angiodysplasia is the second most common cause of gi bleeding in elderly patients with end - stage renal disease ( esrd ) .
these lesions respectively account for about 20 and 30% of upper and lower gi bleeding and approximately one - half of recurrent upper gi bleeding .
a double - balloon endoscope ( dbe ) is a newly developed device that can be inserted more deeply into the small intestine via either an oral or anal approach .
it can support endoscopic observation and treatment for the entire small intestine while obviating general anaesthesia .
after both endoscope itself and overtube reach the duodenum , the balloon fitted to the tip of overtube is firstly inflated to fix the tube to the intestine . then the endoscope is inserted further through the overtube in place . when the endoscope is inserted as far as possible
thereafter , the balloon of the overtube is deflated , and the overtube can reach the tip of the endoscope with the use of the endoscope itself like a guidewire . when the distal end of the overtube reaches the end of the endoscope , the balloon on the overtube is inflated to fix a distal side to the intestine .
the above - described sequence is repeated until the endoscope arrives at the target portion of intestine .
we present herein those cases as well as several considerations about newly developed techniques that enable us to observe the small intestine .
the patient was a 70-year - old male who started to receive haemodialysis because of diabetic nephropathy in 1992 .
although he had undergone both upper and lower gastroenteral endoscopy repeatedly , the bleeding point was not determined .
scintigraphy performed to detect gi haemorrhage revealed an accumulation of activity on the right side of the common iliac artery , which suggested small intestinal bleeding .
moreover , his blood type of ab and d negative was difficult to match for blood transfusion .
he was referred to our hospital in june 2006 for more extensive examination and treatment .
he underwent dbe , which showed red spots at the middle portion of the jejunum .
we treated this lesion using argon plasma coagulation ( apc ) and clipping ( figure 1-a , b ) .
thereafter , the same type of lesion appeared four times in different areas of the intestine .
however , we treated these lesions successfully using the same method ( figure 1-c ) .
the patient was a 58-year - old male who started to receive haemodialysis for a condition of unknown aetiology in 2006 .
he had liver cirrhosis and received radiofrequency abrasion therapy for treatment of hepatocellular carcinoma . after he developed a sudden decrease in hb as well as haematochezia ,
scintigraphy performed to detect gi haemorrhage revealed an accumulation of activity on the upper jejunum .
he underwent capsule endoscopy ( ce ) , which showed diffuse antral vascular ectasia ( dave ) and angiodysplasia in the small intestine ( figure 1-d ) .
the patient was a 74-year - old male who started to receive haemodialysis for a condition of unknown aetiology in 1989 .
he was referred to our hospital in april 2008 for more extensive examination and treatment .
he underwent ce , which showed angiodysplasia at the upper side of the jejunum ( figure 1-e ) . immediately after the ce procedure he developed an inflammatory reaction of unknown aetiology .
we postponed the scheduled dbe until his general status was resolved . during the follow - up , his haematochezia stopped .
we continued to monitor the patient closely without therapy because the active bleeding had ceased .
the patient was a 59-year - old male who started to receive haemodialysis because of diabetic nephropathy in 2005 .
he had liver cirrhosis caused by hepatitis c virus infection , which was treated with interferon .
he received upper and lower endoscopy at an outpatient clinic , but the bleeding point was not detected .
he was referred to our hospital in may 2008 for more extensive examination and treatment .
although vascular ectasia was detected at the upper jejunum using ce , we were unable to identify the source of the active bleeding point .
although he underwent dbe , we were unable to identify the source of bleeding ( figure 1-f ) . during the follow - up ,
although his hb had been as low as 7.1 g / dl at the outpatient clinic , his haemoglobin concentration recovered to 9.3 g / dl at admission .
the patient was a 70-year - old male who started to receive haemodialysis because of diabetic nephropathy in 1992 .
although he had undergone both upper and lower gastroenteral endoscopy repeatedly , the bleeding point was not determined .
scintigraphy performed to detect gi haemorrhage revealed an accumulation of activity on the right side of the common iliac artery , which suggested small intestinal bleeding .
moreover , his blood type of ab and d negative was difficult to match for blood transfusion .
he was referred to our hospital in june 2006 for more extensive examination and treatment .
he underwent dbe , which showed red spots at the middle portion of the jejunum .
we treated this lesion using argon plasma coagulation ( apc ) and clipping ( figure 1-a , b ) .
thereafter , the same type of lesion appeared four times in different areas of the intestine .
however , we treated these lesions successfully using the same method ( figure 1-c ) .
the patient was a 58-year - old male who started to receive haemodialysis for a condition of unknown aetiology in 2006 .
he had liver cirrhosis and received radiofrequency abrasion therapy for treatment of hepatocellular carcinoma . after he developed a sudden decrease in hb as well as haematochezia ,
scintigraphy performed to detect gi haemorrhage revealed an accumulation of activity on the upper jejunum .
he underwent capsule endoscopy ( ce ) , which showed diffuse antral vascular ectasia ( dave ) and angiodysplasia in the small intestine ( figure 1-d ) .
the patient was a 74-year - old male who started to receive haemodialysis for a condition of unknown aetiology in 1989 .
he was referred to our hospital in april 2008 for more extensive examination and treatment .
he underwent ce , which showed angiodysplasia at the upper side of the jejunum ( figure 1-e ) . immediately after the ce procedure he developed an inflammatory reaction of unknown aetiology .
we postponed the scheduled dbe until his general status was resolved . during the follow - up , his haematochezia stopped .
we continued to monitor the patient closely without therapy because the active bleeding had ceased .
the patient was a 59-year - old male who started to receive haemodialysis because of diabetic nephropathy in 2005 .
he had liver cirrhosis caused by hepatitis c virus infection , which was treated with interferon .
he received upper and lower endoscopy at an outpatient clinic , but the bleeding point was not detected .
he was referred to our hospital in may 2008 for more extensive examination and treatment .
although vascular ectasia was detected at the upper jejunum using ce , we were unable to identify the source of the active bleeding point .
although he underwent dbe , we were unable to identify the source of bleeding ( figure 1-f ) . during the follow - up ,
although his hb had been as low as 7.1 g / dl at the outpatient clinic , his haemoglobin concentration recovered to 9.3 g / dl at admission .
both platelet dysfunction and quantitative abnormality of the von willebrand factor have been considered as important predisposing factors for haemorrhagic diathesis in such patients .
zuckerman et al .   reported a 39% occurrence of clotting abnormalities in patients with chronic renal failure .
acute gi haemorrhage in patients with chronic renal failure is a severe complication causing higher mortality and morbidity rates than in cases without chronic renal disease .
recurrent bleeding is more frequent in patients with chronic renal failure than in those without chronic renal failure .
consequently , early recognition of the exact bleeding site and prompt treatment are important for management of such patients .
haemorrhage at the small intestine is less common than bleeding in the upper gi tract or colon , but its underlying cause is more difficult to diagnose . regarding haemorrhage of the small intestine , assessment of the exact localization and the cause of bleeding have been difficult both clinically and endoscopically .
dbe , a newly developed endoscopic visualization technique of the small intestine , was developed by yamamoto et al .   in 2001 .
a typical dbe comprises a 200 cm long endoscope , a 145 cm long semi - elastic external tube and two latex balloons to fix the endoscope inside the small intestine better and enable easier injection . the endoscope can be inserted via either an oral or anal route .
the dbe method is applied to cases with pathological conditions of the small intestine , to identify a bleeding source , or to detect obstructive and neoplastic changes in the small intestine .
ce is a new diagnostic method that enables non - invasive assessment of lesions of the small intestine mucosa .
the capsule contains a miniature digital video camera , which can take pictures with very little light , and a data transmission apparatus .
after the capsule is swallowed by the patient , it passively moves along the alimentary tract through its peristaltic movements .
ce is applied to cases with chronic bleeding from the alimentary tract and chronic iron - deficiency anaemia , conditions that suggest the presence of a tumour in the small intestine .
ce , however , is contraindicated in patients with cardiac pacemakers because the method uses radiofrequency waves to transmit data through the abdominal wall .
we first adopted ce for chronic anaemia in case 3 because this method is more non - invasive than dbe .
we performed dbe because of deteriorative effects on a pacemaker in case 1 , and because of active bleeding in case 2 .
newly available imaging techniques can replace prior approaches to small bowel pathology . because of its ability to take biopsies and to carry out therapeutic interventions , dbe is the most efficacious among newly developed techniques such as ce and radiological diagnosis with respect to minimizing laparotomy and intraoperative enteroscopy .
those features bring great benefit to esrd patients because the patients often experience repeated bleeding episodes within the small intestine .
additionally , this new system is useful as a therapeutic tool for performing non - surgical haemostasis for bleeding in the small intestine .
moreover , the combination of ce and dbe is a promising elective approach for esrd patients with intestinal haemorrhage .
case 1 : a bleeding point could be observed by double - balloon endoscopy ( a ) . argon plasma coagulation technique was applied to the lesion ( b ) .
clipping under observation by double - balloon endoscopy was also added to the same lesion ( c ) .
( d ) case 2 : diffuse antral vascular ectasia ( dave ) lesion was observed with use of conventional upper gastric fibrescopy .
( f ) case 4 : intestinal erosion was observed by double - balloon endoscopy .
 gastrointestinal ( gi ) bleeding is a common and troublesome complication of end - stage renal disease ( esrd ) . 
 patients often have various lesions in the small bowel and in either upper or lower gi tracts . 
 recently developed double - balloon endoscopy ( dbe ) enables observation of the entire small intestine through a combination of anterograde and retrograde approaches . 
 moreover , dbe is useful not only for diagnosis of small intestinal lesions ; it provides a mode of treating the disease . 
 this article presents patients with several small intestinal diseases from our facility . 
 their bleeding sources were identified using dbe . 
 we also report two representative cases of angiodysplasia that had been diagnosed and treated successfully using dbe . 
 one case particularly underscored the usefulness of the combination of capsule endoscopy ( ce ) and dbe as an electively diagnostic approach for patients with gi bleeding . 
 small intestinal bleeding is often observable repeatedly in a single patient , as described for case 1 . in such circumstances , dbe can treat the lesions successfully without surgical procedures . in this report , 
 esrd patients , in whom comorbid conditions made it difficult to perform surgical procedures , receive great benefit from dbe . 
Background
Case reports
Case 1 (A.T.)
Case 2 (S.M.)
Case 3 (M.K.)
Case 4 (I.Y.)
Discussion
Conclusion