ORIGINAL PAPER Double Balloon Enteroscopy Detects Small Bowel Mass Lesions Missed by Capsule Endoscopy Andrew Ross Æ Shahab Mehdizadeh Æ Jeffrey Tokar Æ Jonathan A. Leighton Æ Ahmad Kamal Æ Ann Chen Æ Drew Schembre Æ Gary Chen Æ Kenneth Binmoeller Æ Richard Kozarek Æ Irving Waxman Æ Charles Dye Æ Lauren Gerson Æ M. Edwyn Harrison Æ Oleh Haluszka Æ Simon Lo Æ Carol Semrad Received: 26 June 2007 / Accepted: 27 October 2007 / Published online: 13 February 2008 Ó Springer Science+Business Media, LLC 2008 Abstract Background Small bowel mass lesions (SBML) are a relatively common cause of obscure gastrointestinal bleeding (OGIB). Their detection has been limited by the inability to endoscopically examine the entire small intes- tine. This has changed with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE) into clinical practice. Study Aim To evaluate the detection of SBML by DBE and CE in patients with OGIB who were found to have SBML by DBE and underwent both proce- dures. Methods A retrospective review of a prospectively collected database of all patients undergoing DBE for OGIB at seven North American tertiary centers was performed. Those patients who were found to have SBML as a cause of their OGIB were further analyzed. Results During an 18 month period, 183 patients underwent DBE for OGIB. A small bowel mass lesion was identified in 18 patients. Of these, 15 patients had prior CE. Capsule endoscopy identified the mass lesion in five patients; fresh luminal blood with no underlying lesion in seven patients, and non-specific erythema in three patients. Capsule endoscopy failed to identify all four cases of primary small bowel adenocarcinoma. Conclusions Double balloon ent- eroscopy detects small bowel mass lesions responsible for OGIB that are missed by CE. Additional endoscopic evaluation of the small bowel by DBE or intraoperative enteroscopy should be performed in patients with ongoing OGIB and negative or non-specific findings on CE. Keywords Enteroscopy Á Small bowel Á Neoplasm Á Obscure gastrointestinal bleeding Introduction Small bowel mass lesions such as primary and metastatic cancers, carcinoids, and stromal tumors are responsible for OGIB in up to 10% of cases [1, 2]. Malignant neoplasms of the small bowel, especially primary small bowel adeno- carcinomas, are often diagnosed at a later stage of disease when compared to other gastrointestinal malignancies [1, 3]. Diagnosis is delayed even after prolonged symptoms because conventional imaging technologies including push enteroscopy, computerized tomography and small bowel series fail to detect small bowel neoplasms in up to 50% of cases [3, 4]. There have been two major advances in small bowel endoscopy in the past 7 years: CE and DBE. Capsule A. Ross Á I. Waxman Á C. Dye Á C. Semrad The University of Chicago, Chicago, USA A. Ross (&) Virginia Mason Medical Center, 1100 9th Ave., Mail Stop C3-GAS, Seattle, WA 98111, USA e-mail: andrew.ross@vmmc.org S. Mehdizadeh Á G. Chen Á S. Lo Cedars-Sinai Medical Center, Los-Angeles, USA J. Tokar Á O. Haluszka Fox Chase Cancer Center, Philadelphia, USA J. A. Leighton Á M. E. Harrison Mayo Clinic Scottsdale, Rochester, USA A. Kamal Á L. Gerson Stanford University, Stanford, USA A. Chen Á K. Binmoeller California Pacific Medical Center, San Francisco, USA D. Schembre Á R. Kozarek Virginia Mason Medical Center, Seattle, USA 123 Dig Dis Sci (2008) 53:2140–2143 DOI 10.1007/s10620-007-0110-0