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Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: M. Pioche and J. C. Saurin are co-investigators for Olympus spiral enteroscopy muticenter study.

Competing Interests: The authors declare that they have no conflict of interest.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Guideline was also reviewed and endorsed by the British Society of Gastroenterology (BSG). It addresses the roles of small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders. Main recommendations 1 ESGE recommends small-bowel video capsule endoscopy as the first-line investigation in patients with obscure gastrointestinal bleeding (strong recommendation, moderate quality evidence). 2 In patients with overt obscure gastrointestinal bleeding, ESGE recommends performing small-bowel capsule endoscopy as soon as possible after the bleeding episode, optimally within 14 days, in order to maximize the diagnostic yield (strong recommendation, moderate quality evidence). 3 ESGE does not recommend the routine performance of second-look endoscopy prior to small-bowel capsule endoscopy; however whether to perform second-look endoscopy before capsule endoscopy in patients with obscure gastrointestinal bleeding or iron-deficiency anaemia should be decided on a case-by-case basis (strong recommendation, low quality evidence). 4 In patients with positive findings at small-bowel capsule endoscopy, ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by capsule endoscopy (strong recommendation, high quality evidence). 5 ESGE recommends ileocolonoscopy as the first endoscopic examination for investigating patients with suspected Crohn's disease (strong recommendation, high quality evidence). In patients with suspected Crohn's disease and negative ileocolonoscopy findings, ESGE recommends small-bowel capsule endoscopy as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known stenosis (strong recommendation, moderate quality evidence).ESGE does not recommend routine small-bowel imaging or the use of the PillCam patency capsule prior to capsule endoscopy in these patients (strong recommendation, low quality evidence). In the presence of obstructive symptoms or known stenosis, ESGE recommends that dedicated small bowel cross-sectional imaging modalities such as magnetic resonance enterography/enteroclysis or computed tomography enterography/enteroclysis should be used first (strong recommendation, low quality evidence). 6 In patients with established Crohn's disease, based on ileocolonoscopy findings, ESGE recommends dedicated cross-sectional imaging for small-bowel evaluation since this has the potential to assess extent and location of any Crohn's disease lesions, to identify strictures, and to assess for extraluminal disease (strong recommendation, low quality evidence). In patients with unremarkable or nondiagnostic findings from such cross-sectional imaging of the small bowel, ESGE recommends small-bowel capsule endoscopy as a subsequent investigation, if deemed to influence patient management (strong recommendation, low quality evidence). When capsule endoscopy is indicated, ESGE recommends use of the PillCam patency capsule to confirm functional patency of the small bowel (strong recommendation, low quality evidence). 7 ESGE strongly recommends against the use of small-bowel capsule endoscopy for suspected coeliac disease but suggests that capsule endoscopy could be used in patients unwilling or unable to undergo conventional endoscopy (strong recommendation, low quality evidence)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Double-balloon enteroscopy (DBE) has been established as an invaluable tool for the diagnosis and treatment of small-bowel diseases. To evaluate complications, procedural data, and diagnostic yield of DBE examinations in Germany the presented database was introduced., Methods: A prospective database of all DBE examinations in 62 endoscopic centers in Germany was developed using data from a standard questionnaire. Information requested included data on personal information, indications, procedural information, interventions, diagnostic yield, and complications., Results: In total, 2245 DBE examinations in 1765 patients were reported prospectively over a 2-year period. The most frequent indication was overt or occult bleeding in the small intestine and the most frequent intervention was argon plasma coagulation of angiodysplasia. The rate of complete enteroscopy was only 23 %. A clear dependency of indication and diagnostic yield could be documented, ranging widely from a diagnostic yield of 16 % in patients with abdominal pain and 82 % in patients with Peutz-Jeghers syndrome. A total of 27 complications produced a complication rate for all examinations of 1.2 %. Pancreatitis was diagnosed in four cases (0.3 % of oral-route DBE). Perforations occurred in three patients, two of whom had undergone polypectomy in the small bowel (1.5 % of 137 polypectomies)., Conclusion: DBE is a safe endoscopic technique according to this large prospective database, with a complication rate of 1.2 %. The diagnostic yield of DBE examinations depends upon the quality of indication, and is very low in patients with the single indications of "diarrhea" or "abdominal pain"., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aim: Double-balloon enteroscopy (DBE) has proven to be a relatively safe method for small-bowel evaluation, with a complication rate of 1 %. The main concern after diagnostic DBE is acute pancreatitis. Single-balloon enteroscopy (SBE) has emerged as a viable alternative to DBE. Until now, no incidence of pancreatitis has been reported for SBE. The aims were to evaluate complication rate and occurrence of hyperamylasemia and to identify the risk factors for hyperamylasemia after SBE., Patients and Methods: Prospectively, consecutive patients undergoing peroral ("proximal") or combined approach SBE were included. Complications were assessed at 1 and 30 days afterwards. Serum amylase and C-reactive protein (CRP) were assessed immediately before and 2 - 3 hours after SBE., Results: 166 SBE procedures were performed in 105 patients (53-male; mean age 51 years, range 9 - 87). The indications for SBE were: anemia (n = 55), Crohn's disease (n = 31) and abdominal complaints suspicious for inflammatory bowel disease (n = 5), Peutz-Jeghers syndrome (n = 1) and other (n = 13). Therapeutic interventions were performed during 21 procedures (13 %). One perforation (1 / 21 therapeutic interventions, 4.8 %) occurred after dilation of a benign stricture. While 13 patients (16 %) had post-SBE hyperamylasemia, none had complaints suggesting acute pancreatitis. Factors such as sex, indication, procedure duration, number of passes, route of SBE, findings, and/or treatment showed no significant correlation with presence of hyperamylasemia., Conclusions: SBE appears to be a safe diagnostic endoscopic procedure. The incidence of hyperamylasemia and pancreatitis after peroral SBE seems comparable to that after DBE., (Georg Thieme Verlag KG Stuttgart.New York.)

Background and Study Aims: Video capsule endoscopy has shown promise for the surveillance of significant small-bowel polyps in patients with Peutz-Jeghers syndrome. In this study the yield of significant small-bowel polyps by capsule endoscopy was compared to the yield of these polyps by barium follow-through in adults with Peutz-Jeghers syndrome., Patients and Methods: A total of 19 adults with Peutz-Jeghers syndrome who were undergoing surveillance underwent both capsule endoscopy and barium follow-through examinations, and the number of small-bowel polyps of at least 1 cm in diameter that were detected was recorded for each method. The two methods were assessed in terms of comfort and convenience for the patients and their preferred future surveillance method, using a questionnaire., Results: Capsule endoscopy detected a median of four significant small-bowel polyps while barium follow-through detected a median of one (P = 0.008). There was a trend towards more participants having at least one significant small-bowel polyp detected by capsule endoscopy than was the case with barium follow-through, though capsule endoscopy seemed to be less reliable for accurate sizing of polyps that were at the limit of clinical significance. Most participants expressed a preference for capsule endoscopy for future surveillance., Conclusions: Capsule endoscopy should replace barium follow-through for the surveillance of small-bowel polyps in adults with Peutz-Jeghers syndrome, but the findings of this study should be interpreted with caution until a more reliable means of sizing polyps by capsule endoscopy is available.

We treated a male teenager with a solitary gastric Peutz-Jeghers type (hamartomatous) polyp showing neither mucocutaneous pigmentation nor inheritance. X-ray studies of the upper gastro-intestinal tract, small intestine and barium enema revealed a solitary thumb tip-sized polypoid mass in the posterior wall of the gastric body, with no evidence of any associated lesion. Histologically, the polypoid mass showed typical features of a Peutz-Jeghers type (hamartomatous) polyp. This may be the first documentation of a "solitary" gastric Peutz-Jeghers type polyp, in the absence of familial polyposis coli and mucocutaneous pigmentation.

A new treatment strategy is presented and evaluated in 5 patients with Peutz-Jeghers syndrome, in an effort to preserve bowel integrity and to eliminate the threat of a short bowel. After conventional endoscopic polypectomy of all reachable lesions, peroperative endoscopic polypectomy is scheduled. Endoscopic peroperative panpolypectomy is carried out and only in bulky, broadbased, multiple or invaginating polyps is an enterotomy or a resection - kept to a minimum thanks to the information provided by the endoscopist - performed. The procedure was well tolerated, hospitalization was remarkably short, and the subsequent follow-up period free of readmission - in contrast to previous observation periods. It is, however, a tedious and time-consuming method, and close collaboration between endoscopist and surgeon is urgently required.