THE AMERICAN JOURNAL OF GASTROENTEROLOGY
1, 2000
© 2000 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
Diagnostic Value of Push-Type
Enteroscopy: A Report From India
Brijesh C. Sharma, D.M., Deepak K. Bhasin, D.M., Gobind Makharia, D.M., Mohinish Chhabra, D.M.,
Kim Vaiphei, M.D., Harinderpal S. Bhatti, Ph.D., and Kartar Singh, D.M.
Departments of Gastroenterology, Pathology, and Parasitology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
OBJECTIVE: We sought to assess the diagnostic value of
push-type enteroscopy in relation to indications.
METHODS: Ninety-nine consecutive patients (mean age,
42 ⫾ 15 yr; 65 men) with suspected small bowel disorders
underwent push enteroscopy. The indications were chronic
diarrhea (n ⫽ 54), obscure gastrointestinal (GI) bleeding
(n ⫽ 21), abdominal pain (n ⫽ 10), abnormal radiological
studies of small bowel (n ⫽ 5), iron deficiency anemia (n ⫽
5), and others (n ⫽ 4). Push enteroscopy was performed
using the Olympus SIF-10 (160-cm) enteroscope.
RESULTS: Endoscopic examination of the jejunum was suc-
cessful in all the patients, except one with a distal duodenal
stricture. The length of the jejunum examined ranged from
10 to 70 cm. The time taken to complete the procedure
varied from 2 to 30 min. Lesions were found in nine (42.8%)
patients with obscure GI bleeding; six (28.5%) had worms
(Ascaris lumbricoides [n ⫽ 3], Ankylostoma duodenale [n ⫽
3]) in the jejunum, producing multiple erosions and bleeding
points. In the chronic diarrhea group, a diagnosis was made
in 13 (24%) patients on enteroscopic visualization and je-
junal histology: celiac disease (n ⫽ 6), tropical sprue (n ⫽
3), Crohn’s disease (n ⫽ 1), secondary lymphangiectasia
(n ⫽ 1), strongyloidiasis (n ⫽ 1), and nodular lymphoid
hyperplasia with giardiasis (n ⫽ 1). In patients with abdom-
inal pain, enteroscopy provided a diagnosis in one (10%)
patient. No positive diagnosis could be made on enteroscopy
in patients with iron deficiency anemia and abnormal radio-
logical studies of small bowel.
CONCLUSION: Push-type enteroscopy is a useful test in the
evaluation of patients with obscure GI bleeding and chronic
diarrhea. In developing countries, in patients with obscure
GI bleeding, the presence of worms in the jejunum is an
important finding on enteroscopy. Tropical sprue, giardiasis,
and strongyloidiasis are distinct findings in patients with
chronic diarrhea in the present series. (Am J Gastroenterol
2000;95:137–140. © 2000 by Am. Coll. of Gastroenterology)
INTRODUCTION
Conventional esophagogastroduodenoscopy (EGD) is lim-
ited to visualization of the second or third part of the
Vol. 95, No.
ISSN 0002-9270/00/$20.00
PII S0002-9270(99)00733-9
duodenum. The traditional way to examine the small bowel
is a small bowel follow-through contrast study or entero-
clysis. Endoscopic visualization of the small bowel has
emerged as an important way to investigate patients with
various small bowel diseases.
Endoscopic methods for examining the small bowel in-
clude push enteroscopy, Sonde enteroscopy, intraoperative
enteroscopy, and retrograde ileoscopy (1, 2). Push enteros-
copy has been the most frequently used method for evalu-
ating the proximal small bowel. The efficacy of push en-
teroscopy in the investigation of small bowel diseases has
been evaluated recently (3–14). However, there is a paucity
of reports from developing countries. We performed a pro-
spective study to evaluate push enteroscopy in patients with
suspected small bowel disorders in India.
PATIENTS AND METHODS
From July 1996 to September, 1998, 99 consecutive patients
(mean age, 42 ⫾ 15 yr; range, 15–70 yr; 65 men) with
suspected small bowel disorders were included in the study.
Indications for enteroscopy included chronic diarrhea, ob-
scure gastrointestinal (GI) bleeding, chronic iron deficiency
anemia, and abnormal radiological studies of the small
bowel (Table 1); EGD was performed and was normal in all
patients.
After an overnight fast, push enteroscopy was performed
in every patient with the Olympus SIF-10 (160-cm) entero-
scope. Sedation was given using i.v. diazepam or midazo-
lam. Hyoscine butyl bromide was given as required to
control motility. Enteroscopy was performed without the aid
of fluoroscopy or an overtube, using the technique described
earlier (1). The endoscope was advanced into the jejunum as
deeply as possible. Care was taken to avoid major deflec-
tions of the endoscope tip. This, coupled with gentle push-
pull movements, facilitated easy passage of the enteroscope
into the jejunum. The length of the jejunum examined was
determined by the length of endoscope advanced beyond the
duodenojejunal flexure (1, 2). While withdrawing the endo-
scope, the mucosa was inspected by deflection of the tip of
the endoscope and torque on the shaft. Jejunal biopsies were
138 Sharma et al. AJG – Vol. 95, No. 1, 2000

Table 1. Indications for Push-Type Enteroscopy (n ⫽ 99) Table 3. Enteroscopic and Histological Findings in Patients With
Chronic Diarrhea (n ⫽ 54)
Indications N (%)
Chronic diarrhea 54 (54.5) Findings N (%)
Obscure gastrointestinal bleeding 21 (21.2) Enteroscopic
Abdominal pain 10 (10.0) Normal 46 (85.1)
Abnormal radiological studies 5 (5.0) Abnormal 8 (14.8)
Chronic iron deficiency anemia 5 (5.0) Thick folds 3
Miscellaneous 4 (4.0) Attenuated folds 2
Ulcers 2
Diffuse polypoid lesions 1
taken when indicated. The length of jejunum examined and Histological
time taken to complete the procedure were recorded. Normal 41 (75.8)
Celiac disease 6 (11.1)
Tropical sprue 3 (5.5)
RESULTS Crohn’s disease 1 (1.8)
Nodular lymphoid hyperplasia 1 (1.8)
Endoscopic examination of the proximal jejunum was suc- Secondary lymphangiectasia 1 (1.8)
cessful in all the patients, except one who had duodenal Strongyloidiasis 1 (1.8)
stricture. The length of jejunum examined ranged from 10 to
70 cm (median, 40 cm). The time taken to complete the
(1.8%), secondary lymphangiectasia due to tuberculosis in
procedure varied from 2 to 30 min (median, 20 min). There
one (1.8%), Strongyloides stercoralis in one (1.8%), and
were no complications.
nodular lymphoid hyperplasia with Giardia lamblia in a
Diagnostic Yield patient with agammaglobulinemia in one (1.8%) (Table 3).
OBSCURE GI BLEEDING. Twenty-one patients pre-
ABNORMAL RADIOLOGICAL FINDINGS. Of five pa-
sented with GI bleeding in whom upper GI endoscopy and
tients with thickened jejunal folds on barium studies, en-
colonoscopy were normal. Of these 21 patients, nine
teroscopy confirmed this only in two. However, mucosal
(42.8%) had detectable lesions on enteroscopy (Table 2). No
biopsies from all five patients showed nonspecific inflam-
lesion was found proximal to the second part of the duode-
mation only.
num. The most common finding was the presence of worms,
in six patients ([28.5%], Ascaris lumbricoides in three, and OTHER INDICATIONS. Of 10 patients with abdominal
Ankylostoma duodenale in three), producing multiple ero- pain, four had thickened folds in the jejunum; however,
sions in the jejunum and oozing of blood. An arteriovenous mucosal biopsies revealed only nonspecific inflammation.
malformation and jejunal diverticula were observed during One patient had a stricture in the distal duodenum that was
enteroscopy in one patient each. One patient who had fresh confirmed to be related to eosinophilic enteritis on histol-
blood in the jejunum obscuring visualization of mucosa on ogy.
enteroscopy was found to have both an arteriovenous mal- None of the diagnostic enteroscopy findings was within
formation and jejunal diverticuli at surgery. the reach of a gastroscope.
CHRONIC DIARRHEA. Of 54 patients with chronic diar-
rhea, eight (14.8%) had abnormal findings on enteroscopy DISCUSSION
(thick folds in three, attenuated folds in two, multiple ulcers
in two, and multiple polypoid lesions in the jejunum in one). The two main indications for push-type enteroscopy in our
Histological examination of the jejunal mucosa obtained study were obscure GI bleeding and chronic diarrhea. En-
during enteroscopic biopsies proved to be diagnostic in 13 teroscopy yielded a diagnosis in 42.8% of patients with
obscure GI bleeding and in 24% of patients with chronic
(24%) patients, detecting celiac disease in six (11.1%),
diarrhea. The procedure was successful in all the patients
tropical sprue in three (5.5%), Crohn’s disease in one
except one, and there were no complications.
Push enteroscopes can be passed well beyond the pylorus,
Table 2. Enteroscopic Findings in Patients With Obscure
Gastrointestinal Bleeding (n ⫽ 21) attaining a depth of 40 –150 cm beyond the ligament of
Treitz. The length of the small bowel visualized cannot be
Enteroscopic Findings N (%)
quantitatively measured because of stretching and pleating
Normal 12 (57.1) of the intestine. Some investigators measure this on fluo-
Abnormal 9 (42.8)
roscopy performed at the limit of total intubation, and others
Worms 6 (28.5)
Hookworms 3 pull the instrument back to straighten out the loops in the
Roundworms 3 stomach, then subtract 60 cm from the total length of the
Arteriovenous malformation 1 (4.7) instrument (1, 2, 7, 12, 14). The estimated length of jejunum
Blood 1 (4.7) examined in our study ranged from 10 to 70 cm (median, 40
Jejunal diverticuli 1 (4.7)
cm). These measurements should be considered only a
AJG – January, 2000
rough estimate. Fluoroscopy has been used to assist the
passage of the enteroscope. However, these days few inves-
tigators use fluoroscopic control to assist the passage of
enteroscopes. Our enteroscopies were performed without
the aid of fluoroscopy, and no difficulty was experienced.
We also performed enteroscopy without the use of an over-
tube. Not all endoscopists use an overtube for push enteros-
copy (1). Intragastric looping may be contained with an
overtube. However, techniques such as aspiration of air and
manual compression of the abdomen can also prevent in-
tragastric loop formation. We found that we could easily
pass our enteroscope into the jejunum without the use of
fluoroscopy or an overtube.
The diagnostic yield of push-type enteroscopy in patients
with obscure GI bleeding in our study was 43%. Push-type
enteroscopy can identify lesions potentially responsible for
bleeding in small intestine in 26 –75% of such patients (1–3,
6, 9, 13, 15–18). Differences in the diagnostic yield of
enteroscopy in patients with unexplained GI bleeding could
be due to differences in the study population, the length of
small intestine examined, and the interpretation of lesions.
Arteriovenous malformations have been reported to be the
most frequent lesion, followed by small bowel tumors and
ulcers (1, 9, 13, 15–19). However, in our study arterio-
venous malformations were found in only two patients (one
detected at enteroscopy and the other at surgery). The most
common observation in our study was intestinal worms
(both hookworms and roundworms), which caused GI
bleeding. The worms were seen distal to the duodenum in all
patients. Patients with worms had fresh blood in the jeju-
num, multiple erosions and bleeding points showing active
oozing of the blood. It is well known that hookworms cause
low-grade blood loss resulting in iron-deficiency anemia.
However, clinically obvious bleeding leading to hemateme-
sis and melena is distinctly uncommon in patients with
hookworms and roundworms.
Other authors report finding many lesions proximal to the
second portion of the duodenum, ranging from 20% to 60%
of the total positive findings of push enteroscopy in patients
with GI bleeding (1–9, 13, 15–18). None of our patients had
such pathology. The explanation for the lack of upper GI
pathology found at enteroscopy is that we follow a policy of
having a second endoscopist re-examine the upper gut when
the first endoscopist does not find a significant lesion on
EGD in patients with GI bleeding.
A positive diagnosis is found by direct visual examination
of the small bowel mucosa and histology in 22–55% of
patients with diarrhea (1, 3, 4, 12–14, 19). Enteroscopy
yielded a diagnosis in 24% of patients with diarrhea in our
study, which corresponds well with the 22% reported by
Landi et al. (3). Tropical sprue, giardiasis, and strongly-
loidiasis were important findings in patients with diarrhea in
our study, this being not unexpected in a developing country.
Enteroscopy did not provide any positive diagnosis in the
patients with radiological abnormalities of small bowel, but
confirmed normality of the small bowel examined. Landi et
Push-Type Enteroscopy in India 139
al. (3) reported the utility of push-type enteroscopy in mak-
ing a firm positive and negative diagnosis in 78% of cases
where abnormalities of the small intestine were detected
radiologically.
No lesions in the distal duodenum and proximal jejunum
could be found in patients with iron-deficiency anemia. The
yield of enteroscopy in patients with iron-deficiency anemia
is quite variable (2–5). Landi et al. (3) found bleeding
lesions in 6% of cases with isolated iron deficiency anemia.
Bouhnik et al. (2) found lesions in 14.6% in small bowel on
two-way push enteroscopy. Chak et al. (5) found a source of
bleeding in the jejunum in 26% of patients with iron-defi-
ciency anemia.
The yield of enteroscopy in patients with abdominal pain
has been reported to be quite low (3). We found a positive
diagnosis only in one patient (10%), who had stricture in the
distal duodenum because of eosinophilic enteritis.
In conclusion, push-type enteroscopy is a useful tool in
the evaluation of patients with obscure GI bleeding and
chronic diarrhea. In developing countries, worm infestation
is an important finding on enteroscopy in patients with
obscure GI bleeding. Apart from tropical sprue, Giardia
lamblia and Strongyloides stercoralis infestation are impor-
tant causes of chronic diarrhea in developing countries.
Reprint requests and correspondence: D. K. Bhasin, D.M.,
1041, Sector 24B, Chandigarh-160023, India.
Received Mar. 22, 1999; accepted Aug. 25, 1999.
REFERENCES
1. Waye JD. Enteroscopy. Gastrointest Endosc 1997;46:247–56.
2. Bouhnik Y, Bitoun A, Coffin B, et al. Two way push video-
enteroscopy in investigation of small bowel disease. Gut 1998;
43:280 –3.
3. Landi B, Tkoub M, Gaudric M, et al. Diagnostic yield of push
type enteroscopy in relation to indication. Gut 1998;42:421–5.
4. Chak A, Koehler MK, Sundaram SN, et al. Diagnostic and
therapeutic impact of push enteroscopy: Analysis of factors
associated with positive findings. Gastrointest Endosc 1998;
47:18 –22.
5. Chak A, Cooper GS, Canto MI, et al. Enteroscopy for the
initial evaluation of iron deficiency. Gastrointest Endosc 1998;
47:144 – 8.
6. Zaman A, Katon RM. Push enteroscopy for obscure gastroin-
testinal bleeding yields a high incidence of proximal lesions
within reach of a standard endoscope. Gastrointest Endosc
1998;47:372– 6.
7. Willis JR, Chokshi HR, Zuckerman GR, et al. Enteroscopy-
enteroclysis. Experience with a combined endoscopic-radio-
graphic technique. Gastrointest Endosc 1997;45:163–7.
8. Huilgol V, Harris MS, Vakil N. Enteroscopy. Outcomes. Gas-
trointest Endosc Clin N Am 1996;6:811–7.
9. Vakil N, Huilgol V, Khan I. Effect of push enteroscopy on
transfusion requirements and quality of life in patients with
unexplained gastrointestinal bleeding. Am J Gastroenterol
1997;92:425– 8.
10. Adrain AL, Krevsky B. Enteroscopy in patients with gastro-
intestinal bleeding of obscure origin. Dig Dis 1996;14:345–55.
11. O’Mahony S, Morris AJ, Straiton M, et al. Push enteroscopy
140 Sharma et al. AJG – Vol. 95, No. 1, 2000

in the investigation of small intestinal disease. Q J M 1996;
89:685–90.
12. Rossini FP, Arrigoni A, Pennazio M. Clinical enteroscopy.
J Clin Gastroenterol 1996;22:231– 6.
13. Davies GR, Benson MJ, Gertner DJ, et al. Diagnostic and
therapeutic push type enteroscopy in clinical use. Gut 1995;
37:346 –52.
14. Pennazio M, Arrigoni A, Risio M, et al. Clinical evaluation of
push type enteroscopy. Endoscopy 1995;27:164 –70.
15. Barkin J, Lewis B, Reiner D, et al. Diagnostic and therapeutic
jejunoscopy with a new, longer enteroscope. Gastrointest En-
dosc 1992;38:55– 8.
16. Foutch PG, Sawyer R, Sanowski RA. Push enteroscopy for
diagnosis of patients with gastrointestinal bleeding of obscure
origin. Gastrointest Endosc 1990;36:337– 41.
17. Schmit A, Gay F, Adler M, et al. Diagnostic efficacy of push
enteroscopy and long term follow-up of patient with small
bowel angiodysplasias. Dig Dis Sci 1996;41:2348 –52.
18. Chong J, Tagle M, Barkin J, et al. Small bowel push type
fiberoptic enteroscopy for patients with occult gastrointestinal
bleeding or suspected small bowel pathology. Am J Gastro-
enterol 1994;89:243– 6.
19. Bini EJ, Weinshel EH, Gamagaris Z. Comparison of duodenal
with jejunal biopsy and aspirate in chronic human immuno-
deficiency virus related diarrhea. Am J Gastroenterol 1998;
93:1837– 40.