Capsule endoscopy and balloon-assisted endoscopy: competing or complementary technologies in the evaluation of small bowel disease?

PURPOSE OF REVIEW: Capsule endoscopy and balloon-assisted endoscopy have revolutionized our ability to evaluate the small bowel. In this review, we will address the question 'capsule endoscopy and balloon-assisted endoscopy: competing or complementary technologies?' RECENT FINDINGS: Capsule endoscopy will effect clinical management in about 50% of cases with obscure gastrointestinal bleeding with complete small bowel endoscopy performed in over 80% of cases. Currently, most data on balloon-assisted endoscopy involve double balloon endoscopy (DBE), which has a diagnostic yield of 60%. Complete small bowel endoscopy with bidirectional endoscopy is possible in 50% of cases. Meta-analyses have suggested capsule endoscopy and DBE to have fairly similar diagnostic yields and to be complementary. Capsule endoscopy-directed DBE is a useful strategy. Lesions found in the first 75% of capsule endoscopy transit time have a high probability of being found on oral DBE. Endoscopic treatment and/or biopsy of capsule endoscopy lesions can be routinely obtained at DBE. A negative capsule endoscopy study without persistent bleeding has a good prognosis and can often obviate the need for DBE, a currently limited resource. SUMMARY: Capsule endoscopy and balloon-assisted endoscopy are complementary procedures. Capsule endoscopy should be done first to direct the approach by balloon-assisted endoscopy. If the capsule endoscopy is negative, balloon-assisted endoscopy should be performed only in patients with a high suspicion of small bowel disease.