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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: Patients with familial adenomatous polyposis (FAP) are at increased risk of developing duodenal and jejunal adenocarcinomas. The aim of this study was to assess the usefulness of double-balloon enteroscopy- (DBE-) assisted chromoendoscopy for the detection and characterization of small-bowel polyps in patients with FAP., Patients and Methods: We performed a prospective evaluation of patients with clinically and genetically proved FAP who were enrolled in an endoscopic surveillance program. DBE was performed using a Fujinon intestinoscope (FN 450P 5/20; Fujinon Corp., Omiya, Japan), and chromoendoscopy was performed using indigo carmine. The severity of small bowel polyposis was based on the Spigelman-Saurin classification., Results: Nine patients underwent DBE-assisted chromoendoscopy. Small-bowel polyps (including papillary adenomas) were detected in seven patients (88 %). The mean depth of small-bowel insertion was 180 cm (range 120-320 cm). The mean Spigelman-Saurin score was 4.6 (range 0-8). Jejunal polyps were detected in six patients (67 %). Chromoendoscopy aided in the detection of additional polyps in two patients. In one patient the polyps were flat and only visible with chromoendoscopy (biopsy confirmed these to be adenomas). Jejunal polyps and advanced neoplasms were more frequent in patients with APC gene mutations in exon 15. The following endoscopic therapies were performed: polypectomy (n = 1), duodenal mucosectomy (n = 1), and ablation therapy with argon plasma coagulation (n = 2)., Conclusions: DBE was found to be a helpful method for the evaluation of small-bowel polyps in patients with FAP. DBE-assisted chromoendoscopy was of further assistance for the detection of jejunal polyps.

Background and Study Aims: Periampullary diverticula are thought to be associated with bile duct stones. However, studies to date have been inconclusive as they have not taken into account the influence of age. Our study analysed the association of diverticula with bile duct stones and with the technical success of endoscopic retrograde cholangiopancreatography (ERCP)., Patients and Methods: A total of 415 consecutive patients who were undergoing ERCP were prospectively entered into a database. Of these patients, 83 (20 %; mean age 73 years; 34 men, 49 women) were found to have diverticula. The age-matched control group comprised 261 patients (mean age 72 years; 106 men, 155 women). The chi-squared test was used to analyse the results., Results: In the diverticula group, 53 (64 %) had bile duct stones, compared with 86 (33 %) of the controls ( P < 0.0001), with an odds ratio of 3.6. Significantly more patients in the diverticula group had primary bile duct stones; also significantly more of them had stones in both the bile duct and gallbladder. There was no difference between the two groups with regard to previous history of pancreatitis (10 % in the diverticula group vs. 11 % in the control group). There were no significant differences found between the diverticula group and the control group in terms of successful duct cannulation (94 % in both groups), sphincterotomies (96 % vs. 98 %) or stone extraction (94 % vs. 88 %). The incidence of complications was similar in the two groups (diverticula group 5 % vs. control group 3.3 %)., Conclusions: Periampullary diverticula are associated with an increased incidence of bile duct stones but not with pancreatitis. Diverticula did not cause any technical difficulties at ERCP or increase the risk of complications.

We describe a case of a perforated duodenal diverticulum, which was managed by a combined percutaneous and endoscopic approach. In combination with conservative treatment, this technique can be a challenging alternative to surgery.

Background and Study Aims: Enteroscopy has been shown to be an effective diagnostic method in patients with obscure gastrointestinal bleeding. Arteriovenous malformations (AVMs) of the small bowel are the most common lesions discovered at enteroscopy. However, bleeding lesions may still be detected in the upper gastrointestinal tract even in patients who have previously undergone esophagogastroduodenoscopy. The aim of this study was to focus on these "missed" upper gastrointestinal lesions., Patients and Methods: A retrospective review was conducted of all enteroscopic examinations carried out in patients with suspected gastrointestinal bleeding or overt gastrointestinal bleeding treated at our institution between 1993 and 1997. All patients had previously undergone an esophagogastroduodenoscopy. The push enteroscope (Olympus XSIF-100) was used in all of them., Results: Push enteroscopy was performed in 233 patients (124 men and 109 women; mean age 63). A suspected bleeding lesion was observed in 53 % of the cases. AVMs represented 63% of the detected lesions. "Missed" upper gastrointestinal lesions were described in 25 patients (10.2 %). In half of these cases, the lesion was located in the upper part of the fundus. Wirsungorrhagia was the cause of bleeding in two cases., Conclusions: The study confirmed that push enteroscopy is an effective method of detecting lesions responsible for occult gastrointestinal bleeding. In this study, the overall diagnostic yield was 53%. In 10% of the patients, the lesion was located in the upper gastrointestinal tract, despite an initial esophagogastroduodenoscopy. The lesions were mainly located in the fundus. Although it is a rare condition, Wirsungorrhagia must be considered in patients with occult gastrointestinal bleeding.

Background and Study Aims: Several endoscopic studies have reported an association between periampullary diverticula and biliary calculi, but the results are inconsistent when the anatomic site of the stones is considered. The aims of our study are to evaluate the association between periampullary diverticula and gallstones according to their site and to clarify the origin of the common bile duct stones by analyzing their composition., Patients and Methods: During a period of 10 months, 611 of 632 consecutive patients having endoscopic retrograde cholangiopancreatography (ERCP) were prospectively enrolled. The data about periampullary diverticula and gallstones were analyzed according to the site of the stones. The stones were initially grouped on the basis of their gross morphology and cross-sectional appearance, and finally analyzed by quantitative infrared spectroscopy., Results: Diverticula were found in 165 of 611 cases (27%) and the incidence increased with age (p<0.01). The incidence of gallbladder or common bile duct stones was higher in patients with periampullary diverticula (73/165,44%) than without (130/446,29%) (p<0.01). Considering the site of the gallstones, this significance was found only in patients with common bile duct stones not associated with gallbladder stones (p<0.001). Of the 40 who had gallstones only in the common bile duct, 32 gave a history of cholecystectomy more than two years previously and had been free of symptoms postoperatively, and on analysis most of the stones (30/36,83%) were brown pigment stones. These therefore were assumed to be primary common bile duct stones. The common bile duct stones with associated gallbladder stones were identical to their paired gallbladder stones in gross and cross-sectional appearance and chemical composition. They were assumed to be secondary common bile duct stones and the difference in the incidence of calculi according to the presence of diverticula was not significant., Conclusion: The incidence of gallstones was significantly higher in periampullary diverticula, and when the site and the origin of the gallstones was considered the association between diverticula and gallstones was significant in patients with primary common bile duct stones but not with the secondary ones.

Two patients with gastric outlet obstruction caused by a gallstone were treated by endoscopic lithotripsy. All fragments of significant size were removed orally, except for one that was left in the stomach in the first patient. This fragment caused a recurrent ileus after initial clinical improvement. The other patient remained clinically well after hospital discharge.

Juxtapapillary diverticula are often associated with biliary lithiasis. The aim of this study was to compare the prevalence of juxtapapillary diverticula in choledocholithiasis and in cholecystolithiasis without common bile duct stones. The results of 520 consecutive retrograde cholangiographies were retrospectively analysed. The prevalence of juxtapapillary diverticula was higher in patients with biliary lithiasis than in patients without: 26.0% vs 10.5% (p less than 0.001). However, juxtapapillary diverticula were more frequently encountered in patients with choledocholithiasis than in those with gallbladder lithiasis or previous cholecystectomy and a stone-free common bile duct: 40.0% vs 10.2% (p less than 0.001). There was no significant difference between the patients with cholecystolithiasis alone and those without biliary lithiasis. Among the patients with previous cholecystectomy or with gallbladder lithiasis, common bile duct stones were more frequently found in patients with juxtapapillary diverticula than in those without: 80.3% vs 40.6% (p less than 0.001). These data suggest that juxtapapillary diverticula are associated only with choledocholithiasis and not with gallbladder lithiasis.

Periampullary duodenal diverticula are known to be associated with an increased incidence of common bile duct stones. The nature of the association with gallstones remains uncertain. We have examined the incidence of periampullary diverticula and stones after cholecystectomy to determine whether the stones originate primarily in the common duct or migrate from the gallbladder under the influence of abnormal biliary motility. Six hundred and forty-one patients undergoing ERCP were studied. Ninety-five patients had diverticula (14.8%). Diverticula occurred more commonly in jaundiced patients, 47/95, (48.4%) than in patients with normal bilirubin 185/546 (33.8%) (p less than 0.01). Common duct stones were associated with the presence of a diverticulum in 41/95 patients (43%), compared with only 98/546 without a diverticulum (18%) (p less than 0.001). There was no difference in the incidence of common duct stones in association with a diverticulum between those who had had a cholecystectomy 20/41, and those with intact gallbladders, 21/54 (N.S.). Thus the absence of a gallbladder did not alter the high incidence of common duct stones. We conclude that the stones in the common duct are most likely to be primary stones which have formed as a result of periampullary dysfunction.

By means of urgent gastroscopy the authors, right before surgery, recognized a pyloric stenosis syndrome and a gallstone that had caused massive melena in a female patient of 73. Cholecystectomy and a Billroth II gastric resection were performed. Following surgery, a transitory duodenal fistula developed. After a month of clinical treatment the patient was sent home cured. This case draws attention to the importance of removing a gallbladder filled with stones as soon as possible in order to prevent complications, as well as to the necessity for gastroscopy in cases of unexplained abdominal complaints.

Aortoenteric fistula is a complication of aortic reconstructive surgery. Here, the authors describe a case of a secondary aortoduodenal fistula causing haemorrhage. Diagnosis was made by upper gastrointestinal endoscopy.

A systematic prospective endoscopic study of the incidence of juxtapapillary diverticula in a variety of digestive disorders was undertaken in the Surgical Clinic at the Provincial Hospital, Port Elizabeth. The findings were related to conditions commonly encountered. The following frequency distribution was found: 33 diverticula out of 164 patients associated with gallstones (20.1%); 15 out of 668 patients not associated with gallstones (2.2%); 1 out of 39 patients with pancreatitis (2.6%); and 3 out of 146 patients with gastric ulcer (2.1%). No diverticulum was noted in 111 patients with duodenal ulcer. These findings suggest that juxtapapillary diverticula are nearly 10 times more common in patients with gallstones than in patients without. There is evidence to suggest that these diverticula tend to precede the gallstones. It is conceivable that juxtapapillary diverticula may predispose to gallstones. Alternatively, both conditions may be manifestations of another underlying disorder as yet to be defined.

This paper presents a review of the clinical significance of juxtapapillary duodenal diverticula in man. The incidence of such diverticula varies considerably in the literature, and possibly depends on the methods of investigation used. Studies show that the incidence of biliary calculi is significantly higher in patients with juxtapapillary diverticula as compared with patients without such diverticula. The assumed higher rate of diverticula in patients with pancreatitis is probably due to the presence of biliary calculi in these patients. Studies have shown that there is an insufficient choledochoduodenal sphincter in patients with diverticula, and also a higher rate of bacterial contamination of the duodenum and bile ducts in these patients. Fecal type flora has been found in most patients with juxtapapillary duodenal diverticula. Further, pigment gallstones have been found in most patients with diverticula, and analyses of these calculi showed that calcium bilirubinate was the main component. Further studies in our laboratory have shown that bacterial cultures produced beta-glucuronidase, a fact which may be connected with the increased frequency of pigment gallstones. Other studies have shown that there is a higher rate of diverticula in patients with recurrent biliary calculi who had undergone cholecystectomy. Recent data have also shown that there is a higher rate of common bile duct calculi in patients with diverticula, than in those without diverticula and without prior cholecystectomy--a fact supporting the theory on the pathogenesis of biliary calculi in patients with juxtapapillary diverticula. Other, and rare complications due to such diverticula are also mentioned.

Obstructive jaundice was cured in a 70-years-old woman after endoscopic removal of a bezoar located in a prepapillary duodenal diverticulum.

Up to now, surgery was the only possible treatment for choledochoduodenal fistulas, which are seen more often in Japan than in Europe. This paper presents the value and effect of endoscopic fistulotomy (EFT) as an alternative treatment in those cases. Parapapillary choledochoduodenal fistulas are abserved usually on the longitudinal fold of the papilla or on its oral side. The papillotome is inserted into the common bile duct through the orifice of the duodenal papilla, then the wall between its orifice and the fistula is cut to open widely the distal portion of the choledochus. EFT was performed successfully in 7 cases. The procedure led to a wide open stoma of the distal common bile duct with free bile outflow. Residual stones, a common occurrence in cases of parapapillary choledochoduodenal fistulas, may pass spontaneously after EFT or can be removed with a basket catheter. In cases of parapapillary choledochoduodenal fistula, EFT is a reliable method, especially in high-risk patients, and an alternative to surgical treatment.