Investigating obscure gastrointestinal bleeding: capsule endoscopy or double balloon enteroscopy?

The possibility to visualise the small bowel has dramatically improved with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). CE and DBE have become standard practice in investigating suspected diseases of the small bowel. An important reason to perform small bowel investigations is obscure gastrointestinal bleeding. To investigate obscure gastrointestinal bleeding, some advocate performing CE while others recommend DBE. In this systematic review, we provide an overview of studies in which patients with obscure gastrointestinal bleeding underwent both CE and DBE. These data show that CE and DBE have comparable diagnostic yields in the evaluation of obscure gastrointestinal bleeding of 50 to 60%. Therapeutic interventions using DBE were performed in II to 57% of cases. In most studies, there was good concordance between the two procedures but both techniques can be falsely negative. Given its safety, patient tolerability and ability to view the entire small bowel, CE can be recommended as the first investigation for obscure gastrointestinal bleeding, if necessary, followed by DBE. Finally, we provide an algorithm with practical guidelines for the evaluation of obscure gastrointestinal bleeding.