Introduction Historically the small bowel has been considered a black box, which is technically difficult to examine due to its length, tortuosity and location. Diagnosis and management of small bowel pathology has entered a new era with the advent of capsule endoscopy (CE) and enteroscopy. We have been providing a comprehensive small bowel endoscopy service and we present our experience from the last 13 years, evaluating demand, diagnostic yield and management.

Method A retrospective analysis was conducted on patients who underwent CE, push enteroscopy (PE), double balloon enteroscopy (DBE) and intraoperative enteroscopy (IOE) between January 2002 and October 2014. Data collected included demographics, indications, diagnosis, subsequent change in management and complications.

Results A total of 4288 CEs, 294 PEs, 399 DBEs and 19 IOEs were performed over 142 months. The most common indication across all 4 modalities was obscure gastrointestinal bleeding (OGB). The majority of patients (91%) had CE prior to DBE or PE, which helped direct the route and modality of enteroscopy. The diagnostic yield for CE, PE, DBE and IOE were 29%, 43%, 49% and 89% respectively (p < 0.0001). Whilst the demand for CE has continued to rise over the years (p < 0.0001), the diagnostic yield has fallen (p < 0.0001). The diagnostic yield was highest for the indication of OGB (36%) in CE compared to Crohn’s disease (30%, p < 0.001). Significant pathology was found outside the small bowel in 8% of patients (colon 36%, gastric 64%). With the advent of DBE, the demand for PE has fallen (p = 0.03, r = -0.6) and was mainly used for proximal lesions seen on CE. In contrast, the demand for DBE has risen gradually in tandem with the diagnostic yield (p < 0.0001, r = 0.9). Management was altered by CE in 25%, 43% for PE and 41% for DBE. The rate of therapeutics for PE and DBE were 21% and 24% respectively. In 2014, for every 13 CEs performed, one patient underwent DBE locally. Whilst there were no complications for PE, the complication rate for DBE was 1.25% and 10.5% for IOE. Capsule retention data was collected for patients undergoing CE from 2010. Of the 2882 procedures done in this period, CE retention >2 weeks occurred in 6 patients (0.2%), of which 5 were due to a stricture (Crohn’s n = 4, non-steroidal n = 1) and 1 was due to delayed gastric emptying. Three patients required further intervention for capsule removal (endoscopic n = 2, surgery n = 1).

Conclusion This is the largest series to date comparing the clinical utility of all four small bowel endoscopic modalities. Enteroscopy has an important role in altering management post CE in patients with small bowel pathology as reflected by the rising demand and yield. Future tariffs for the modalities particularly CE are likely to influence this demand.

Disclosure of interest None Declared.