Search

Background/aims Small bowel malignancies often present a diagnostic challenge due to their relative rarity and nonspecific clinical symptoms. However, technical developments in endoscopic instruments, including video capsule endoscopy (VCE) and enteroscopy, have allowed for the visualization of the entire small bowel. This study aimed to investigate the clinicopathological features of small bowel malignant tumors diagnosed by VCE and double-balloon enteroscopy (DBE) in a single tertiary center. Methods We retrospectively analyzed VCE and DBE findings from Korea University Guro Hospital from January 2010 through September 2018. Results A total of 510 VCE and 126 DBE examinations were performed in 478 patients. Small bowel malignancies were diagnosed in 28 patients (15 males; mean age, 61.0 years; range, 42 to 81 years). Among them, 8 had lymphoma, 8 had primary adenocarcinoma, 7 had gastrointestinal stromal tumor (GIST) and 5 had metastatic cancer. Abdominal pain and obstructive symptoms were the most common findings in metastatic cancers (4/5, 80%). On the other hand, obscure gastrointestinal bleeding was the most common symptom of GIST (6/7, 85.7%) and adenocarcinoma (3/8, 37.5%). Conclusions Approximately 6% of the patients who underwent either VCE or DBE were diagnosed with small bowel malignancy. These findings demonstrated the different clinical characteristics among small bowel malignancies and merit further study.

The small bowel had long been considered a dark unapproachable tunnel until the invention of capsule endoscopy and doubleballoon enteroscopy in the 21st century, which revolutionized the diagnosis and management of small bowel diseases, including bleeding. Various imaging modalities such as computed tomographic enterography, angiography, capsule endoscopy, and balloonassisted enteroscopy play vital roles in the diagnosis and management of small bowel bleeding. The choice of modality to use and timing of application differ according to the availability of the modalities, patient's history, and physician's experience. Small bowel bleeding is managed using different strategies as exemplified by medical treatment, interventional radiology, endoscopic therapy, or surgical intervention. Balloon-assisted enteroscopy enables endoscopic interventions to control small bowel bleeding, including electrocautery, argon plasma coagulation, clip application, and tattooing as a prelude to surgery. In this article, we clarify the recent approaches to the optimal diagnosis and management of patients with small bowel bleeding.

Heterotopic gastric mucosa (HGM) is a rare anomaly in the small bowel and may be the cause of intussusception when it gets a lead point in the jejunum. All cases of intussusception due to intestinal HGM have been treated with surgical resection. A 5-year-old girl presented with chief complaints of vomiting and abdominal pain for 2 weeks. A computed tomography scan of the abdomen showed intussusception at the proximal jejunal loops. Three air reductions and one saline reduction were attempted without success. She continued to be symptomatic, and endoscopic evaluation was performed. Enteroscopy revealed some variable-sized polypoid mucosal lesions with erosions on the proximal jejunum. Endoscopic mucosal resection was performed using a snare. The resected tissues histologically showed a hyperplastic polyp arising from the HGM. Her symptoms did not recur within 1 year after the treatment. Our case showed that enteroscopy could be useful for the diagnosis and management of jejunal intussusception caused by HGM.

Inflammatory bowel diseases are idiopathic inflammatory diseases of two main types, Crohn’s disease and ulcerative colitis. Crohn’s disease can affect the entire gastrointestinal tract, and the distal ileum is involved in up to 70% of patients. Moreover, Crohn’s disease in one-quarter to one-third of patients involves isolation of the small bowel. Due to the nonspecific symptoms and anatomical location of the disease, small bowel Crohn’s disease is a phenotype that is particularly difficult to manage. Since the introduction of capsule endoscopy in 2000 and balloon-assisted enteroscopy in the 21st century, it is now possible to directly inspect for small bowel Crohn’s disease. However, the new modalities still have limitations, such as capsule retention and invasiveness of balloon-assisted enteroscopy. The diagnostic yields of both capsule endoscopy and balloon-assisted enteroscopy are high for patients with suspected small bowel Crohn’s disease. Therefore, earlier use of capsule endoscopy or balloon-assisted enteroscopy can help with the diagnosis and earlier treatment of these patients to avert possible disastrous outcomes.

Although metastasis from cutaneous malignant melanoma to the small intestine is not uncommon, primary small bowel melanoma (SBM) is extremely rare. This case report describes a rare case of primary SBM, diagnosed by single-balloon enteroscopy. A 74-year-old man presented with recurrent melena. Upper endoscopy and colonoscopy were unremarkable. Abdominal computed tomography (CT) revealed an ileal mass with ileo-ileal intussusception. Subsequent single-balloon enteroscopy identified an ileal tumor, which was histologically diagnosed as melanoma. Extensive clinical examination did not reveal any primary cutaneous lesions. To the best of our knowledge, this is the first case of primary SBM in South Korea.

The balloon-assisted enteroscope has been regarded as the standard device for direct visualization of deep small bowels and allows for the diagnosis and treatment of small bowel disease. At the beginning, its application was focused on the diagnosis of obscure gastrointestinal bleeding, inflammatory bowel disease, and small bowel tumor. However, the indications are being expanded to various therapeutic procedures, not only confined to bleeding control. With the expansion of the indications, the need to perform enteroscopy effectively and safely is increasing. Recent studies have been focused on the diagnostic yield, therapeutic yield, and long-term outcomes of the device. However, with the increasing number of procedures, procedural guidelines and quality indicators are also needed.

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of therapy for pancreatobiliary diseases. While ERCP is safe and highly effective in the general population, the procedure remains challenging or impossible in patients with surgically altered anatomy (SAA). Endoscopic ultrasound (EUS) allows transmural access to the bile or pancreatic duct (PD) prior to ductal drainage using ERCP-based techniques. Also known as endosonography-guided cholangiopancreatography (ESCP), the procedure provides multiple advantages over overtube-assisted enteroscopy ERCP or percutaneous or surgical approaches. However, the procedure should only be performed by endoscopists experienced in both EUS and ERCP and with the proper tools. In this review, various EUS-guided diagnostic and therapeutic drainage techniques in patients with SAA are examined. Detailed step-by-step procedural descriptions, technical tips, feasibility, and safety data are also discussed.

While the domain of gastrointestinal endoscopy has made great strides over the last several decades, endoscopic assessment of the small bowel continues to be challenging. Recently, with the development of new technology including video capsule endoscopy, device-assisted enteroscopy, and computed tomography/magnetic resonance enterography, a more thorough investigation of the small bowel is possible. In this article, we review the systematic approach for patients with suspected small bowel disease based on these advanced endoscopic and imaging systems.

Angiodysplasia (AD) is increasingly being recognized as a major cause of gastrointestinal bleeding. Morphologically flat lesions are common types of AD, whereas the polypoid types are rare. We report a case of multiple polypoid AD in the small bowel causing severe anemia and requiring surgical treatment. A 60-year-old male patient visited our hospital with dyspnea and hematochezia. He had a history of myocardial infarction and was taking both aspirin and clopidogrel. Capsule endoscopy, enteroscopy, computed tomography, and angiography revealed multifocal vascular lesions with a polypoid shape in the jejunum. Surgical resection was performed because endoscopic treatment was considered impossible with the number and the location of lesions. The risk of recurrent bleeding related to the use of antiplatelet agents also contributed to the decision to perform surgery. AD was histologically diagnosed from the surgical specimen. He resumed taking both aspirin and clopidogrel after surgery. He fully recovered and has been doing well during the several months of follow-up.

Background/Aims: The diagnostic algorithms used for selecting patients with obscure gastrointestinal bleeding (OGIB) for capsule endoscopy (CE) or balloon-assisted enteroscopy (BE) vary among facilities. We aimed to demonstrate the appropriate selection criteria of CE and single balloon-assisted enteroscopy (SBE) for patients with OGIB according to their conditions, by retrospectively comparing the diagnostic performances of CE and BE for detecting the source of the OGIB. Methods: We investigated 194 patients who underwent CE and/or BE. The rate of positive findings, details of the findings, accidental symptoms, and hemostasis methods were examined and analyzed. Results: CE and SBE were performed in 103 and 91 patients, respectively, and 26 patients underwent both examinations. The rate of positive findings was significantly higher with SBE (73.6%) than with CE (47.5%, p

An inflammatory fibroid polyp (IFP) is a mesenchymal tumor of the gastrointestinal tract. IFPs in the small intestine are the most frequently detected with symptoms, such as abdominal pain and tarry stool due to intussusception. Accordingly, few studies have reported jejunal IFP as a cause of occult gastrointestinal bleeding (OGIB) diagnosed via both of capsule endoscopy (CE) and double-balloon enteroscopy (DBE). A 68-year-old woman presented with a progression of anemia and a positive fecal occult blood test result. Esophagogastroduodenoscopy and total colonoscopy findings were unremarkable. CE revealed a tumor with bleeding in the jejunum. DBE also revealed a jejunal polypoid tumor. Bleeding from the tumor seemed to have caused anemia. The patient underwent partial laparoscopic resection of the jejunum, including resection of the tumor. The tumor was histopathologically diagnosed as IFP. To our knowledge, this is the first reported case of laparoscopic resection of jejunal IFP with OGIB diagnosed via CE and DBE preoperatively.

The vast majority of foreign bodies (FBs) that enter the stomach pass through the gastrointestinal tract spontaneously. When the FB enters the small bowel-beyond the reach of conventional endoscopy-daily radiographs are needed to ensure its safe passage. However, endoscopic intervention is an appropriate management strategy for a sharp-pointed FB, because sharp FBs have a higher risk of intestinal perforation. We describe here a case in which a 1.5-cm, sharp-pointed screw nail in the proximal jejunum was removed successfully by double-balloon enteroscopy from a 19-year-old-male with autism. This case adds to the growing body of evidence demonstrating the value of therapeutic double-balloon enteroscopy in the field of FB ingestion.

Self-expanding metal stents are a useful therapy to palliate malignant and benign luminal gastrointestinal obstruction. Self-expanding metal stents has been widely reported for colonic, esophageal, and gastric obstruction. However, endoscopic delivery and placement to the small bowel is more challenging and difficult. This case illustrates the usefulness and technical advantages of the balloon-overtube and enteroscopy technique for the palliative treatment of neoplastic stenosis affecting the small intestine.

Obscure gastrointestinal bleeding (OGIB) accounts for 5% of all gastrointestinal (GI) bleeding cases and is often caused by small bowel lesions. Capsule endoscopy (CE), which allows non-invasive visualization of the small bowel mucosa, has revolutionized the evaluation of OGIB. CE is preferred by both patients and physicians mainly because of its non-invasiveness, and is widely used as the first-line diagnostic modality for OGIB. The diagnostic yield of CE in OGIB has been reported to be in the range of 32% to 83%. Although no direct comparison has been made, a meta-analysis showed similar diagnostic yields between CE and double-balloon enteroscopy (DBE) for OGIB. However, CE could enhance the yield of subsequent DBE and serve as a guide for optimizing the insertion route for DBE. Even after negative CE, selected patients could benefit from second-look CE for OGIB. In terms of outcomes, a favorable clinical impact after CE has been reported in several studies. However, observations indicate that CE might not influence clinical outcomes directly, but rather play a role in selecting patients with OGIB who are likely to benefit from subsequent evaluation and intervention.

Endoscopic investigation has a critical role in the diagnosis and treatment of gastrointestinal (GI) diseases. Since 2001, capsule endoscopy (CE) has been available for small-bowel exploration and is under continuous development. During the past decade, CE has achieved impressive improvements in areas such as miniaturization, resolution, and battery life. As a result, CE is currently a first-line tool for the investigation of the small bowel in obscure gastrointestinal bleeding and is a useful alternative to wired enteroscopy. Nevertheless, CE still has several limitations, such as incomplete examination and limited diagnostic and therapeutic capabilities. To resolve these problems, many groups have suggested several models (e.g., controlled CO2 insufflation system, magnetic navigation system, mobile robotic platform, tagging and biopsy equipment, and targeted drug-delivery system), which are in development. In the near future, new technological advances will improve the capabilities of CE and broaden its spectrum of applications not only for the small bowel but also for the colon, stomach, and esophagus. The purpose of this review is to introduce the current status of CE and to review the ongoing development of solutions to address its limitations.

Advances in technology have facilitated the common use of small-bowel imaging. Intraoperative enteroscopy was the gold standard method for small-bowel imaging. However, noninvasive capsule endoscopy and invasive balloon enteroscopy are currently the main endoscopic procedures that are routinely used for small-bowel pathologies, and the indications for both techniques are similar. Although obstruction is a contraindication for capsule endoscopy, it is not considered to be problematic for double-balloon enteroscopy. The most important advantage of double-balloon enteroscopy is the applicability of therapeutic interventions during the procedure; however, double-balloon enteroscopy has certain advantages as well as disadvantages.

See “Roles of Capsule Endoscopy and Single-balloon Enteroscopy in Diagnosing Unexplained Gastrointestinal Bleeding” by Shohei Ooka, Kiyonori Kobayashi, Kana Kawagishi, et al., on page 56-60 Obscure gastrointestinal bleeding (OGIB) is defined as overt or obscure gastrointestinal bleeding of unknown origin despite an initial endoscopic evaluation including colonoscopy and esophagogastroduodenoscopy. The majority of patients with OGIB have a bleeding source in the small intestine. In past decades, the evaluation of the small bowel was extremely limited because of difficult intubation using conventional endoscopes. However, this limitation has been overcome by technical advances including capsule endoscopy (CE), balloon-assisted enteroscopy (BAE), and computed tomography or magnetic resonance enterography. The main strength of CE is noninvasive exploration of the entire small bowel. Complete small bowel evaluation can be performed in 79% to 90% of patients, and the diagnostic yield in patients with suspected small bowel bleeding is 38% to 83% [1]. BAE is distinguished by its diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was described first and single-balloon enteroscopy (SBE) followed. The basic techniques and mechanisms of SBE are similar to those of DBE. Although DBE appeared to be superior to SBE in complete small bowel evaluation, diagnostic yield, ability to treat, and complication rates are similar between DBE and SBE [2]. In this issue of Clinical Endoscopy, Ooka et al. [3] reported that the rate of positive findings for OGIB was significantly higher with SBE (73.6%) than with CE (47.5%), and SBE may be more appropriate for overt OGIB. However, caution is required in the interpretation of the results of this report. CE was performed before SBE in 28.5% of the SBE group in this study. CE is useful for screening before performing BAE in patients with OGIB, and CE before BAE is known to increase the diagnostic and therapeutic yields [4]. In this study, CE might have improved the diagnostic yield in the SBE group, although CE was performed in a part of the SBE group. CE can also guide the insertion route of BAE. An oral approach is usually preferred when a lesion is located within the proximal two-thirds of the small bowel. In this issue of Clinical Endoscopy, it did not appear that a bidirectional approach was tried, because SBE was performed in 91 patients and the oral and anal approaches in 43 and 48, respectively. When an oral or anal approach fails to detect significant findings or reach the targeted lesion, the other route can be tried in practice. A 73.6% diagnostic yield by SBE in patients with OGIB is relatively surprising, even though only one route was tried in all cases. Diagnostic yield of CE and BAE for patients with overt bleeding is higher than that for patients with occult bleeding, and the diagnostic yield for patients with ongoing overt bleeding is higher than that for patients with previous overt bleeding. In Ooka’s study [3], the percentage of patients with overt bleeding was higher in the SBE group than in the CE group (80.8% vs. 58.4%), and ongoing overt bleeding was also more frequent (100.0% vs. 90.9%) in the SBE group. The results might have changed if the authors performed multivariate analyses according to the amount and timing of bleeding. Actually, CE and BAE are not competitive, but complementary. According to the American College of Gastroenterology guidelines, CE should be considered a first-line procedure for suspected small bowel bleeding, and BAE should be attempted if a small bowel lesion is strongly suspected based on clinical presentation and abnormal CE results [5]. However, the results of Ooka’s study do not seem to be sufficient to change current diagnostic guidelines for small bowel bleeding.

Background/aims Intestinal lavage (IL) administration immediately before capsule enteroscopy (CE) is superior to lavage the day before the procedure. We aimed to determine the effect of IL timing on CE diagnostic yield. Methods Patients referred for CE were randomized prospectively into two equal groups according to the timing of IL with 2 L of polyethylene glycol solution. Group A and B underwent IL over 2 hours beginning 14 and 4 hours, respectively, before the scheduled CE. The primary outcome measure was preparation quality, measured with a predetermined validated grading scale. Results A total of 34 patients were randomized. The frequency of mucosal abnormalities (77% vs. 82%, p=not significant [NS]) and diagnostic yield (47% vs. 53%, p=NS) were similar between the two groups. Moreover, no significant association between the quality of small bowel preparation and the timing at which the purgative for IL was administered was observed (overall fluid transparency, p=0.936; overall mucosal invisibility, p=0.091). Conclusions Day-before IL is equivalent to same-day IL in terms of overall preparation quality, proportion of complete studies to cecum, small bowel transit time, frequency of identified mucosal abnormalities, and overall diagnostic yield.

See "A Single-Center Randomized Controlled Trial Evaluating Timing of Preparation for Capsule Enteroscopy" by Katherine R. Black, Wiley Truss, Cynthia I. Joiner, Shajan Peter and Frederick H. Weber Jr, on page 234-238 Bowel preparation prior to video capsule endoscopy (VCE) is as essential as bowel preparation prior to colonoscopy, since several factors, such as food material, air bubbles in the small bowel and delayed gastric and small bowel transit time (SBTT) influence the small bowel visualization quality (SBVQ), diagnostic yield (DY), and completion rate (CR). The 2009 European Society of Gastrointestinal Endoscopy guidelines advise that purgative bowel preparations enhance the DY of a small bowel examination using VCE and do not affect the VCE CR (category of evidence 2a; grade of recommendation B).1 According to the 2013 Korean guidelines from the Korean Gut Image Study Group,2 bowel preparation with polyethylene glycol (PEG) solution enhances SBVQ and DY, but has no effect on cecal CR. Bowel preparation with 2 L of PEG solution is similar to that with 4 L of PEG in terms of the SBVQ, DY, and CR of VCE. Bowel preparation with fasting or PEG solution combined with simethicone enhances the SBVQ, but does not affect the CR of VCE. Bowel preparation with prokinetics does not enhance the SBVQ, DY, or CR of VCE. A 2 L PEG-based purge, administered the day before the procedure, is the most widely practiced preparation regimen.3 To date, there is no consensus regarding the optimal timing of bowel preparation for VCE.4 Black et al.5 conducted a single-center randomized controlled trial evaluating preparation for VCE. Thirty-four patients were randomized prospectively into two equal groups according to the timing of intestinal lavage (2 L of PEG). Group A had the intestinal lavage over 2 hours, beginning 14 hours before the scheduled VCE, and group B began ingestion 4 hours prior to the study. The results regarding mucosal abnormalities (77% vs. 82%, p=not significant [NS]) and DY (47% vs. 53%, p=NS) were similar for both groups. There was no significant association between the quality and timing of small bowel preparation. The day before intestinal lavage was similar to same-day preparation with respect to overall preparation quality, CR, SBTT, frequency of identified mucosal abnormalities, and overall DY. To the best of our knowledge, this is the first study to consider the timing of bowel preparation for VCE and is the first to assess the optimal 'timing' for initiating intestinal lavage in VCE. As mentioned, timing of purgative administration may be a critical factor for visualization and VCE CRs. Most purgative studies have administered purgatives the day prior to the VCE.6,7,8,9,10 A Korean study compared fasting for 12 hours and receiving 2 or 4 L of PEG 4 hours prior to PEG. It showed that bowel preparation with PEG resulted in a better image quality than fasting alone,11 but no significant difference was observed between 2 and 4 L of PEG. With respect to bowel preparation for the colonoscopy, the quality of bowel preparation is significantly better when there is a shorter time between bowel preparation and the start of colonoscopy.12 A shorter ( 8 hours) interval.13 Since the small intestine is anatomically proximal, the authors hypothesized that a similar lavage timing concept would be advantageous for VCE small intestinal visualization and perhaps transit. The overall evidence base for small bowel VCE is immature and validated scales for quality of cleansing are not yet available.4 One of the issues for bowel preparation of VCE is that the distal segment of the small intestine should be improved. However, there was no significant difference between the two groups (day-before VCE vs. 4 hours prior to VCE) in this study.5 Recently, different kinds of bowel preparation such as PEG, PEG plus ascorbic acid, sodium picosulfate and phosphate (NaP) have become available.14 NaP is not generally recommended for bowel cleansing due to the potential for renal damage and other adverse events. However, the use of NaP is acceptable in patients for whom PEG or sodium picosulfate is ineffective or not tolerated.4 There was no published evidence to support the use of sodium picosulfate; however, it is used in some units. Anecdotal evidence suggests that it is not as effective as PEG.4 For each of these agents, a consensus should be reached regarding the optimal timing of bowel preparation. The main limitation of this study is that the number of patients (n=34) is not sufficient for generalization to actual practice. Therefore, a large, multicenter randomized controlled trial is needed to clarify the optimal timing of bowel preparation for VCE. Guidelines for timing of bowel preparation should be made in the near future.

Patients with altered anatomy such as a Roux-en-Y anastomosis often present with various pancreaticobiliary problems requiring therapeutic intervention. However, a conventional endoscopic approach to the papilla is very difficult owing to the long afferent limb and acute angle of a Roux-en-Y anastomosis. Balloon-assisted enteroscopy can be used for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered anatomy. We experienced six cases of Roux-en-Y anastomosis with biliary problems, and attempted ERCP using single balloon enteroscopy (SBE). SBE insertion followed by replacement with a conventional endoscope was attempted in five of six patients. The papilla was successfully approached using SBE in all cases. However, therapeutic intervention was completed in only three cases because of poor maneuverability caused by postoperative adhesion. We conclude that in patients with Roux-en-Y anastomosis, the ampulla can be readily accessed with SBE, but longer dedicated accessories are necessary to improve this therapeutic intervention.

Obscure gastrointestinal bleeding (OGIB) refers to gastrointestinal (GI) bleeding of unclear origin that persists or recurs after negative findings on esophagogastroduodenoscopy and colonoscopy. OGIB accounts for approximately 5% of all types of GI bleeding. More than 80% of OGIB cases originate in the small bowel. The ability to detect OGIB in the small bowel has significantly advanced and been revolutionized since the introduction of the capsule endoscopy and double-balloon enteroscopy techniques in 2000 and 2001, respectively. With these new methods for small-bowel evaluation, new guidelines have been proposed for the diagnosis and management of OGIB. However, some issues remain unsolved. The purpose of this article is to review the various modalities used for evaluating OGIB, including capsule endoscopy and double-balloon enteroscopy, and to help guide clinicians in their decisions on which modality will be the most effective.

The advent of deep enteroscopy (DE) has dramatically changed diagnostic and therapeutic approaches to small bowel diseases. Unlike capsule endoscopy, which is unable to obtain biopsies or treat a disease, DE techniques have diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was introduced in 2001, and single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) were subsequently developed for small bowel investigation. In published reports comparing these different enteroscopy techniques, most comparative parameters (depth of insertion, complications, learning curve, diagnostic yield, and therapeutic yield) were comparable among DBE, SBE, and SE. However, the procedure duration appears to be shorter for SE than for DBE and SBE. The rate of complete enteroscopy is clearly superior for DBE, compared with SE and SBE. Because these results do not indicate an increase in diagnostic or therapeutic yield, the clinical impact of complete enteroscopy remains controversial. According to previous studies, the three DE methods seem to be equally effective and safe in the clinical setting. Although larger randomized controlled trials are needed to evaluate the procedural characteristics and clinical impact, the selection of an enteroscopic technique should be based on availability and the endoscopist's experience.

Brunner's gland adenoma is a rare benign proliferative lesion developing most commonly in the posterior wall of the duodenum. It is usually small in size and asymptomatic. Depending on its size or location, however, the clinical manifestations of this tumor may be variable from nonspecific symptoms to gastrointestinal bleeding or obstruction. Brunner's gland adenoma in the proximal jejunum is extremely rare. We report a very rare case of giant Brunner's gland adenoma developing in the proximal jejunum which presented as iron deficiency anemia and mimicked intussusceptions on radiologic studies.

Ileal Dieulafoy lesion is an unusual vascular abnormality that can cause gastrointestinal bleeding. It can be associated with massive, life-threatening hemorrhage and requires urgent angiographic intervention or surgery. Ileal Dieulafoy lesion is hard to recognize due to inaccessibility and normal-appearing mucosa. With advances in endoscopy, aggressive diagnostic and therapeutic approaches including enteroscopy have recently been performed for small bowel bleeding. We report two cases of massive ileal Dieulafoy lesion bleeding diagnosed and treated successfully by single balloon enteroscopy with a review of the literature.