Small-bowel endoscopy.

An overview of the scientific literature on small-bowel enteroscopy demonstrates that sonde enteroscopy is becoming more and more limited in its indications. Push enteroscopy is now a well-accepted modality for evaluation of the patient with small-bowel disease, including those with undiagnosed causes for gastrointestinal bleeding, various types of malabsorption, and radiological abnormalities. Intraoperative enteroscopy has very specific indications, and there is a high rate of positive findings. It appears that an enterotomy with passage of a shorter, more maneuverable enteroscope is an acceptable way to evaluate the small bowel, although use of a sonde enteroscope may be an innovative method for intraoperative enteroscopy. In the evaluation of patients with iron-deficiency anemia or occult gastrointestinal bleeding in whom colonoscopy is negative, it is evidently more cost-effective to use a dedicated push enteroscope early on. The use of two different instruments--a gastroscope followed by a dedicated push enteroscope--is more expensive, and probably does not increase the yield for pathology. Many lesions that are responsible for obscure bleeding are actually located within reach of an upper intestinal endoscope, but are not recognized. This is probably due to inexperience on the part of the original endoscopist, who may see the pathology, but does not invoke it as the cause for bleeding. Outcome studies are now being performed, and there are some interesting considerations for combination hormonal therapy in patients with recurrent obscure bleeding, which most likely emanates from small-bowel arteriovenous malformations.