Evaluation of the small bowel has been traditionally challenging due to the length of the small intestine and difficulty with access other than by operative means. Introduction of video capsule endoscopy (VCE) and deep enteroscopy in the early 2000s has allowed physicians to visualize the entirely of the small bowel and perform therapeutic maneuvers. Despite these advances, patients with bleeding or other abnormalities of the small bowel remain more difficult to diagnose and treat compared to patients with disorders in the upper or lower gastrointestinal tracts. Consequently, these patients have accrued greater medical costs and longer hospital stays. While it is unclear at the present time whether evaluation with VCE and/or deep enteroscopy has reduced overall costs for patients with small bowel disorders, we have learned that use of these tools early in the presentation of suspected small bowel bleeding is associated with higher diagnostic yields. With the advent of computed tomographic enterography (CTE) and MRI enterography (MRE), pathologic findings that are extraluminal can now often be detected, increasing the diagnostic yield for patients with normal endoscopic examinations. In addition, CTE and MRE have greatly enhanced our ability to characterize inflammatory lesions of the small bowel with more accuracy. For patients with massive suspected small bowel bleeding, use of CT angiography prior to angiography has enhanced the interventional radiologist’s ability to detect bleeding sources and direct subsequent angiographic intervention.
This issue of Gastrointestinal Endoscopy Clinics of North America presents articles on anatomy and physiology of the small bowel, technical aspects associated with reading of VCE studies, photodocumentation of normal and abnormal findings on VCE, including vascular findings, inflammatory and neoplastic disorders, and celiac disease. There is an additional article focusing on outcomes and treatment options for patients with small bowel angiodysplastic lesions. Subsequent articles describe double- and single-balloon enteroscopy, when and how to perform radiologic examinations, including CT and MR enterography, angiography, and nuclear medicine studies, and potential roles for intraoperative enteroscopy. The final article focuses on updated algorithms for patients with suspected small bowel bleeding. Given the technological advances in small bowel imaging, the term “obscure gastrointestinal bleeding” has now been reserved for patients with suspected small bowel bleeding and normal findings on VCE, enteroscopy, enterography, and other diagnostic examinations.
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