研究目的：本研究在於針對不明消化道出血，傳統的檢查方式均有其局限性而無法滿足臨床需求。而雙氣囊小腸鏡(double-balloon enteroscopy,DBE)是一種能快速安全地檢查小腸, 利用經口腔和經肛門途徑上下結合的檢查方式能使整個小腸得以全面徹底的檢查，同時能提供內視鏡止血術及染色定位功能，在治療上也有顯著的角色來進行實地的驗證。

研究方法及資料：本研究自2007年 1 月開始至 2010年 3 月本院共有25位不明消化道出血病人因為臨床症狀(反覆或持續的消化道出血或黑便)或先前檢查結果(陽性大便潛血反應或缺鐵性貧血)而接受雙氣囊小腸鏡檢查，所有病患均接受過同時上下消化道檢查後仍未發現出血點 ，經醫師建議並充分告知雙氣囊小腸鏡檢查的優缺點及限制，在病患或家屬簽署同意(informed consent)後始進行。進行檢查之前，病患可能已接受小腸鋇劑攝影，血管攝影，同位素掃描，推式小腸鏡或是膠囊內視鏡先行評估，而我们會先選擇最靠近病灶的途徑而決定經由口端或肛門端進入，檢查過程多數會給予靜脈注射進行全身麻醉，在麻醉科醫師協助下以靜脈麻醉進行檢查工作或少數視檢查時間決定是否進行吸入式全身麻醉。檢查後會觀察病人有無出現嚴重腹痛而決定是否追蹤血清澱粉脢(amylase)及腹部X 光檢查。接著採取回溯性的分析方式，觀察這些病患的雙氣囊小腸鏡檢查成功率，接受雙氣囊小腸鏡檢及內視鏡止血或轉介外科治療的病患，經過3個月後再追蹤臨床上有無再次出血，並追蹤病患長期預後。

研究結果：雙氣囊小腸鏡檢查經口途徑總共執行18人次，而經肛門途徑總共執行14人次，有7例接受經口腔和經肛門途徑上下結合的檢查方式而整個小腸得以全面徹底的檢查有3例，使用雙氣囊小腸鏡的檢出陽性率 (Yield rate)在經口途徑為83.3%(15/18)，在經肛門途徑為71.3%(10/14)，雙氣囊小腸鏡有相當高的診斷率80%(20/25)。在所有接受雙氣囊小腸鏡檢而發現不明消化道出血病患中有4位在發現可能出血病灶後轉介外科治療，而75%(3/4)經過3個月的追蹤臨床上沒有再次出血。而有10 位在發現可能出血病灶後使用內視鏡止血術治療，而60%(6/10)經過3個月的追蹤臨床上沒有再次出血。

結論與建議：對於臨床上不明消化道出血，因為傳統的檢查方式均有其局限性而無法滿足臨床需求。而雙氣囊小腸鏡(double-balloon enteroscopy,DBE)是一種能快速安全地檢查小腸, 利用經口腔和經肛門途徑上下結合的檢查方式能使整個小腸得以全面徹底的檢查，對於較明顯的不明消化道出血(Overt obscure GI bleeding)或急性出血(Ongoing bleeding) ，雙氣囊小腸鏡有相當高的診斷率。文獻上報告有關雙氣囊小腸鏡檢查所出現的併發症極為少數如急性胰臟炎、腸穿孔及介入性治療所出現的併發症在本篇研究有限的病例來看至今仍無出現。因此雙氣囊小腸鏡不僅是一種安全有效的診斷工具，對於血管性病灶(Vascular lesions)及可能的出血點(potential bleeders)都能先採取介入性治療而降低再出血率，值得在臨床推廣應用。

Background:
Obscure gastrointestinal bleeding(OGIB) is difficult to treat and diagnose.Yamamoto et al established a balloon assisted insertion method for enteroscopy that allows examination of the entire small bowel and perform interventional options,such as performing tattooing and carrying out hemoclipping,or argon plasma coagulation.

Objective :
The aim of our study was to evaluate the efficacy of the double balloon enteroscopy in patients with obscure GI bleeding.

Setting:
Single-center retrospective study

Patients & Methods:
From January 2007 to March 2010, 25 patients with obscure gastrointestinal bleeding underwent DBE examinations at CSMUH,Taichung,Taiwan, the clinical characteristics of the patients are listed in table 2. All patients provided written informed consent to undergoing DBE.A total of 32 DBE procedures were carried out in 25 patients,criteria for inclusion was the absence of an identified bleeding source after standard endoscopic evaluation(all patients had undergone more than one upper and lower endoscopic examination without identified bleeding source).
The type of obscure GI bleeding was overt (melana or hematochezia) (n=22) or occult(positive stool occult blood or iron deficiency anemia) (n=3).
Exclusion criteria were cardiopulmonary disease that prohibited conscious sedation.DBE was carried out using Fujinon enteroscopes (Fujinon EN-450P5, EN-450T5),all procedures were performed under conscious or deep sedation,which was administered and supervised by one physician. There was no special preparation for the peroral examination besides an 8-12h fast,for the peranal examination,the bowel preparation was carried out as in colonoscopy.The choice of insertion route, either peroral or peranal approach depended on the suspected origin of bleeding within the small bowel based on the clinical manifestations or any previous examination data.
In the event of insufficient localization clues,peroral route examination was performed first ,which could reduce interference from blood in the small bowel.If no bleeder was identified ,tattooing with Indian ink was carried out at the most distant point during the examination,then switched our approach to the opposite route,and confirmed total enteroscopy when the enteroscopy reached the Indian-ink mark.

Main outcomemeasurements:
Diagnostic yield for the patients with obscure
gastrointestinal bleeding(OGIB) and patient treated with no further bleeding at 3 months of follow up and long term outcome.

Results :
We examined the small intestine by oral approach in 18 procedures,by anal approach in 14 procedures, A total of 32 DBE procedure were carried out .Both oral and anal approaches for 7 patients were performed and 3 patients examined the entire small intestine(amounting to total enteroscopy).Over all diagnostic rate was 80%(20/25).
Endoscopic intervention was performed in 10 (47.7%)of the 21 patients with potential bleeder.In 6 (60%) of these patients underwent endoscopic intervention, the cause of bleeding were identified and treated without rebleeding at 3 months of follow up.DBE was completed without major complications(such as perforation or pancreatitis) in all patients.

Limitations:
Small number of patients and pathologic diagnosis was confirmed only 30%(6/20).

Conclusions:
The data suggest that double balloon enteoscopy (DBE)
is useful for evaluation and treatment of patients with obscure gastrointestinal bleeding (OGIB).
when potential bleeders are encountered,during the DBE procedure ,especially for vascular lesions (Angiodysplasia,
Dieulafoy’s lesion), therapeutic intervention should be attemped,and such intervention may reduce the rebleeding rate.

目 錄 …………………………………………………………………1
中文摘要 ……………………………………………………………4
英文摘要 ……………………………………………………………5
第 壹 章 緒 論 ……………………………………………………7
第一節 前言 ……………………………………………………7
第二節 名詞解釋 ………………………………………………8
第貳章 材料和方法 …………………………………………… 9
第一節 研究對象 ………………………………………………9
第二節 檢查流程……………………………………………… 9
第三節 檢查工具及操作說明………………………………… 10
第四節 資料分析 ………………………………………………11
第參章 結果 …………………………………………………………12
第一節 本院實施雙氣囊小腸鏡的適應症統計 ………………12
第二節. 雙氣囊小腸鏡於不明消化道出血的診斷率 ………12
第肆章 討論 …………………………………………………………15
第一節 如何診斷不明消化道出血 ………………………… 15
第二節 不明消化道出血是實施雙氣囊小腸鏡的主要適應症…18
第伍章 結論 …………………………………………………………20
參考文獻 ……………………………………………………………21
圖表. …………………………………………………………………24


表1:文獻已發表有關雙氣囊小腸鏡在不明消化道出血的診斷率…24
表2：25位不明消化道出血病患的統計資料……………………… 24
表3：進行雙氣囊小腸鏡檢查之前的其他影像檢查統計資料…… 25
表4：在不明消化道出血的診斷工具之診斷率…………………… 25
表5：在不明消化道出血的診斷工具之優缺點…………………… 26
表6：雙氣囊小腸鏡在不明消化道出血的診斷和追蹤結果統計… 27
表7. 在重症病患(ICU critical illness patient)不明消化道出血
的診斷和長期追蹤結果統計……………………………… 28


圖1A：對於不明消化道出血建議的流程圖…………………………29
圖1B：山本博德對小腸血管性病灶的內視鏡型態分類……………29
圖1C: 2007年至2010年，全院實施雙氣囊小腸鏡的適應症統計…30
圖2A: 例一、 一名四歲幼童解大量黑便,經檢查發現一出血憩室(Bleeding meckel’s diverticulum)
圖2B: 例二、 一男性病人罹患黑便多年經檢查後發現一小腸間質瘤(GIST)位於空腸
圖2C: 例三、 一年約71歲病人於空腸發現血管異常增生(Angiodysplasia)合併出血給予氬氣電凝固止血術成功(Argon plasma coagulation)
圖2D: 例四、一年約35歲肝硬化病人於十二指腸遠端發現靜脈瘤(Duodenal varix)破裂出血予以硬化劑注射止血成功

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