Positioning double-balloon enteroscopy in the diagnostic algorithm for suspected small bowel Crohn’s disease: a retrospective analysis of decision-making at a tertiary referral centre

Background: Small bowel capsule endoscopy (SBCE) enables non-invasive mucosal assessment of the small bowel, while double-balloon enteroscopy (DBE) allows histological confirmation and therapeutic intervention. Appropriate patient selection is essential to maximise diagnostic yield and minimise unnecessary invasive procedures. Methods: We performed a retrospective analysis of patients referred for investigation of suspected small bowel Crohn's disease over a two-year period at a tertiary referral centre. Demographic data, prior investigations, SBCE findings, and subsequent DBE decisions were recorded. The primary outcome was the decision to proceed to DBE. Secondary outcomes included the diagnostic yields of SBCE and DBE. Multivariate logistic regression was used to identify factors associated with DBE referral. Results: Ninety-eight patients with complete data were included. SBCE was performed as the initial investigation in 90.8%, while 5.5% proceeded directly to DBE for therapeutic or histological indications. The SBCE-to-DBE conversion rate was 30.4%. SBCE alone established or excluded inflammatory bowel disease in 70% of patients. Among those undergoing DBE, Crohn's disease was confirmed in 21% and excluded in 79%. Increasing age (OR 1.04 per year; 95% CI 1.01-1.07) and diagnostic uncertainty on SBCE (OR 2.0; 95% CI 1.8-3.5) independently predicted DBE referral. Conclusion: SBCE is diagnostic in the majority of patients with suspected small bowel Crohn's disease and functions effectively as a triage tool. DBE should be reserved for cases requiring histological confirmation, clarification of indeterminate findings, assessment of proximal disease, or therapeutic intervention.