American Journal of Gastroenterology ISSN 0002-9270


C 2006 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2006.00745.x
Published by Blackwell Publishing

Prospective Comparison of Push Enteroscopy and

Push-and-Pull Enteroscopy in Patients with Suspected
Small-Bowel Bleeding
Andrea May, M.D., Ph.D., Lars Nachbar, M.D., Marion Schneider, M.D., and Christian Ell, Ph.D.
Department of Internal Medicine II, HSK Wiesbaden, Teaching Hospital of the University of Mainz,
Wiesbaden, Germany

BACKGROUND The management of patients with suspected mid-gastrointestinal bleeding has in the past been
AND AIMS: difficult, as push enteroscopy (PE) only allows limited endoscopic access for diagnosis and
treatment. Recently published uncontrolled data on push-and-pull enteroscopy (PPE) using the
double-balloon technique suggest that this new method has a high diagnostic yield and therapeutic
efficacy. A prospective controlled study was therefore carried out to compare PPE with PE as the
common nonsurgical gold standard method.
METHODS: The diagnostic yield, complications, and various examination parameters were compared in 52
consecutive patients with suspected mid-gastrointestinal bleeding who were evaluated with both
enteroscopy methods.
RESULTS: No relevant complications were observed with either method. Sedoanalgesia, examination times,
and X-ray exposure were lower with PE. The insertion depth was significantly greater with PPE than
with PE (230 cm vs 80 cm, p < 0.0001). The overall diagnostic yield with PPE (38 of 52 patients,
73%) and the results of oral PPE only (33 of 52 patients, 63%) were superior to those with PE (23
of 52 patients, 44%; p < 0.0001). PPE identified additional lesions in deeper parts of the small
bowel in PE-positive patients in 78% of cases (18 of 23 patients).
CONCLUSIONS: For endoscopic examination of the small bowel in patients with suspected mid-gastrointestinal
bleeding, PPE is superior to PE with regard to the length of small bowel visualized, as well as the
diagnostic yield. As the method also allows endoscopic treatment to be carried out, PPE should
always be considered before open surgery and intraoperative endoscopy in patients with
mid-gastrointestinal bleeding.
(Am J Gastroenterol 2006;101:2016–2024)

INTRODUCTION enteroscopy in a similar way as capsule endoscopy, while si-

Since the introduction of wireless capsule endoscopy in 2001,
much more effective detection of bleeding sources in the
small bowel has become possible in patients with chronic or
acute recurrent gastrointestinal bleeding in whom the loca-
tion of the bleeding source is unclear (1–5). However, the
capsule is a purely diagnostic device that does not allow
biopsy samples to be taken or treatment to be carried out.
Push enteroscopy (PE) became the established endoscopic
method of examining the proximal part of the small bowel
during the 1980s, and with its facilities for biopsy sampling
and treatment it has continued to hold its place. However,
the insertion depth is generally limited to the proximal je-
junum (6, 7). The new method of push-and-pull enteroscopy
(PPE) using a double-balloon technique was first introduced
in Japan by Yamamoto and colleagues in 2001 (8) and by
May and colleagues in Europe in 2003 (9). PPE allows total
multaneously providing an ability to take biopsies and carry
out endoscopic interventions in the small bowel as in PE
and intraoperative enteroscopy, which were the endoscopic
methods of choice for examining the small bowel before the
introduction of PPE. To date, however, there have been no
prospective trials comparing the new push-and-pull method
of enteroscopy with PE as the usual nonsurgical gold standard
method.
The prospective study presented here included 52 consec-
utive patients with suspected chronic or acute recurrent mid-
gastrointestinal bleeding and compared PE with PPE using
the double-balloon technique. The aim of the study was to
evaluate the length of small bowel examined, the diagnostic
yield, complications, examination time, and other parame-
ters such as the amount of sedoanalgetic medication and X-
ray exposure, as well as staffing requirements, with the two
methods.

2016

PATIENTS AND METHODS
Patients
Between December 2003 and October 2004, 69 patients
with chronic or acute recurrent gastrointestinal bleeding
and a suspected bleeding source in the small bowel (mid-
gastrointestinal bleeding) presented for PPE at our tertiary
referral center. Mid-gastrointestinal bleeding was defined as
a bleeding source or sources not accessible either with stan-
dard upper gastrointestinal endoscopy (esophagogastroduo-
denoscopy) or standard colonoscopy. Fifty-two patients, with
a mean age of 55 ± 17 yr, were enrolled in the study after
providing written consent and underwent both examinations.
Data for the patients are listed in Table 1. Seventeen patients
declined to undergo the additional PE. The average lowest
hemoglobin level was 8.0 ± 6.9 g/dL (median 6.9 g/dL, range
3.8–11.4 g/dL). Thirty-five of the 52 patients (67%) had re-
ceived blood transfusions, with a median of 10 blood units
(range 2–170). The obscure gastrointestinal bleeding had per-
sisted for a median of 21.5 months (range 0.5–288 months)
(Table 1). All of the patients were suffering from overt or oc-
cult bleeding. Overt bleeding is defined as macroscopically
visible bleeding—i.e., evidence of melena or hematochezia.
In occult bleeding, there is no melena or peranal bleeding,
but the fecal occult blood test is positive. No bleeding sources
had been identified in any of the diagnostic procedures, such
as upper and lower gastrointestinal endoscopy (with multiple
procedures in the majority of cases), carried out at external in-
stitutions before the patients were admitted to our department.
Radiological diagnostic procedures (computed tomography,
enteroclysis, and/or angiography) and scintigraphic diagnos-
tic procedures had been carried out in 32 of the 52 patients
(61.5%) without the bleeding source being identified. Cap-
sule endoscopy had been carried out in 22 of the 52 patients
(42%), revealing pathological lesions that were assessed as
representing a definite, potential, or uncertain bleeding source
in 14 of the 22 patients (64%). In two patients (9%), only
Table 1. Patient Data and Bleeding Parameters
Study Group
Parameter (N = 52)
Men/women 32/20
Age (yr)
Mean ± SD 55 ± 17
Range 26–84
Lowest hemoglobin value (g/dL)
Mean ± SD 8.0 ± 6.9
Median 6.9
Range 3.8–11.4
Period of CGB (months)
Median 21.5
Range (0.5–288)
Patients requiring blood transfusion, N (%) 35 (67%)
Units of packed red cells transfused
Median 10
Range (2–170)
CGB = chronic gastrointestinal bleeding.
Push Enteroscopy versus Push-and-Pull Enteroscopy 2017
blood was seen in the small bowel, without a bleeding source
being identified. No relevant pathological findings had been
identified in six of the 22 patients (27%).
PE examinations were carried out first, followed by oral
PPE examinations, by experienced investigators for both en-
teroscopy techniques (AM, LN). Before the study was started
approximately 50 PPE procedures had been done. Anal PPE
was carried out if the oral examination did not identify a
bleeding source or there was a suspicion that some lesions
were also located in the distal part of the small bowel (e.g.,
angiodysplasias seen with capsule endoscopy). Depending
on the individual patient’s condition, the anal PPE procedure
was conducted on the next day or the day after.
A standardized form was completed after each examina-
tion to record the following data: all information about the
patients, including age, gender, and examination date; and en-
teroscopy data, including the number of staff required, time
required for the examination, amount of sedoanalgetic med-
ication, X-ray exposure time (min and dGy/cm2 ), insertion
depth, pathological findings, and acute complications. Ther-
apeutic procedures such as argon plasma coagulation of an-
giodysplasias were only carried out in PPE sessions. The en-
doscopic diagnosis obtained with PE was not blinded for the
endoscopist performing PPE, as only two endoscopists con-
ducted all of the investigations in the study. The intention was
to ensure that the enteroscopies—including parameters that
are quite examiner-dependent, such as the assessment of the
insertion depth—were carried out in a standardized way and
that all aspects of interest were documented prospectively.
Push Enteroscopy
A standard scope (Fujinon EN-410WM, Fujinon Inc.,
Saitama City, Japan) with a working length of 230 cm and
an outer diameter of 10.5 mm was used for PE (Fig. 1). The
reusable overtube is 835-mm long, with an outer diameter
of 14.6 mm. The enteroscope’s working channel has a di-
ameter of 2.8 mm. The overtube was used in all of the PE
Figure 1. A radiological view of push enteroscopy, with an insertion
depth of 80 cm.
2018 May et al.

procedures, as prospective studies have shown that the inser-

tion depth is significantly greater when an overtube is used
(6, 7). The overtube is positioned just in front of the pylorus
to avoid damage to the small-bowel tissue and the papilla,
as it has been reported that perforation and pancreatitis are
possible complications during PE (10, 11). The enteroscope
is inserted as far as possible into the small bowel (Fig. 1). As
the enteroscope is advanced, the overtube is held in a stable
position, avoiding withdrawal and advancement in order to
reduce the risk of complications. Under fluoroscopic guid-
ance, the position of the enteroscope is checked and looping
within the stomach is avoided. After straightening, the scope
is pulled back until the pylorus is reached again. The distance
in centimeters between the pylorus and the deepest point af-
ter straightening of the scope is documented as the inser-
tion depth. During withdrawal of the enteroscope, hyoscine
butylbromide (butylscopolamine) is administered in order to
reduce peristalsis in the small bowel and thus optimize visu-
alization. No specific preparation was administered for the
oral approach. The examinations were carried out with the
patients under conscious sedation, and there was no need for
general anesthesia. The examinations were all carried out on
an in-patient basis, and the patients were asked about symp-
toms approximately 4 h after the end of the examination and
also the next day.
PPE with the Double-Balloon Technique
The double-balloon enteroscopy system (Fujinon EN-
450P5/20, Fujinon Inc.) consists of a high-resolution video
endoscope with a working length of 200 cm and an outer
diameter of 8.5 mm, and a flexible single-use overtube with
a length of 145 cm (including the balloon) and an outer di-
ameter of 12 mm (Figs. 2 and 3). The enteroscope’s working
channel has a diameter of 2.2 mm. Latex balloons are at-
tached at the tip of the enteroscope and the overtube, and
are inflated and deflated with air from a pressure-controlled
pump system. The small bowel is threaded onto the overtube
by alternating the inflation and deflation of the balloons, al-
ternating the insertion of the scope and overtube, and pulling
back the enteroscope and overtube (Fig. 2A–C). The prin-
ciple of the double-balloon technique has been described in
detail previously (8, 9). During withdrawal, hyoscine butyl-
bromide is administered in order to reduce peristalsis in the
small bowel and thus optimize visualization.
No specific preparation was administered for the oral
approach. For enteroscopy from the anal approach, bowel
cleansing was performed in the same way as in colonoscopy.
The examinations were carried out with the patients under
conscious sedation, in the same way as in colonoscopy and
upper gastrointestinal endoscopy. General anesthesia was not
required. The examinations were all carried out on an in-
patient basis, and the patients were asked about symptoms Figure 2. (A) Radiological view of an oral push-and-pull en-
approximately 4 h after the end of the examination and also teroscopy with an insertion depth from the pylorus of approximately
200 cm. (B) Radiological view of an anal push-and-pull enteroscopy
the next day. with an insertion depth of approximately 350 cm from the ileocecal
The method used to measure the small-bowel segments valve. (C) Radiological view of a complete small-bowel endoscopy
visualized has been described in detail elsewhere previously from the pylorus to the cecum within one oral PPE session.

(12). The endoscopist has to estimate the effective insertion
length of the enteroscope by endoscopic checking of the in-
strument’s advancement, and has to estimate the length of
small bowel “released” during insertion of the overtube and
pulling back of the enteroscope and overtube. The length of
small bowel visualized and threaded on during each push-
and-pull maneuver is noted on a standardized form. At the
end of the examination, all of the individual lengths advanced
are added up. This technique requires some experience, but
has been evaluated using an animal model (12).
Ethical Aspects
A standard information pamphlet (proCompliance publish-
ers, Erlangen, Germany) was used for PE, as this exami-
nation is already an established investigation method in the
small bowel.
All of the patients provided written consent to undergo
PPE, including endoscopic treatments such as argon plasma
coagulation or polypectomy/mucosal resection, after receiv-
ing extensive information regarding the experimental nature
of the procedure. All of the patients were informed that sur-
gical laparotomy with intraoperative enteroscopy or small-
bowel resection is currently the standard approach if conven-
tional PE is unable to find the bleeding source or to reach a
lesion requiring treatment that has previously been identified
using other methods such as capsule endoscopy. Approval
for administering PPE in patients with suspected or proven
disease of the small bowel was received from the Ethics Com-
mittee of the State of Hesse, Germany.
Statistical Analysis
Descriptive statistics were calculated for the patients’ data
and clinical parameters and presented as means and medi-
ans, as well as standard deviations and ranges (minimum-
maximum) for continuous data and absolute and relative
frequencies for categorical data. For continuous data, com-
parisons between the two groups were carried out using the
Mann-Whitney U test. A p value of ≤0.05 was considered to
be statistically significant. The χ 2 test was used for categor-
ical data.
The null hypothesis of the test was that PPE is equivalent
to PE. On the basis of previous experience, it was assumed
that 40% of the patients would have positive PE findings.
It was further assumed that under the aforementioned null
hypothesis, a PPE procedure subsequent to a PE procedure
would identify 8% more positive cases and would recapture
all positive PEs. The null hypothesis therefore implies a 48%
rate of positive PPE findings. Because this is a paired-sample
design in which double-positive cases do not contribute to the
test statistic, only patients with negative PE findings are rele-
vant for the comparison. Hence, P0 = 0.133 ( = 0.08/0.60) is
the null hypothis to be tested by the binomial test against the
alternative of more than 13.3% positive PPEs among nega-
tive PEs. The number of cases is calculated for the alterna-
tive hypothesis that subsequent PPE provides a 30% rate of
additional positive findings among all patients or P1 = 0.5
Push Enteroscopy versus Push-and-Pull Enteroscopy 2019
( = 0.3/0.6) among PE-negatives. A test with 5% type I er-
ror rate and 90% power needs 19 patients with negative PE
findings. To obtain at least 19 negative PE findings with a
probability of 90%, 38 patients are needed. With 38 patients,
the overall power is at least 81%.
RESULTS
PE and PPE were carried out successfully in all of the patients
without relevant technical problems. No severe enteroscopy-
associated complications (in either PE or PPE), such as per-
foration, bleeding induced by mucosal injury, or pancreati-
tis, were observed. In one female patient, a mucosal injury
was noted in the proximal esophagus just below the up-
per esophageal sphincter after PE, probably induced by the
overtube. The patient suffered from odynophagia for several
days, but no severe problems occurred. Six of the 52 patients
(11.5%) reported a sore throat after PE. With regard to PPE,
minor side effects such as abdominal pain on the day of in-
vestigation and the following day (probably mainly caused
by air insufflation) and sore throat occurred in 11 of the 52
patients (21%). One patient had a raised temperature (39◦ C)
during the night after the PPE, without further symptoms,
and the fever dropped spontaneously without antibiotics by
the next day.
Details of the conscious sedation and investigation param-
eters such as X-ray exposure time, investigation time, and the
depth of endoscope advancement in centimeters are listed in
Tables 2 and 3. Generally, a combination of midazolam and
meperidine (pethidine) and/or fat-soluble diazepam was cho-
sen for conscious sedation; propofol was administered alone
or in combination with meperidine. For PE, 29 patients re-
ceived a combination of midazolam, fat-soluble diazepam,
and meperidine; midazolam and meperidine were adminis-
tered in 18 patients; four patients received propofol; and one
patient received a combination of propofol and meperidine.
For oral PPE, 27 patients received a combination of midazo-
lam, fat-soluble diazepam, and meperidine; two patients re-
ceived a combination of midazolam and meperidine; and one
patient received midazolam alone. Propofol was given alone
in 13 patients, and a combination of propofol and meperidine
was administered in nine patients. For anal PPE, a combi-
nation of midazolam, fat-soluble diazepam, and meperidine
was chosen in 16 patients; a combination of midazolam and
meperidine was administered in 10 patients; and propofol
was given in one patient.
Statistically significant differences were seen between the
two groups (PE vs oral PPE) with regard to conscious se-
dation (midazolam p < 0.0001 and propofol p < 0.002)
and investigation parameters such as X-ray exposure (du-
ration p < 0.0001 and dGy/cm2 p < 0.006), insertion depth
(p < 0.0001), and investigation time (p < 0.0001). The inser-
tion depth with oral PPE was nearly three times greater than
with PE (230 cm vs 80 cm). Staffing requirements were gen-
erally higher with PPE, with three persons (one doctor and
two nurses for endoscopic assistance, or two doctors and one
2020 May et al.

Table 2. Comparison of Push Enteroscopy and Push-and-Pull Enteroscopy with Regard to Sedoanalgetic Medication
Push Enteroscopy Oral Push-and-Pull
Conscious Sedation (N = 52) Enteroscopy (N = 52) p Value
Midazolam (mg)
Mean ± SD 8±3 11 ± 3 <0.0001
Median 7 12.5
Range 5–15 5–17
Meperidine (pethidine) (mg)
Mean ± SD 50 ± 0 52 ± 12 n.s. (p = 0.202)
Median 50 50
Range 50–50 25–100
Diazepam (mg)
Mean ± SD 9±3 10 ± 3 n.s. (p = 0.349)
Median 10 10
Range 2.5–15 5–20
Propofol (mg)
Mean ± SD 317 ± 137 692 ± 287 <0.002
Median 300 690
Range 80–500 50–1,150
Hyoscine butylbromide (mg)
Mean ± SD 32 ± 11 48 ± 20 <0.0001
Median 40 40
Range 20–60 20–100

nurse for endoscopic assistance) being needed—especially in Table 4. Altogether, pathological lesions were found with PE
case of therapeutic interventions or using propofol sedation— in 23 of the 52 patients (44%) and with PPE in 38 of the 52
in comparison with two persons for PE (one doctor and one patients (73%). The bleeding source was found with oral PPE
nurse for endoscopic assistance). in 32 of the 52 patients (61.5%); the diagnosis was only made
With PPE, the examination time is approximately three with anal PPE in six of the 52 patients (11.5%)—including
times longer than with PE (median 21 min vs 68 min). How- colon cancer (N = 2); ulcerations resulting from nonsteroidal
ever, it should be taken into account that endoscopic treatment
procedures were carried out during the PPE sessions, while
PE was only carried out for diagnostic purposes. Table 4. Diagnostic Yield of Push Enteroscopy and Push-and-Pull
The detailed results with regard to the diagnostic yield of Enteroscopy
PE and PPE and the therapeutic implications are listed in
Push Oral Anal
Pathological Enteroscopy PPE PPE
Table 3. Comparison of Push Enteroscopy and Push-and-Pull En- Findings (N = 52) (N = 52) (N = 27)
teroscopy with Regard to Examination Parameters Small bowel
Angiodysplasias 17 21 2∗
Push Oral Push-and
Diverticulosis 2 2 –
Enteroscopy Pull Enteroscopy p Value
Malignant tumor – 3 –
X-ray exposure Benign polyp – 1 1
time (min) NSAID ulcerations – 1 –
Mean ± SD 1.0 ± 1.2 3.0 ± 3.6 <0.0001 Hypertensive enteropathy 1 1 –
Median 0.60 1.6 Behçet’s disease 1 1 –
Range 0.1–5.1 0.0–17.1 Dieulafoy ulcer – 1
Dosage (dGy/cm2 ) Ulceration of an anastomosis – – 1
Mean ± SD 108 ± 121 206 ± 239 <0.006 Total 21 31 4
Median 68.0 102.0 Outside of the small bowel
Range 10–746 0–1172 Colon cancer – – 2
Insertion depth (cm) NSAID ulceration in – – 1
Mean ± SD 80 ± 18 230 ± 100 <0.0001 the colon
Median 80 220 Angiodysplasias in – – 1†
Range 30–110 0∗ –510 the colon
Examination Ulceration in the stomach 1 2‡ –
time (min)
NSAID = nonsteroidal antiinflammatory drug; PPE = push-and-pull enteroscopy.
Mean ± SD 21 ± 10 68 ± 25† <0.0001 ∗
Angiodysplasias had already been found on oral PPE in one patient.
Median 21 67 †
In this patient, anal PPE revealed one angiodysplasia in the colon, but the diagnosis
Range 0–54 10–120 had been already made with oral PPE, which identified several angiodysplasias in the
proximal part of the small bowel.
∗ ‡
PPE was not performed because of the ulcer seen in the stomach. An ulceration not seen during push enteroscopy was found in the gastric fundus in
†
Including therapeutic interventions. one patient.

antiinflammatory drugs (NSAIDs) in the colon (N = 1); ul-
ceration in the ileum at the anastomosis after a small-bowel
resection (N = 1); a polyp (N = 1); and angiodysplasias in
the ileum (N = 1). PPE thus provided a significantly higher
diagnostic yield than PE, even when only PE and oral PPE
were compared (p < 0.0001).
A significant difference still persists if all the lesions not
located in the small bowel are omitted. PE then identified the
bleeding source in 21 of 47 patients (46%), oral PPE in 31 of
47 patients (66%), and anal PPE in three of 47 patients (6%).
The lesions found with the anal PPE had not been reachable
with a colonoscope. In all, PPE provided a diagnostic yield for
small-bowel lesions of 72% (34 of 47 patients). Twenty-six
patients had negative PE findings, 11 of whom had positive
oral PPE findings. The proportion 11/26 = 0.43 is signifi-
cantly larger than 0.133 (p <0.0001). The 95% confidence
interval for the conditional probability of achieving a positive
oral PPE, given a negative PE, is 0.26–0.61.
Total enteroscopy with a combination of the oral and anal
approaches was carried out in eight of the 52 patients (15%);
only a minority of patients required a total enteroscopy. Total
enteroscopy was achieved in 8 of the 12 patients in whom
it was attempted (67%). All of the lesions found with PE
were confirmed on PPE. Additional information (such as
more angiodysplasias) was obtained with oral PPE in 18
of the 23 PE positive patients (81%), i.e., who had posi-
tive findings on PE.
The bleeding source was found outside of the small bowel
in five patients. Two patients were suffering from a colon
carcinoma located in the cecum that had not been detected
during the previous colonoscopy. Passage through the colon
had been very difficult in these cases, so that the cecum had
probably not been reached before. In a third patient, some,
probably NSAID-induced, ulcerations were found in the as-
cending colon during anal PPE. This patient, who had sev-
eral concomitant diseases, always had problems with colon
cleansing, which may explain why the ulcerations had not
been found previously. In addition, he had some angiodys-
plasias in the stomach and duodenum, so that further an-
giodysplasias in the small bowel were suspected. The fourth
patient was a young man with a history of intensive treat-
ment for scrotal carcinoma; a large ulceration was found in
the fundus. The lesion had probably not been identified during
a previous esophagogastroduodenoscopy because the patient
had been investigated in an external institution on an out-
patient basis without any sedation, and he reported having a
very strong gag reflex. In the fifth patient, in addition to some
tiny angiodysplasias, an ulceration in the stomach was found
that had probably been the relevant bleeding source. These
findings underline the necessity to always check whether an
upper or lower GI endoscopy has to be repeated before a
small-bowel diagnostic is done.
With regard to the therapeutic implications, the results
of the enteroscopy influenced the subsequent treatment in
38 of the 52 patients (73%). Twenty-six of the 52 patients
(50%) underwent endoscopic therapy: argon plasma coagu-
lation in 24 of 38 (63%) patients with positive findings, with
Push Enteroscopy versus Push-and-Pull Enteroscopy 2021
a combination of injection therapy with diluted epinephrine
solution in four patients; polypectomy was carried out in 2
of the 38 patients (5%). All of the endoscopic treatments
were administered without complications. Medical therapy
was started or changed in 3 of the 52 patients (6%). Surgi-
cal treatment was found to be indicated by the PPE findings
in 9 of the 52 patients (17%); eight of these patients un-
derwent abdominal surgery, and one received intraoperative
enteroscopy with argon plasma coagulation. In the latter pa-
tient, total enteroscopy was not possible with PPE because
of multiple prior abdominal operations, and the patient was
continuing to have bleeding from angiodysplasias.
Pathological findings were not identified with either PE or
PPE in only 14 of the 52 patients (27%); in these cases, a wait-
and-see approach without further measures was chosen.
DISCUSSION
The management of patients with suspected mid-
gastrointestinal bleeding—i.e., with a bleeding source
suspected in the small bowel after negative upper and lower
gastrointestinal endoscopies—has been problematic for a
considerable period. The results of uncontrolled studies of
the new method of PPE, which allows endoscopic exami-
nation of the entire small bowel or at least a large part of
it, have recently been published and have suggested a high
diagnostic and therapeutic yield, as well as a low compli-
cation rate (13–16). However, no data have previously been
available comparing this new device with the common non-
surgical gold standard method of PE. PE was previously the
method of choice for screening the upper part of the jejunum
in patients with obscure bleeding, and for treating lesions
in the proximal part of the small bowel. It appears that the
length of the enteroscope does not significantly affect the in-
sertion depth (17) and that using an overtube can significantly
increase the length of small bowel capable of being visual-
ized endoscopically (6, 7). With an overtube, a postpyloric
insertion depth of up to 120 cm was found to be possible in
two prospective studies (6, 7). A single-center retrospective
analysis even reported average insertion depths of 120 cm
(18)—lengths that have otherwise only been reported with
the new type of variable-stiffness enteroscope (19, 20). The
examiners’ level of experience is one possible explanation
for these divergences, and the use of different measurement
methods may also play a role. However, the average inser-
tion depth of about 70 cm reported in the two prospective
trials (6, 7) appears to reflect the general situation better and
is confirmed by the prospective data obtained in the present
study, with an average insertion depth of 80 cm. As the use
of an overtube is important for effective PE, a system with
an overtube was used in the present study. Complications
such as mucosal stripping, perforation, and pancreatitis that
have been reported with PE were caused by the overtube and
mainly located in the duodenum (10, 11, 21). To minimize
the risk of complications, it was decided in the present study
to position the overtube in front of the pylorus and not to pass
the pylorus. This is probably the reason why there was only
2022 May et al.
one minor complication in the proximal part of the esophagus
in this trial, with no problems being encountered in the small
bowel and no cases of pancreatitis.
Even when a combination of the oral and anal route is
used with PE, it is not possible to achieve total enteroscopy
of the entire small bowel—partly explaining the low diag-
nostic yield of 26% with PE in this study (18). In previously
published data, the reported diagnostic yield with PE in pa-
tients with obscure gastrointestinal bleeding has ranged from
26% to 75% (7, 11, 21–25). Three points are very important
in interpreting these data: the selection of patients and num-
ber of patients, on the one hand, and the number of lesions in
the proximal upper gastrointestinal tract, on the other. Partic-
ularly in papers reporting a high diagnostic yield, about 50%
of the findings have been located in the upper gastrointestinal
tract, accessible with a standard gastroscope; this means that
the percentage of pathological findings in the distal duode-
num and proximal jejunum in which PE is needed to obtain
the diagnosis is much lower. In a prospective study including
a large number of patients, Taylor et al. (25) reported a diag-
nostic yield of 40%, a rate that is quite similar to the present
results at about 45%. One of the reasons for the diagnostic
yield of PE being higher in the present study than in trials
comparing the results of PE and capsule endoscopy (1, 2, 26–
28) is the large numbers of angiodysplasias, often scattered
all over the small bowel. The diagnostic yield of PE in these
comparative studies varied from 28% to 38% in comparison
with the results of capsule endoscopy, which had figures about
two times higher. The explanation for this is clear—capsule
endoscopy allows the examination of the entire small bowel,
whereas the insertion depth of PE is limited. Intraoperative
enteroscopy was therefore for a long period the gold stan-
dard for the detection and treatment of lesions in the small
bowel, with a diagnostic yield of 70–80% (29–33). Even after
the introduction of wireless capsule endoscopy, intraopera-
tive enteroscopy continued to be the method of choice for
the treatment of lesions in the deep small bowel that were
not accessible using PE. However, intraoperative enteroscopy
requires considerable time, staff, and costs, and is associ-
ated with a substantial risk of complications and mortality
(5, 29–33).
The new method of PPE with the double-balloon technique
(double-balloon enteroscopy) (9, 8, 13, 14) for the first time
allows total enteroscopy and visualization of a large part of
the small bowel with a conventional endoscope without the
need for surgical laparotomy. In rare cases, total enteroscopy
can be achieved via the oral route alone, but generally a com-
bination of the oral and anal routes is necessary. Because
the whole small bowel, or at least a large part of it, can
be seen—approximately 250 cm with the oral approach, on
average—a high diagnostic yield can be expected with PPE.
This assumption has been confirmed by several prospective
and retrospective single-center and multicenter trials of PPE,
reporting diagnostic yields of approximately 70–80% (13–
16). These data correspond to the results of the present trial,
with an overall diagnostic yield of approximately 70%. How-
ever, even in cases in which PE did provide a diagnosis, PPE
was able to identify additional lesions in the deeper part of
the small bowel in nearly 80%, as well as providing the op-
tion of treating them. This advantage comes at the cost of a
significantly longer investigation time, as well as increased re-
quirements for sedoanalgetic medication, longer X-ray expo-
sure, and higher staffing requirements in comparison with PE.
However, it can be assumed that time, staffing, and costs are
much lower in comparison with intraoperative enteroscopy,
although there have not yet been any prospective trials or cost
analyses on these issues. In addition, the complication rate of
PPE, at about 1% (13–16), appears to be lower than that in
intraoperative enteroscopy, for which complication rates up
to about 50% have been reported (29–33). In addition, there
have not yet been any cases of mortality associated with PPE,
compared with the approximately 2% rate of perioperative
mortality associated with intraoperative enteroscopy (5).
With regard to the complication rate, no severe complica-
tions occurred in the present study with either PE or PPE.
Complication rates of 0.6–2% have been reported in two
larger series investigating PE (18, 25). The main risks in PE
are perforation and pancreatitis; no cases of mortality have
yet been reported with the method. On the basis of the papers
published to date, the complication rates with PE and PPE ap-
pear to be similar (13–16). Fortunately, no complications were
encountered in any of the additional endoscopic interventions
carried out during PPE in the present trial—illustrating the
easy handling and good control that the system provides.
In summary, in patients with suspected mid-gastroi-
ntestinal bleeding, PPE is superior to PE for endoscopic ex-
amination of the small bowel, both with regard to the length
of small bowel visualized and to the diagnostic yield. As the
method also allows treatment to be carried out, PPE should
always be considered before laparotomy and intraoperative
endoscopy in patients with mid-gastrointestinal bleeding.
ACKNOWLEDGMENT
We are grateful to Michael Robertson for translating and re-
vising the manuscript and to Prof. Manfred Berres (Depart-
ment of Mathematics and Applied Technology, University of
Applied Sciences, Koblenz, Germany) for sample size calcu-
lation and assistance in statistical analysis.
STUDY HIGHLIGHTS
What Is Current Knowledge
r Insertion depth of push enteroscopy is limited to the
proximal jejunum.
r The diagnostic yield of push enteroscopy can be esti-
mated on approximately 40%.
r With the new method of push-and-pull enteroscopy in
double-balloon technique also deeper parts of the small
bowel can be reached.

What Is New Here
r This is the first prospective study comparing push en-
teroscopy and push-and pull enteroscopy in double-
balloon technique in patients with mid GI bleeding.
r Push-and-pull enteroscopy is superior to push en-
teroscopy both with regard to the length of small bowel
visualized and to the diagnostic yield.
Reprint requests and correspondence: Andrea May, M.D., Ph.D.,
Department of Internal Medicine II, HSK Wiesbaden, Ludwig-
Erhard-Strasse 100, 65199 Wiesbaden, Germany.
Received February 8, 2006; accepted April 11, 2006.
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