mean time of entrapment was 83 days (range, 4-272 days). There were 15 cases of retained video capsule endoscopy (VCE) with a mean entrapment time of 106 days (range, 7-272 days). Two VCEs could not be removed safely with enteroscopy. Other retained small bowel objects included in this study were nails and fish hooks. Their average entrapment time was 13 days (range, 4-43 days). Of the 30 enteroscopies, there was only 1 case (3%) with a complication (perforation). According to this case series, experienced endoscopists can safely and effectively retrieve foreign bodies in the small bowel, particularly VCE, that are retained for extended periods of time.

Complications of endoscopy of the upper gastrointestinal tract: a single-center experience.

OBJECTIVE: To evaluate prospectively the complications that occurred during consecutive endoscopies of the upper gastrointestinal tract. PATIENTS AND METHODS: We evaluated all endoscopies of the upper gastrointestinal tract (except endoscopic retrograde cholangiopancreatography and endosonography) performed at the Ambulatory Surgical Center at the Mayo Clinic in Jacksonville, Fla, between January 1999 and June 2002. A staff gastroenterologist with or without a trainee performed these procedures. Therapeutic procedures included esophageal band ligation, injection sclerotherapy, botulinum toxin injection, extended upper endoscopy, pneumatic balloon dilation, endoscopic mucosal resection, and endoscopic ablation using thermal laser, argon beam coagulator, or photodynamic therapy. All complications were tabulated prospectively as per mandatory state licensure reporting. RESULTS: Complications after diagnostic endoscopy of the upper gastrointestinal tract were related to anesthesia in 2 of the 12,841 patients. Perforations in 5 patients were associated with esophageal dilation (2), resection of duodenal lesions (2), or passage of a side-viewing instrument into the duodenum (1). No deaths occurred. CONCLUSIONS: Diagnostic endoscopy of the upper gastrointestinal tract is safe, with a complication rate of less than 1 per 5000 cases. Therapeutic endoscopy increases the risk of complications. Compared with complication rates published previously, our results from a single center indicate a favorable reduction in complications related to endoscopy of the upper gastrointestinal tract.

Resource utilization and procedure parameters for the Stretta procedure: comparison with endoscopic ultrasonography and colonoscopy.

BACKGROUND: No data are available regarding resource utilization of the Stretta procedure and its impact on endoscopy units in comparison with other endoscopy procedures. METHODS: This observational cohort study compared the demographic data and procedural parameters for our first 13 cases undergoing the Stretta procedure, with similar endoscopic colonoscopy and ultrasonography (EUS) cases. RESULTS: The characteristics of the patients were similar among these groups. The patients undergoing the Stretta procedure required significantly more sedative medication than those undergoing colonoscopy or EUS. The Stretta procedure time and recovery time were significantly longer than the colonoscopy procedure time and recovery time. The Stretta procedure time was also significantly longer than the EUS procedure time, but the Stretta recovery time was not significantly longer than the EUS recovery time. CONCLUSIONS: Although this study is small and not randomized, it provides useful information regarding how endoscopic procedures compare with one another. Furthermore, these findings have implications for determining endoscopy unit staffing, work equivalency, and appropriate reimbursement.

Clinical Review of Small-Bowel Endoscopic Imaging.

Endoscopic imaging of the small bowel, frequently used in gastroenterology practice, encompasses mainly video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE). Both tests are essential diagnostic tools to evaluate obscure gastrointestinal bleeding and suspected small-bowel disorders, such as Crohn's disease. VCE solely identifies and localizes small-bowel pathology, whereas DAE offers both visualization and tissue sampling to diagnose diseased structures and perform therapeutic maneuvers, such as those needed to achieve hemostasis. In this context, VCE is frequently used as a screening test for small-bowel abnormalities that, when present, are then managed with DAE.

Changes in efficiency and resource utilization after increasing experience with double balloon enteroscopy.

AIM: To investigate changes in efficiency and resource utilization as a single endoscopist's experience increased with each subsequent 100 double balloon enteroscopy (DBE) procedures. METHODS: We reviewed consecutive DBE procedures performed by a single endoscopist at our center over 4 years. DBE was employed when the clinician deemed the procedure was needed for disease management. The approach (oral, anal or both) was chosen based on suspected location of the target lesion. All DBE was performed in a standard endoscopy room with a portable fluoroscopy unit. Fluoroscopy was used to aid in shortening the small intestine and reducing bowel loops. For oral DBE, measurements were taken from the incisors. For anal DBE, measurements were taken from the anal verge. Enteroscopy continued until the target lesion was reached, until the entire small intestine was examined, or until no further progress was deemed possible. The length of small intestine examined (cm), procedure duration (min), and fluoroscopy time (s) were analyzed for sequential groups of 100 DBE. Sub-groups of diagnostic and therapeutic procedures were analyzed using multivariable linear regression. RESULTS: 802 consecutive DBE procedures were analyzed. For oral DBE, median [interquartile range (IQR)] length of small bowel examined was 230.8 cm (range: 210-248 cm) and for anal DBE was 143.5 cm (range: 100-180 cm). No significant increase in length examined was noted for either the oral or anal approach with advancing position in series. In terms of duration of procedure, the median (IQR) for oral DBE was 86 min (range: 71-105 min) and for anal DBE was 81.3 min (range: 67-105 min). When comparing by the position in series, there was a significant (P value < 0.001) decrease in procedure duration for both upper and lower procedures with increasing experience. Median (IQR) time of exposure to fluoroscopy for oral DBE was 190 s (114-275) compared to anal DBE which was 196.4 s (312-128). This represented a significant (P value < 0.001) decrease in the amount of fluoroscopy used with increasing position in series. For both oral and anal DBE, fluoroscopy time was reduced by greater than 50% over the course of 802 total procedures performed. Sub-group analysis was conducted on therapeutic and diagnostic groups. Out of 802 procedures, a total of 434 were considered therapeutic. Argon plasma coagulation was by far the most common therapeutic intervention performed. There was no evidence of a difference in length examined or fluoroscopy exposure among oral DBE for diagnostic and therapeutic procedures, P = 0.91 and P = 0.32 respectively. The median (IQR) for length was 235 cm (range: 178-280 cm) for diagnostic vs 230 cm (range: 180-275 cm) for therapeutic procedures; additionally, fluoroscopy time median (IQR) was 180 s (range: 110-295 s) and 162 s (range: 102-263 s) for no intervention and intervention. However, there was a significant difference in procedure duration among oral DBE (P < 0.001). The median (IQR) was 80 min (range: 60-97 min) and 94 min (range: 77-110 min) for diagnostic and therapeutic interventions respectively. CONCLUSION: For a single endoscopist, increased DBE experience with number of performed procedures is associated with increased efficiency and decreased resource utilization.

Double balloon enteroscopy procedure in patients with surgically altered bowel anatomy: analysis of a large prospectively collected database.

INTRODUCTION: Patients with surgically altered bowel anatomy frequently undergo the double balloon enteroscopy (DBE) procedure to evaluate various small bowel diseases. There are limited data on the diagnostic yield and safety of DBE in these patients. We evaluated the diagnostic yield and complication rates of DBE in patients with surgical altered bowel anatomy. We also evaluated the success rate of DBE in achieving complete examination of the excluded segment of the small bowel and excluded stomach in these patients. SUBJECTS AND METHODS: Our study was a single-center retrospective analysis of a large prospectively collected DBE database. Patients with a history of surgically altered bowel anatomy who had a DBE procedure performed between January 2006 and August 2011 were included in the study analysis. Patients' demographics, procedure indications, findings, endoscopic interventions, and postprocedural recovery data were recorded. We used frequency statistics to calculate the diagnostic yield and complication rates of DBE in these patients. RESULTS: In total, 1215 DBEs were performed at our institution during the study period. Sixty-two patients with a history of altered bowel anatomy underwent 53 DBEs and 11 DBE-assisted endoscopic retrograde cholangiopancreatographies (ERCPs). The overall diagnostic yield of DBE was 61%, and that of DBE-assisted ERCP was 64%. No serious early or delayed DBE-associated complications were identified. In patients with surgically altered bowel anatomy containing excluded small bowel and excluded stomach, DBE success rate to achieve their complete examination was 92% (n=46). CONCLUSIONS: DBE including DBE-assisted ERCP is feasible, safe, and associated with reasonably high diagnostic yield in patients with surgically altered bowel anatomy.

Indexes of von Willebrand factor as biomarkers of aortic stenosis severity (from the Biomarkers of Aortic Stenosis Severity [BASS] study).

We correlated von Willebrand factor (VWF) activity indexes and brain natriuretic peptide (BNP) with measures of aortic stenosis (AS) severity, bleeding, symptoms, and freedom from death or aortic valve replacement. Patients with AS (n = 66 [16 mild, 20 moderate, and 30 severe]) and aortic valve replacement (n = 21) were assessed with VWF antigen, VWF latex agglutination immunoturbidic activity, platelet function analyzer collagen plus adenosine diphosphate (PFA-CADP), VWF multimer ratio, and BNP level after echocardiography. In patients with AS, the mean gradient correlated with BNP (Spearman r = 0.29, p = 0.02), VWF latex agglutination immunoturbidic activity/VWF antigen ratio (r = -0.41, p <0.001), PFA-CADP (r = 0.49, p <0.001), and VWF multimer ratio (r = -0.76, p <0.001). The area under the curve for detection of severe AS was 0.62 (95% confidence interval [CI] 0.48 to 0.77) by elevated BNP, 0.81 (95% CI 0.69 to 0.92) by PFA-CADP closure time, 0.69 (95% CI 0.55 to 0.82) by VWF latex agglutination immunoturbidic activity/VWF antigen ratio, and 0.86 (95% CI 0.76 to 0.95) by VWF multimer ratio. For the VWF multimer ratio, a threshold of 0.15 yielded a sensitivity and specificity for severe AS of 77% and positive predictive value of 74%. Bleeding (in 14%) was associated with a prolonged PFA-CADP time and reduced VWF latex agglutination immunoturbidic activity/VWF antigen ratio. Symptoms were associated with elevated BNP and low Duke Activity Status Index score. In 66 patients with AS, freedom from death (n = 4) or aortic valve replacement (n = 22) was associated with PFA-CADP (p = 0.003), VWF high-molecular-weight multimers (p = 0.009), and VWF latex agglutination immunoturbidic activity/VWF antigen ratio (p <0.001) but not BNP (p = 0.32). In severe AS versus aortic valve replacement, the PFA-CADP and VWF multimer ratio differed (p <0.001), but BNP and the VWF latex agglutination immunoturbidic activity/VWF antigen ratio did not. In conclusion, the VWF activity indexes were associated with AS severity and bleeding and were predictive of cardiovascular outcomes.

Initial experience with double-balloon enteroscopy at a U.S. center.

BACKGROUND: Double-balloon enteroscopy (DBE) allows direct visualization and intervention in the entire small intestine. Concerns include long procedure times and a long learning curve after training. OBJECTIVES: To analyze the initial experience of a single endoscopist when using DBE; assess resource utilization, safety, clinical utility, and the learning curve. DESIGN: Prospective study. SETTING: Tertiary-referral center. PATIENTS: A total of 137 consecutive patients with bleeding or other small-intestine disorders. MAIN OUTCOME MEASURES: Clinical impact at the time of DBE and changes in the procedure time and extent with experience. RESULTS: Two hundred DBE procedures were performed without major complications. For 115 oral DBEs, the mean (SD) procedure duration was 101 +/- 35 minutes and length of examined small intestine was 220 +/- 80 cm, with no significant change with experience. For 85 anal DBEs, the mean (SD) procedure duration was 96 +/- 33 minutes, and the length examined was 124 +/- 60 cm; the length examined increased with experience, but the duration did not decrease. The percentage of patients in which a DBE had a helpful clinical impact rose from 58% in the first 50 DBEs, to 86% in the last 50 of 200 DBEs. The total enteroscopy rose from 8% in the first 50 DBEs, to 63% in the last 50 of 200 DBEs. LIMITATIONS: No follow-up data on outcomes. CONCLUSIONS: DBEs required significant time and did not always allow for a total enteroscopy. DBEs were safe and helpful in the management of most patients. An experienced endoscopist may perform a safe and useful DBE after limited training, but the development of expertise may require more than 100 to 150 DBE procedures.

Failure of esophageal peristalsis in older patients: association with esophageal acid exposure.

OBJECTIVES: Gastroesophageal reflux disease (GERD) is common in all ages, but its prevalence appears to increase with age. Older patients often need aggressive medical therapy and are frequently being considered for antireflux surgery. We sought to evaluate the physiological defect (lower esophageal sphincter [LES] pressures, esophageal motility, and acid exposure) in a group of GERD patients >or= 65 yr old in comparison with a younger population (or=65 yr old and the control group of those 10%). Motility parameters (LES and esophageal body) were compared between the two groups. RESULTS: Of 349 patients who underwent manometry and pH testing during the study period, 133 were >or=65 yr old, and 48 were 10% (12.6 mm Hg in the or=65-yr-old patients, p < 0.05). The percentage of swallows that induced normal peristalsis was lowest in the >or=65-yr-old patients compared with the 10% acid exposure (62.5% vs 95%, p < 0.05). CONCLUSION: Reflux in older patients is complicated by disordered esophageal motility. This impaired motility may decrease acid clearance, result in more difficult to control disease, and may render these patients susceptible to GERD complications.