Clinical outcomes after deep enteroscopy in patients with obscure gastrointestinal bleeding: a single-center retrospective study

BACKGROUND: Double balloon enteroscopy (DBE) is a key diagnostic and therapeutic tool for small bowel pathologies, particularly in patients with obscure gastrointestinal bleeding (OGIB). Although DBE's diagnostic value is well established, long-term quantitative data on hemoglobin recovery and transfusion needs remain limited. AIM: To evaluate the effectiveness of DBE and endoscopic intervention in improving hemoglobin levels and reducing transfusion and iron supplementation requirements in patients with OGIB. METHODS: We conducted a retrospective cohort study at Rambam Medical Center between January 2014 and June 2023, including 77 adults who underwent 96 DBE procedures. Data were collected from electronic medical records and community health centers, with follow-up of up to 5 years. The primary endpoint was an increase in hemoglobin of ≥ 2 g/dL or > 9 g/dL at ≥ 6 months post-procedure. Secondary outcomes included blood transfusion requirements, intravenous iron supplementation, repeat enteroscopy, and surgery. RESULTS: Angioectasias were the most common lesions (42%). Therapeutic endoscopic intervention was performed in 51% of patients, most commonly argon plasma coagulation (72%). The mean follow-up duration was 3.6 years. Overall, mean hemoglobin increased from approximately 9 g/dL pre-procedure to 11.5 g/dL at last follow-up, with 52% achieving a ≥ 2 g/dL rise and 79% attaining hemoglobin > 9 g/dL. Compared with diagnostic-only DBE, patients undergoing intervention were older (72 vs 64 years, p = 0.003), had lower baseline hemoglobin (8.35 vs 9.59 g/dL, p = 0.009), and higher prior transfusion rates (62% vs 37%, p = 0.041). At follow-up, they had lower mean hemoglobin (10.62 vs 12.41 g/dL, p = 0.001) and required more transfusions (38% vs 11%, p = 0.007). Fewer intervention patients achieved hemoglobin > 9 g/dL (69% vs 89%, p = 0.047), while the proportion achieving a ≥ 2 g/dL rise was similar (46% vs 58%). Outcomes were comparable between overt and occult bleeding. Patients undergoing DBE without prior VCE required significantly more pre-procedure transfusions (87% vs. 40%, p = 0.001) and had less favorable outcomes, including a lower proportion achieving hemoglobin > 9 g/dL at follow-up (53% vs 85%, p = 0.011). Among patients with negative DBE but prior VCE (n = 22), VCE frequently identified lesions-most commonly angioectasias (45%), followed by ulcers (27%) and polyps (14%). CONCLUSION: Patients requiring therapeutic DBE appear to represent a higher-risk population with more severe baseline anemia and ongoing transfusion needs. These findings suggest that combined endoscopic management and adjunctive medical therapy may be necessary in complex small-bowel bleeding. Prospective studies are needed to clarify the impact of DBE-directed therapy on long-term clinical outcomes.