Nghiên cứu ứng dụng nội soi bóng đơn trong chẩn đoán và điều trị chảy máu tiêu hóa nghi ở ruột non Tóm tắt tiếng anh

RESEARCH SUMMARY

1.Background
Gastrointestinal bleeding (Gastrointestinal bleeding) is one of the most common emergencies both in
surgery and in internal medicine. According to the traditional classification, gastrointestinal bleeding
(GIB) is divided into two categories: upper GIB and lower GIB. Today, this classification has been
divided more specifically according to regions, including: GIB in the small intestine and lower GIB
(bleeding in the colorectum).
Despite progress in diagnosis and treatment, especially with various new drugs being used in clinical
practice, the mortality rate due to GIB is still high, ranging from 6-8%. There have been many techniques
applied to the diagnosis and treatment of GIB in general and in small intestinal, including single-ball
endoscopy. So far, in Vietnam, there are several hospitals (including Bach Mai Hospital, Military Central
Hospital 108, Cho Ray Hospital ...) that use single balloon enteroscopy to diagnose and manage lesions in
small intestine, including pathology of the small intestine lesion causing GIB. However, studies and
evaluation of the effectiveness of this method in Vietnam are still limited, so we conducted this research
on the “Application of single balloon endoscopy in diagnosis and treatment of suspected
gastrointestinal bleeding in small intestine” with the two following objectives:
1. Investigate clinical features, diagnostic results, and interventions through single-balloon endoscopy
in patients with suspected gastrointestinal bleeding in the small intestine.
2. Evaluation of specification and safety of single-balloon endoscopy in patients with gastrointestinal
bleeding in the small intestine.
2. The necessity
In the 60s and 70s of the last century, GIB in the small intestine was considered as a "mysterious area"
because there were no means of diagnosis and intervention. By the end of the 20th century, a series of
diagnostic imaging methods became available, making the diagnosis of GIB causes in the small intestine
more feasible. However, the disadvantage of these methods was only to help diagnosis, instead of
intervention. In 2001, for the first time, the double ball colonoscopy technique was introduced. By 2006,
Olympus company (Japan) launched a single ball colposcope. These techniques have been introduced to
bring high efficiency in diagnosis and endoscopic intervention (hemoclip, polypectomy ...) with lesions in
the small intestine. Since 2010, the Department of Functional Exploration - Bach Mai Hospital has also
implemented single ball colonoscopy technique to diagnose and treat GIB in the small intestine.

Therefore, a full research on the efficacy of single balloon endoscopy in the diagnosis and treatment of
GIB in the small intestine is essential.
3. Contributions of the thesis
The dissertation has determined the diagnostic effectiveness and treatment potential through single
balloon endoscopy. Specifically:
- The rate of detecting lesions in the small intestine through single balloon endoscopy is: 64/89 patients
(71.9%).
- Common lesions (n = 64): Small intestine ulcers: 34.4%; inflammation of the of the small intestine
mucosa 23.4%; tumors: 17.2% and vascular dysplasia: 12.5%.
- Common lesion location: ileum: 40.6%; jejunum: 50%; ileum + jejunum: 9.4%.
- Rate of intervention through single balloon small bowel endoscopy: 90.1%.
- Types of intervention: biopsy: 60.9%; clip hemostasis: 10.9%; hemostasis injection: 7.9%; coagulation
by electricity: 4.7%; polypectomy: 4.7%.
At the same time, the dissertation has also raised the technical characteristics and safety of single
endoscopy in patients with suspected GIB in the small intestine.


4. The thesis layout
The thesis is presented 132 pages including: 2-page problem statement, 34-page overview, 29-page
subjects and research methods, 30-page research results, 34-page discussion, 2-page conclusions and onepage recommendations.
The thesis has 38 tables, 8 charts, including 164 references including 16 Vietnamese documents and 148
English documents.
CHAPTER 1
DOCUMENT OVERVIEW
1.1. Small intestine anatomy and physiology
1.2. Classification, clinical, factors related to GIB in small intestine.
1.2.1. Classification of gastrointestinal bleeding
1.2.2. Clinical GIB in small intestine
1.2.3. Level and early prognostic factors for GIB in small intestine
1.3. Causes of GIB in the small intestine.

Table 1.3. Causes GIB from small intestine.
Causes
Lesions
Vascular lesions
* Arteriovenous malformation: AVM
* Venous ectasia
* Angioplasia
* Telangiectasia
* Varices
* Dieulafoy’s lesion
* Arterial aneurysm
* Aortoenteric fistula
Structural
* Mucosal ulcerations
abnormalities
* Meckel’s Diverticulum
* Radiation enteritis
* Diverticulosis
* Tuberculosis, parasite
* Endometriosis
* Crohn’s Disease
Benign small
* Adenoma
bowel tumors
* Lipoma
* Neurofibroma
* Hemangioma
* Cowden Disease
* Schwannomas
* Nodular lymphoid hyperplasia

Malignant small
* Adenocarcinoma
bowel tumors
* Lymphoma
* Leiomyosarcoma – GIST
* Carcinoid
Metastatic small
Lung carcinoma
bowel tumors
Breast carcinoma
Renal cell carcinoma


1.4. Methods of diagnosing GIB in the small intestine
1.4.1. Enterography with barium
1.4.2. Computerized tomography
1.4.3. Angiogram
1.4.4. Tc-99m scans attached to autologous red blood cells.
1.4.5. Modern methods on investigation of the small intestine
1.4.5.1. Capsule endoscopy
1.4.5.2. Spiral enteroscopy
1.4.5.3. Double balloon enteroscopy
1.4.6. Single balloon enteroscopy
Single balloon endoscopy has several advantages such as:
+ Giving alive images of the entire small intestine.
+ Being able to do procedure and take samples when detecting lesions.
+ Doable technique and does not need a lot of assistants during the procedure.
+ Complications tend to be less than that of dual ball colonoscopy.
The main disadvantages of single balloon enteroscopy include:
+ The duration of a colonoscopy can be long.

Diagnostic and therapeutic efficacy of single ball colonoscopy:
There are 6 randomized pilot studies comparing the rate of detecting small intestine lesions between
single balloon enteroscopy (SBE) and double balloon enteroscopy (DBE). The rate of detecting lesions in
the small intestine of SBE ranges from: 42-64.6%. The rate of detecting lesions in the small intestine of
DBE ranged from 28-67.1%.
Research findings show that the ability of the DBE to complete the small intestine tends to be better than
the SBE. Although the ability to complete small intestine enteroscopy is not as high as the one of DBE.
But in contrast, manipulation of doing SBE is simpler, and time is shorter via oral route than that of the
DBE.
Advantage of enteroscopy is that it can be therapeutic. The therapeutic intervention includes hemostatic
clipping, polypectomy, coagulated hemostasis, and lesion biopsy ... Depending on different studies, the
rate of therapeutic intervention is also different. The intervention rates ranged from 4.6% to 48%.
There are studies presenting complications after SBE as well as DBE, which include abdominal pain,
diarrhea, vomiting blood, black stools, nausea, indigestion ... However, the authors also believe that the
rate of complications depends much on different factors, especially in terms of the endoscopist's
experience and the patient's well-being.
1.4.6. Research on enteroscopy in Vietnam
CHAPTER 2
SUBJECTS AND METHODS OF RESEARCH
2.1. Subjects
89 patients with suspected GIB in the small intestine. They underwent gastroscopy and colonoscopy, but
no lesions were found. Patients were hospitalized at the Gastroenterology Department - Bach Mai
Hospital and Gastroenterology Department - National 108 Hospital. All patients were undergone a SBE
during the treatment period in hospital.


Study period: April 2010 to June 6, 2020.
2.1.1. Criteria for selecting research candidates.
- Clinical: patients have symptoms of vomiting blood and/or black stools.
- The patient has had twice both gastroscopy and colonoscopy, but no lesions were found.

* Criteria for selection of enteroscopy route: Patients will be selected for oral enteroscopy first if bleeding
points cannot be detected through both gastroscopy and colonoscopy because the oral approach is easier,
and the exploration distance is longer. Patients selected for rectal-approach examination before having
oral enteroscopy with undetectable lesions and when colonoscopy showed fresh blood, blood clots at the
end of the ileum and cecum (Suspected bleeding in the lower segment of the small intestine).
- All patients underwent oral and / or rectal SBE.
2.1.2. Exclusion criteria
- Patient is too old and weak, pregnant woman
- Patients with heart failure, respiratory failure is contraindicated for endoscopic anesthesia
- Patients with hemodynamic disorders
- Patient disagrees to participate in the study.
- Patient has history of serval abdominal surgeries.
2.1.2.1. Indications and contraindications for SBE
Contraindications and contraindications for SBE.
- Indication:
+ Bleeding due to lesion in the small intestine
+ Occult GI bleeding suspected in the small intestine.
+ Diagnosis and treatment of lesions that narrow the small intestine.
+ Removal of foreign bodies in the small intestine
+ Other small bowel diseases (diarrhea, tumors, polyps ...)
- Contraindicated
+ Availability of acute diseases in the esophagus such as chemical burns, acute ulcers, esophageal stenosis
+ Severe heart failure
+ Myocardial infarction
+ High blood pressure, low blood pressure
+ Dilated aorta
+ Pulmonary embolism, respiratory failure
+ Colon perforation
+ Peritonitis
+ Having shock condition.

+ Difficulty breathing due to any cause.
+ Cardiac arrhythmia without anesthesia indication
+ Patient recently operated on the stomach, colon, pelvic area.
+ Ulcerative colitis with severe bleeding
+ Patients with old age, severely debilitated condition and cannot undergo the examination.
+ Uncoordinated mental patients.
+ Severe blood clotting disorder
+ Pregnant condition
2.1.2.2. Contraindicated with anesthetics.
- Allergy to the anesthetics, contrast drug
- Epilepsy unstable, mentally ill, or difficult to communicate
- Pregnant women, children under 3 years old
- Severe liver failure, kidney failure


2.2. Research Methods
2.2.1. Research Methods
Descriptive study, cross-sectional study, interventional treatment.
2.2.2. Research design
Conduct research according to cross-sectional descriptive method, therapeutic intervention.
- The sample size is calculated by the following formula:
Z21-α/2 x p x (1 - p)
n=
d2
Where: Z21-α / 2 = 1.96 (95% confidence interval)
p: is the accuracy of the solution. In this study, we choose p = 0.66. We based on the study of Kim TJ et al
because the object of this study is quite similar to our study.
d: is desired absolute error We choose d = 10% (0.1) and when replacing the formula, we have n = 88
+ In the period from April 2010 to June 2020, there were 89 patients suitable with the selection criteria to
be included in the study.

2.2.3. Study stages
2.2.4. SBE.
2.2.4.1. SBE system
+ Small bowel endoscope (Olympus SIF-Q180, Japan).
+ Splinting tube.
+ Balloon Control Unit (OBCU).
2.2.4.2. Other accessory equipment and tools
2.2.4.3. Single balloon enteroscopy
a) Prepare the patient for the procedure
b) Technical technique
c) Steps to conduct a single balloon colonoscopy
* Perform anesthesia.
* Enteroscopy of the small intestine by oral route
+ Insert the splint into the endoscope and push up near the middle of the scope.
+ Put the endoscope through the esophagus - stomach, to the duodenum and try to push the scope into the
deep of the jejunum.
+ When the scope is fully in place, push the splint to the insider, near the curved end of the scope, then
stop. To be careful, check the end of the brace on the bright display.
+ Then, proceed to inflate the balloon to fix the small intestine, then pull the splint and the scope out.
When not pulling anymore, continue to push the filament deep inside. This process was repeated over and
over, until the most profound lesions are found, and the scope reaches the deepest area in the small
intestine.
* Enteroscopy with the rectal approach
+ Step 1 (at Sigma colon): Pump up the balloon, pull out both the scope and the splint to shorten the
Sigma colon.
+ Step 2. Aspiration in the balloon to deflate the balloon and continue to push the colonoscope to the
splenic colon.
+ Step 3. In the colon the spleen angle inflates the balloon
+ Step 4 and 5. Push the machine across the transverse colon, down to the ascending colon.
+ Step 6. inflate the ball, pull out the scope and the tube brace.

+ Step 7. Push the scope through the valve Bauhin into the ileum. In the ileum, the steps for enteroscopy
are the same as for the technique via oral route.
2.2.4.4. Techniques for interventions with SBE
2.2.5. Research indicators


2.2.5.1. Clinical investigation, diagnosis and endoscopic intervention results
a) General characteristics of the patient
b) Clinical information prior to admission
+ Reason for admission
+ Characteristics of vomit: color, number of times, quantity.
+ Stool features: color, number of times, quantity.
+ Evaluate the GIB status
c) Diagnosis through SBE
- The rate of lesion detection on SBE
- Characteristics of endoscopic lesions: location (ileum, jejunum, ileum + jejunum), types of lesions
(vascular dysplasia, tumor of the small intestine, ulcer of the small intestine, inflammation of the small
intestine, Meckel diverticulosis ...)
d) Intervention through SBE
- Rate of biopsy through SBE
- Histopathology
- The rate of treatment through SBE
- Endoscopic treatment techniques: polypectomy, hemostasis injection, hemostatic clip, coagulation ...
2.2.5.2. Specification and safety of single-ball colonoscopy
a) Technical specification of single balloon enteroscopy
- Average time of performance.
- Depths of small bowel insertion (m):
- Assessment of lesion: number, size, location, morphology, bleeding status (bleeding, no longer
bleeding ...)
b) Single balloon enteroscopy

+ Images of normal small intestine endoscopy: the small intestinal mucosa villi has a finger-shaped
protrusion in the lumen of the intestine, 0.5-1mm high, the highest in the jejunum and shorter in the
ileum. The blood vessels observed were clearer in the ileum than in other intestinal segments.
+ Hypertrophy of lymphocysts: is a condition where there are 10 lymphocysts protruding from the surface
of the mucosa, overgrown lymphoid follicles are white, yellowish, soft and have diameter up to 2 mm.
Small bowel disease caused by NSAID: manifested in an ulcerative form often with bleeding, perforation,
narrowing or obstruction of the intestine. Lesions on endoscopic images vary from villi degeneration and
erosive erosions to major lesions such as perforation and septum formation. These lesions are numerous
and have thin walls, concentric mucosa-like septum, narrowing the intestinal lumen.
+ Angiodysplasia.
+ Small bowel tumor: Carcinoid tumors usually locate under the mucosa, prominent in the ileum, slightly
increased in size and often found by chance.
+ Bleeding due to Meckel diverticula ulcers.
+ GIST: The most found in jejunum, then the ileum, and the duodenum. GIST usually develops from the
muscular layer, as submucosal mass, but sometimes as sub-serosa mass.
+ Blood tumor: is a neoplastic lesion caused by the vascular production of blood vessels, which is usually
benign.
+ Dieulafoy ulcer: is a bleeding artery damage but no ulcer.
+ Aphthous ulcer: is a small, shallow, concave lesion with loss of villi. These lesions are considered early
stage of Crohn's disease. Endoscopic image with erosions or small ulcers.
+ Inflammatory fibroid polyp: is a non-malignant hyperplasia of the gastrointestinal tract. Lesions have
the form of a submucosal tumor that is not sessile or sessile.
+ Submucosal tumor: is a tumor that develops from the lower epithelial layer protruding the mucosa into
the lumen of the intestine.
c) Follow-up for complications
Complications during anesthesia: slow pulse, low blood pressure, respiratory failure, hiccups, increased
secretion in the mouth ...


+ Complications during endoscopy: bleeding, perforation, blood pressure drop.

+ Complications after enteroscopy: abdominal distension, abdominal pain, fever, acute pancreatitis,
infection, perforation, respiratory inflammation ...
2.2.6. Histopathological standards
2.3. Data processing
The collected data are processed according to the statistical algorithm used in biomedical program with
SPSS 20.0 software.
2.4. Research ethics
CHAPTER 3
RESULTS
3.1. Characteristics of the research population
3.1.1. Age
The most common age is 20 - 59, accounting for 60.7%; 60 and over accounting for 34.8%, patients under
20 only account for 4.5%. The average age of women is: 49.7 ± 18.0, in men: 49.07 ± 20.23. Average age
in both gender: 49.3 ± 19.33.
3.1.2. Gender characteristics
The number of male patients accounts for: 62.9%. The ratio of male/female = 1.7
3.1.4. History of gastrointestinal bleeding
64% of patients had a history of GIB prior to admission, of which mainly happened one time (59.6%).
3.1.5. The reason for admission
The main reason that patients admitted to the hospital is black stools (62.9%). Other symptoms are more
frequent.
3.1.6. Initial diagnosis
3.1.7. Signs and symptoms
Table 3.5. Signs and symptoms upon admission
Symptoms
N (n= 89)
Abdominal pain
11/89
Fatigue
66/89

Orthostatic hypotension
61/89
Dizziness
60/89
Unconsciousness
42/89
Hematemesis
13/89
Hematochezia/Melena
57/89
Pale skin color
63/89

%
12,3
74,2
68,5
67,4
47,2
14,6
64,0
70,8

Comments: the most common signs are fatigue (74.2%), dazzled (68.5%), dizziness (67.45); the most
common physical symptoms are blood stools (85.4%), pale skin (70.8%).
3.1.9. Classification of clinical blood loss level
Severe, medium and mild GIB level accounts for 11.3%, 39.3% and 49.4%, respectively.
3.2. Endoscopic findings
3.2.1. Lesion detection rate on SBE
64/89 patients (71.9%) had lesions on the enteroscopy.

3.2.2. Images of lesions on SBE
Table 3.13. Endoscopic images of lesions detected on enteroscopy
Causes
N (n= 64)
%


Angiodysplasia
8
12,5
Tumor
11
17,2
Bleeding ulcer on Merkel’s
2
3,1
diverticula
Dieulafoy’s lesions
1
1,6
Jejunum/ileum’s ulcers
22
34,4
Jejunum/ileum’s polyps
3
4,7
Subepithelial tumors
2
3,1
Jejunum/ileum’s mucositis

15
23,4
Total
64
100,0
Comments: Common lesions include ulcers in the small intestine (34.4%), inflammation of the small
intestine mucosa (23.4%), tumors (17.2%) and angiodysplasia (12.5%)
3.2.3. Proportion of lesions found on enteroscopy routes.
Table 3.14.The rate of lesions detected by enteroscope routes
Route
n
%
p
Anterograde
24/64
37,5
Retrograde
7/64
10,9
0,29
Dual route
33/64
51,6
Total
64/64
100,0
Comments: 51.6% of lesions are detected through the combined endoscopy, 37.5% is via oral and 10.9%
is via anal approach.
Table 3.15. The rate lesions detected by the length of small intestine
Length of small

Non
Yes
Total
p
intestine examined (m)
n
%
n
%
n
%
<1
0
0,0
4
6,2
4
4,4
1-<2
5
20,0 7
10,9
12
13,5
2-<3
1
20,3
7
20
28,0 3

22,5
0,33
≥3
4
62,6
13
53
52,0 0
59,6
Total
100, 6
100,0
25
89
100,0
0
4
Average
2,61 ± 0,93
3,12 ± 1,35
2,97 ± 1,26
0,09
Comment: The detection rate of small intestinal lesions tends to increase with the length of the intestine
examined.
3.2.4. Relationship between endoscopic lesions and gender
Table 3.16. Relationship between causes of GIB and gender
Gender
Female
Male
p

Causes of GB
n
%
n
%
Angiodysplasia
2
8,7
6
14,6
0,5
Tumor
5
21,7
6
14,6
Bleeding ulcer on Merkel’s
0
0,0
2
4,9
diverticula
Dieulafoy’s lesions
1
4,3
0
0,0
Jejunum/ileum’s ulcers
7
30,4

15
36,6
Jejunum/ileum’s polyps
2
8,7
1
2,4


Subepithelial tumors
0
0,0
2
4,9
Jejunum/ileum’s mucositis
6
26,2
9
22,0
Total
23
100,0
41
100,0
Comments: The rate of inflammation lesion on small intestine mucosa and small bowel tumors tends to be
seen more in women; In contrast, vascular dysplasia, intestinal ulcers tend to be more common in men.
3.3. The lesion's location on the SBE findings and its relationship
3.3.1. Distribution of lesion location on the SBE
Table 3.19. Location of lesions on the SBE findings
Locations

N (n= 64)
%
Ileum
26
40,6
Jejunum
32
50,0
Jejunum + ileum
6
9,4
Total
64
100,0
Image of lesions on enteroscopy is most common in the jejunum (50.0%).
3.3.2. The relationship between the lesion location and the manifestation of blood vomiting
3.3.5. Relation of lesion location with lesion image
Table 3.23. Relationship of lesion location and the endoscopic images
Lesion location
Ileum
Jejunum
Ileum +
Total
Causes of GB
jejunum
Angiodysplasia
5 (62,5)
3 (37,5)
0
8 (100,0)

Tumor
3 (27,3)
8 (72,7)
0
11 (100,0)
Bleeding
ulcer
on
1 (50,0)
1 (50,0)
0
2 (100,0)
Merkel’s diverticula
Dieulafoy’s lesions
0
1 (100,0)
0
1 (100,0)
10 (45,5)
7 (31,8)
5 (22,7)
22
Jejunum/ileum’s ulcers
(100,0)
Jejunum/ileum’s polyps
3 (100,0)
0
0
3 (100,0)
Subepithelial tumors

0
2 (100,0)
0
2 (100,0)
Jejunum/ileum’s
4 (26,7)
10 (66,7)
1 (6,6)
15
mucositis
(100,0)
Total
26 (40,6) 32 (50,0)
6 (9,4)
64
(100,0)
Comments: The rate of vascular dysplasia, small bowel ulcers, polyps had a higher prevalence in the
ileum, while the rate of small bowel tumors, submucosa tumors, inflammation of the small intestinal
mucosa was more common in the jejunum (p = 0.14)
3.4. Histopathology and its association
3.4.1. Histopathology test rate
There are 42/89 patients (47.2%) undergoing histopathological tests when performing enteroscopy.
3.4.2. Histopathology findings
Table 3.24. Histopathological results
n (n= 42)
Chronic ulcers
10/42
Hyperplastic polyps
3/3
GIST

2/42
Small intestine mucositis
22/42
Gastrointestinal
1/42

%
23,8
7,1
4,8
52,4
2,4


lymphangiectasia
Ileum inflammation
1/42
2,4
Chronic duodenum
3/42
7,1
inflammation
Comments: Common injury includes inflammation of small intestinal mucosa (52.4%), chronic ulcer
(23.8%).
3.4.3. Relationship between histological result and some clinical features
Table 3.29. Relationship between histopathological results and causes of GB
HR
Chronic HyperGIST
muco Others
-ulcers

plastic
sitis
Causes of GB
polyp
Tumors (8)
0
0
2
5
1
Ulcers (17)
10
0
0
5
2
Polyp (3)
0
3
0
0
0
Mucositis (14)
0
0
0
12
2
Total
10

3
2
22
5
Comment: In 3 cases of polyps, histological result is all polyp (100%); 17 cases of small bowel ulcers,
Histological results: chronic ulcer (n = 10), inflammation of the small intestine mucosa (n = 5); 14 cases
of mucosal congestive inflammation, histological result: inflammation of the small intestinal mucosa (n =
12).
Table 3.30. Relationship between histopathological results and lesion locations.
HR
ChronicHyperGIST
mucositis Others
ulcers
plastic
Location of lesions
polyp
Ileum
4 (40,0)
3 (100,0)
0 (0,0)
9 (40,9)
1 (20,0)
Jejunum
2 (20,0)
0 (0,0)
2 (100,0) 11 (50,0) 4 (80,0)
Jejunum + ileum
4 (40,0)
0 (0,0)
0 (0,0)

1 (9,1)
0 (0,0)
Total
10
3
2
22
5
Comment: Inflammation of the small intestinal mucosa (chronic, progressive) in the jejunum tends to be
higher in the ileum, while chronic ulceration tends to be higher in the ileum than in the jejunum (p =
0.04).
3.5. Therapeutic intervention with SBE
3.5.1. The rate of therapeutic intervention with SBE
There are 59/64 patients (90.1%) among the SBE candidates.
3.5.2. Types of intervention with SBE
Table 3.31. SBE interventional procedures
Procedures
N (n= 64)
%
Non
7
10,9
Polypectomy
3
4,7
Electric coagulation
3
4,7
Clips
7

10,9
Biopsy
39
60,9
Adrenalin injection
5
7,9
Total
64
100,0
The patients with ulcer on Meckel diverticulum or submucosal tumors are not intervened, while the
intervention rates of other lesions are all over 90%.
Table 3.32. Relationship between SBE interventions and causes of GB
SBE interventions
No
Yes
p


Causes of GB
n
Angiodysplasia
0
Tumor
1
Bleeding ulcer on Merkel’s
2
diverticula
Dieulafoy’s lesions
0

Jejunum/ileum’s ulcers
1
Jejunum/ileum’s polyps
0
Subepithelial tumors
2
Jejunum/ileum’s mucositis
1
Total
7
3.6. Technical specification and the safety of SBE
3.6.1. Sedation method
3.6.2. Enteroscopy approach

Antegrade

%
0,0
9,1

n
8
10

%
100,0
90,9

100,0

0

0,0

0,0
4,5
0,0
100,0
6,7
10,9

1
21
3
0
14
57

100,0
95,5
100,0
0,0
93,3
89,1

Retrograde

<
0,001

Dual

Figure 3.7. Distribution of the SBE routes
3.6.3. The length of the small intestine examined.
Table 3.35. Examined length (m) of small intestine in
Length (m)
N
%
<1
3
3,9
1-<2
11
14,5
2-<3
31
40,8
Antegrade
≥3
31
40,8
Total
76
100
Average
2,49 ± 0,94 (0,3 - 4,5)
<1
15
26,3
1-<2

30
52,6
2-<3
9
15,8
Retrograde
≥3
3
5,3
Total
57
100
Average
1,32 ± 0,74 (0,2 - 4,0)
<1
4
4,4
1-<2
12
13,5
2-<3
20
22,5
Dual
≥3
53
59,6
Total
89
100

Average
2,94 ± 1,26 (0,3 - 6,6)
Remarks: The average length (meters) of the small intestine examined through the mouth, the anus and
both lines, respectively: 2.49 ± 0.94; 1.32 ± 0.74 and 2.94 ± 1.26.


3.6.4. Time to perform SBE
Table 3.36. Time to perform SBE (minutes)
N
Average
Maximum Minimum
32
95,31 ± 40,42
180
15
13
51,92 ± 29,69
120
15
161,70 ±
200
135
44
16,46
Comment: Average endoscopy time (minutes) for oral, anal and both lines, respectively: 95.31 ± 40.42;
51.92 ± 29.69 and 161.70 ± 16.46
3.6.5. Monitoring unexpected effects with sedation
Common undesirable symptoms during anesthesia are increased secretion (15.7%), hiccups (13.5%), slow
pulse (12.4%).
3.6.6. Complications and undesirable outcome after SBE

Table 3.37. Complications during and after SBE
Complications
n
%
Perforation
0/89
0
Bleeding after SBE
1/89
1,1
Mild acute pancreatitis
3/89
3,4
Biliary tract infection
1/89
1,1
Total
89
100,0
Table 3.38. Undesirable outcome after SBE
SBE route Antergrad Retrograde
Dual
Total
e
Symtoms
25 (33,8)
10 (13,5)
39 (52,7) 74 (83,1)
Tired
13 (28,9)

10 (22,2)
22 (48,9) 45 (51,7)
Abdominal
pain
5 (26,3)
0 (0,0)
14 (73,7) 19 (21,3)
Sore throat
5 (45,5)
4 (36,4)
2 (18,2)
11 (12,4)
Abdominal
distention
4 (80,0)
1 (20,0)
0 (0,0)
5 (5,6)
Nausea
Comments: Fatigue and abdominal pain are the most common undesirable signs after endoscopy (83.1%
and 51.7%) respectively.
SBE routes
Antegrade
Retrograde
Dual

CHAPTER 4
DISCUSS
4.1. General features of GIB patients in small intestine
4.1.1. Age and gender characteristics of the research team

The research findings show that: The most common age is 20 - 59, accounting for 60.7%; The number of
people aged 60 and over accounts for 34.8% and only 4.5% under 20 years old. The average age of
women is: 49.7 ± 18.0. Average age of male is: 49.07 ± 20.23. There is no difference in mean age between
men and women (p = 0.88). The average age for both men and women is 49.3 ± 19.33, of which the
youngest patient is 6 years old, and the oldest patient is 88 years old. Thus, diseases in the small intestine
can appear both the young (children) and the elderly (the elderly). Research results also show that the rate
of men suffering from this disease is higher than that of women. The ratio between men and women is:
56/33 = 1.7.


4.1.2. Investigation of risk factors and comorbidities
4.1.3. History of GIB
Mostly, patients with GIB in the small intestine, when hospitalizing to a referral medical center often have
a history of GIB at least once; at anterior hospitals, the cause was usually not defined. In our study, there
are many the patients who were referred from other provincial hospitals. Over two thirds of these patients
had gastroscopy and/or colonoscopy, but no lesions were found. Research results show that: the number
of patients with a history of GIB accounts for 57/89 (64%), of which the number of patients with a history
of GIB once, twice, and ≥ 3 times, accounts for the proportion of the corresponding ratios: 56.9%, 19.3%
and 21.1%. Our research results are also consistent with those of Kieu Van Tuan, Tran Tuan Viet and
Nguyen Thi Huong Giang. In the studies of these authors, it is reported that over 50% of patients have
had a history of GIB at least once before they are transferred to referral hospitals.
4.2. Clinical and endoscopic characteristics and causes of gastrointestinal bleeding from the small
intestine with SBE.
4.2.1. Clinical characteristics of small intestinal GIB
4.2.1.1. Signs of patients with GIB in the small intestine
In our study the common signs include fatigue (74.2%), dizziness (68.5%), abdominal pain (68.5%),
dizziness face (67.4%) … In general, these signs are similar to the results of other domestic authors’
research, they are often non-specific and may be results of different diseases. Therefore, to make an
accurate diagnosis of the disease, doctors must base on physical exams, as well as additional tests for
these patients.

4.2.1.2. Physical signs in patients with GIB in the small intestine
In our study (table 3.5) shows that vomiting blood in 20/89 patients (22.5%), black stools: 76/89 patients
(85.4%). We have 02 patients with severe abdominal pain, combined with black stools, causing severe
anemia. We have combined all three diagnostic methods: abdominal computed tomography, imaging and
SBE. Computer tomography and CT scans show suspicious signs of injury in the small intestine.
Confirmed diagnosis must be based on SBE with a diagnosis of GIB due to Meckel diverticulitis in the
ileum. These patients were promptly transferred to surgical treatment to save the patient's life. After the
treatment, these patients recovered quickly.
4.2.2. Laboratory tests
4.2.3. Diagnosis effectiveness and lesion characteristics on the SBE
4.2.3.1. Diagnosis effectiveness on SBE
We performed small bowel endoscopy with SBE for all 89 patients with a diagnosis of GIB suspicion in
the small intestine. There was a total of 167 enteroscopies, of which oral, anal and combined endoscopy
(oral and anal) approach was in 66, 57 and 44 times respectively. Endoscopic results have found lesions in
64/89 patients (71.9%). Thus, about 28% of these patients were not defined with any cause. However, for
final results, all patients require close monitoring and repeated endoscopy to avoid missing lesions. This
research results are quite consistent with the study of Tao Z et al in China when conducting SBE for 186
patients and found that 129/186 patients (76.7%) had lesions in the small intestine. These results have
shown that SBE is very valuable in diagnosing lesions on endoscopy and this is very meaningful to guide
the right treatment strategy.
4.2.3.2. Characteristics of the lesions on the SBE
Lesions in the small intestine are varied. However, studies in the world have shown that vascular lesions
are the main cause of GIB in the small intestine (70-80%), with vascular malformations accounting for
most of the lesions. In European and American countries, the rate of vascular dysplasia in the small
intestine often accounts for the highest rank, especially in elderly patients. In Asia, by contrast, the
number of patients with inflammation or ulcers is often the main cause of GIB in the small intestine. In
our study, the most common lesions include inflammation of the small intestine mucosa (23.4%),
ulceration (34.4%), tumors (17.2%), Angio-metaplasia (12.8%). In addition, there are some other rare
lesions, such as 02 cases with Meckel diverticulum (3.1%), 01 case with Dieulafoy lesions (1.6%). Some
patients have recently had ulcers associated with the diverticulum of small intestine causing GIB,

accounting for 6/64 patients (9.4%).


4.2.3.3. Lesion location on endoscopy images
Unlike capsule endoscopy, SBE or DBE can determine the location of the lesion on endoscopy. This
positioning plays an important role in guiding the physician to intervene in the correct location, especially
when the patient needs to switch to surgical treatment. In the study results, 64 patients were detected with
lesions on SBE, the most common location is the jejunum (50.0%), ileum (40.6%), and both location
(9.4%). Based on this result, lesions of the jejunum account for the highest proportion and tends to
increase gradually with age. However, in order to properly assess the location of the lesion in the small
intestine, various studies suggest that a larger number is needed, and the entire small intestine must be
covered.
4.2.3.4. Characteristics of histopathology
In 89 patients with SBE, there are 42/89 patients (47.2%) indicated for histopathology. The findings were
as follows: enteritis 22/42 (52.4%), chronic ulcer (23.8%), adenocarcinoma (7.1%), gastrointestinal
stromal tumor (4, 8%). Unfortunately, we did not find any malignant tumors, or chronic pathology
(tuberculosis of the small intestine ...).
4.2.4. Therapeutic intervention through
In addition to a histopathological biopsy, therapeutic endoscopy can also be done during the endoscopy. In
our study, among 89 patients with SBE, 64 patients (71.9%) were detected with endoscopic lesions. Of
these 64 patients, 57/64 (89%) were intervened for endoscopic treatment and histopathology (endoscopic
biopsy). The results of the study showed that polyps were removed (4.7%), electrically ablation (4.7%),
hemostasis with clip (10.0%), endoscopic hemostasis injection (7.9 %), biopsy (60.9%). Regarding the
patients with intervention (hemostasis clip, polypectomy, hemostasis injection ...), it accounts for the
proportion of 21/64 patients (32.8%).
4.3. Evaluation of treatment results for emergency hemostasis and safety of SBE.
4.3.1. The rate of total enteroscopy through SBE
A total enteroscopy is an indicator that should be achieved with single or double balloon endoscopy.
Endoscopy of the entire small intestine will help to avoid missing the lesion. To evaluate complete small
intestine enteroscopy, it requires a combined endoscopy (oral and anus approach). Normally, we do an

oral enteroscopy first, and when we reach the furthest point of the small intestine that the tip of the scope
touches, we will mark that site with a clip or inject a methylene blue solution. At the next rectal exam, if
there is a marked site (clip or methylene blue), then the entire length of the small intestine has been
investigated. In our study, the number of patients with complete colonoscopy for the entire small intestine
accounted for 9/89 patients (10.1%). The study of Kieu Van Tuan showed that the rate of colonoscopy
with the complete small intestine by SBE reached the rate of 54 patients (56.9%). According to the
research of Nguyen Thi Huong Giang, the total enteroscopy with SBE reached the rate of 17/29 patients
(58.6%). In the world, there are many studies reporting on the rate of complete colonoscopy of SBE,
ranging from 40 - 86%.
However, the rate of complete enteroscopy depends on many factors such as history of abdominal
surgery, intestinal adhesion, damage to the small intestine that causes intestinal obstruction or narrowing
or the patient's ability to tolerate the procedure. In our study, there are no cases of complete small
intestinal examination through only one oral or anal route.
4.3.2. Evaluation of techniques on SBE on patients with GIB in small intestine
4.3.2.1. Selection of endoscopy route
The choice of the oral or anal route or a combination is up to the endoscopist. Usually, we decise the
enteroscopy pathway during the initial examination of the patient based on the location of the lesion
suggested by the clinical examination or in combination with other diagnostic imaging methods such as
computed tomography, ultrasound, X-ray. In the absence of the lesion location, the oral route is the first
line of access due to the better and more favorable way than that of the anus.
In our study, the number of patients with oral enteroscopy reached: 32/89 patients (36.0%), the anal route:
13/89 patients (14.6%) and both: 44/89 diseases (49.4%). Thus, nearly 50% of patients undergo


enteroscopy with both ways. Our aim is to examine the entire length of the small intestine and avoid
missing lesions. In the first cases where the path of access cannot identify the lesion, the patient also has a
second endoscopy in the opposite direction to find lesions. However, depending on the patient's condition,
the practitioner's experience, the choice of pathway is also different.
4.3.2.2. Average time of SBE performance
The length of the colonoscopy of the small intestine for either single or double balloon is also an indicator

of the quality of the enteroscopy. The duration of an enteroscopy is highly dependent on the experience of
the endoscopist. Those doctors who have had long-term endoscopy experience, are proficient in
manipulation, the endoscopy time will be less than those who just started doing the job. Duration of the
enteroscopy also depends on the patient's condition (fat, thinness, and comorbidities). For each oral exam,
we calculate the time that begins when the endoscope moves from the mouth and ends when it cannot go
any further. For rectal exams, the time begins when the endoscope moves from the anus and ends when
the marker was found on the previous oral exam or was unable to go deeper into the small intestine (no
timed biopsy or marker procedure). In our study, the time of small intestinal endoscopy by mouth, anus,
both lines and the mean endoscopy time (minutes) accounted for 95.31 ± 40.42; 51.92 ± 29.69; 161.70 ±
16.46 and 121.80 ± 51 (minutes), respectively.
4.3.2.3. Methods and side effects when anesthesia in SBE
4.3.2.4. Complications during and after SBE.
Single-balloon or double-balloon enteroscopy are both invasive procedures. In addition to complications
(possible) of anesthesia, complications during - after the procedure may also occur. These complications
depend on many factors such as patient's condition (fat, thinness, ..), experience of the endoscopist and
endoscopic equipments (old or new) ...
In our study: No patient had a perforation relating to the enteroscopy, as well as after other therapeutic
procedures; 3/89 patients (3.4%) had mild acute pancreatitis (edema-hemolytic acute pancreatitis).
However, these three patients responded to treatment, thanks to fasting, adequate fluids and intravenous
antibiotics. We have 1/89 patients (1.1%) with mild GIB after polypectomy (clipping after resection).
4.3.2.5. Comparing complications between SBE with DBE
The limitation in our study is that there is no controlled study, specifically a comparison between the SBE
with DBE.
4.3.2.6. Undesirable effects after SBE
In our study, the undesirable symptoms after the SBE include fatigue (83.1%), abdominal pain (51.7%),
sore throat (21.3%), bloating (12, 4%), nausea (5.6%).
CONCLUSION
1. Investigating several clinical features, diagnosis results and interventions through SBE in patients
with suspected gastrointestinal bleeding in the small intestine.
* Investigating some clinical features:

Average age: 49.3 ± 19.3. Male / female ratio: 56/33 (1.7).
The most common symptoms include fatigue: 66/89 (74.2%), dazzled 61/89 (68.5%), dizziness 60/89
(67.4). Common physical symptoms: blood stools 57/89 (64.0%), vomiting blood: 13/89 (14.6%).
Severe and moderate gastrointestinal bleeding of the small intestine: 45/89 patients (50.6%)
* Diagnostic findings on SBE:
+ The rate of detecting injury in the small intestine through SBE is: 64/89 patients (71.9%)
+ Common lesions (n = 64): small intestinal ulcers: 22/64 patients (34.4%), inflammation of the small
intestinal mucosa: 15/64 patients (23.4%), tumors 11/64 patients (17.2%) and angio-metaplasia 8/64
patients (12.5%).
+ Common lesion sites: ileum: 26/64 patients (40.6%), jejunum: 32/64 patients (50%), ileum + jejunum:
6/64 patients (9.4 %).


+ The rate of histopathology: 42/89 patients (47.2%). Common histopathological findings: chronic
inflammation of the small intestinal mucosa (33.3%), progressive inflammation of the small intestinal
mucosa (19.1%), chronic ulcer (23.8%).
* Results of intervention through SBE:
Rate of intervention through SBE: 59/64 patients (90.1%)
Interventional procedures: lesion biopsy: 39/64 patients (60.9%), hemostatic clip: 7/64 patients (10.9%),
hemostatic injection: 5/64 patients (7.9%), coagulated ablation: 3/64 patients (4.7%), polypectomy: 3/64
patients (4.7%)
2. Evaluation of specification and safety of SBE in patients with suspected gastrointestinal bleeding
in the small intestine.
* Technical evaluation:
Rate of: oral SBE: 32/89 patients (35.9%), anal route: 13/89 patients (14.6%), for both ways: 44/89
patients (49.4%).
Average time of: oral SBE: 95.31 ± 40.42 (minutes), rectal: 51.92 ± 29.69 (minutes), both ways: 161.70 ±
16, 46 (minutes)
+ Average length (meters) of the SBE via oral, anal and both lines, respectively: 2.49 ± 0.94; 1.32 ± 0.74
and 2.94 ± 1.26

* Safety of SBE:
Undesirable outcome encountered during anesthesia include increased secretion (15.7%), hiccups
(13.5%), slow pulse (12.4%), hypotension: 5.6%
Complications of SBE: mild acute pancreatitis: 3/89 patients (3.4%), post-operative mild bleeding: 1/89
patients (1.1%), cholangitis: 1/89 patients (1.1%). There are no serious complications.
Side effects after SBE: fatigue (83.1%), abdominal pain (51.7%), sore throat (21.3%), bloating (12.4%),
nausea (5.6%). No serious side effects were found.