Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website https://www.gastrores.org

Original Article

Volume 15, Number 6, December 2022, pages 353-363

Clinical Features and Management of Small Bowel Masses Detected During Device-Assisted Enteroscopy: A Multi-Center Experience

Figure 1. Lesion histology frequency (%). GIST: gastrointestinal stromal tumor; NET: neuroendocrine tumor; GI: gastrointestinal.

Figure 2. Representative endoscopic images of different small bowel mass lesions detected on device-assisted enteroscopic exams. NET: neuroendocrine tumor; GIST: gastrointestinal stromal tumor.

Figure 3. Representative biopsy histologic slides of the two most common small bowel mass lesion pathologies diagnosed on device-assisted enteroscopic exams in our study. The slide to the left shows a well-differentiated NET. The slide to the right shows a hamartoma. NET: neuroendocrine tumor.

**Table 1.** Patient Characteristics
	All patients (n = 218)
Values are n (%) unless otherwise specified. BMI: body mass index; GI: gastrointestinal.
Age, years (median (Q1, Q3))	63 (47, 71)
Gender
Female	100 (45.9)
Male	118 (54.1)
BMI at diagnosis (kg/m²)
< 18.5	4 (1.8)
18.5 - 24.9	51 (23.4)
25 - 29.9	64 (29.4)
30 - 39.9	69 (31.7)
> 40	19 (8.7)
Unknown	11 (5.0)
Race
Caucasian	149 (68.3)
African American	50 (22.9)
Other	8 (3.7)
Unknown	11 (5.0)
Family history GI malignancies
Yes	38 (17.4)
Colorectal cancer	29 (13.3)
Gastric cancer	5 (2.3)
Small bowel cancer	6 (2.8)
Pancreatic cancer	2 (0.9)
Multi-site GI cancer	1 (0.5)
No	180 (82.6)
History of hereditary cancer or polyposis syndrome
No	171 (78.4)
Peutz-Jeghers syndrome	40 (18.3)
Familial adenomatous polyposis	3 (1.4)
Other	3 (1.4)
Unknown	1 (0.46)
Tobacco use
Former	51 (23.4)
Current	17 (7.8)
No	144 (66.1)
Unknown	5 (2.3)

Table 1. Patient Characteristics

All patients (n = 218)

Frequency (%)

Values are n (%) unless otherwise specified. BMI: body mass index; GI: gastrointestinal.

Age, years (median (Q1, Q3))

63 (47, 71)

Gender

Female

100 (45.9)

Male

118 (54.1)

BMI at diagnosis (kg/m²)

< 18.5

4 (1.8)

18.5 - 24.9

51 (23.4)

25 - 29.9

64 (29.4)

30 - 39.9

69 (31.7)

> 40

19 (8.7)

Unknown

11 (5.0)

Race

Caucasian

149 (68.3)

African American

50 (22.9)

Other

8 (3.7)

Unknown

11 (5.0)

Family history GI malignancies

Yes

38 (17.4)

Colorectal cancer

29 (13.3)

Gastric cancer

5 (2.3)

Small bowel cancer

6 (2.8)

Pancreatic cancer

2 (0.9)

Multi-site GI cancer

1 (0.5)

180 (82.6)

History of hereditary cancer or polyposis syndrome

171 (78.4)

Peutz-Jeghers syndrome

40 (18.3)

Familial adenomatous polyposis

3 (1.4)

Other

3 (1.4)

Unknown

1 (0.46)

Tobacco use

Former

51 (23.4)

Current

17 (7.8)

144 (66.1)

Unknown

5 (2.3)

**Table 2.** Presenting Symptoms
	All patients (n = 218)
Values are n (%) unless otherwise specified.
Presenting symptoms
Iron-deficiency anemia/bleeding	160 (73.4)
Abnormal imaging study	73 (33.5)
Abdominal pain	27 (12.4)
Diarrhea	24 (11.0)
Weight loss	8 (3.7)
Bowel obstruction	7 (3.2)
Constitutional symptoms	4 (1.8)
Other	31 (14.2)
Duration of presenting symptoms (months)
< 1	18 (8.3)
1 - 6	55 (25.7)
6 - 12	17 (7.8)
> 12	75 (34.4)
Unknown	52 (23.9)

Table 2. Presenting Symptoms

All patients (n = 218)

Frequency (%)

Values are n (%) unless otherwise specified.

Presenting symptoms

Iron-deficiency anemia/bleeding

160 (73.4)

Abnormal imaging study

73 (33.5)

Abdominal pain

27 (12.4)

Diarrhea

24 (11.0)

Weight loss

8 (3.7)

Bowel obstruction

7 (3.2)

Constitutional symptoms

4 (1.8)

Other

31 (14.2)

Duration of presenting symptoms (months)

< 1

18 (8.3)

1 - 6

55 (25.7)

6 - 12

17 (7.8)

> 12

75 (34.4)

Unknown

52 (23.9)

**Table 3.** Prior Diagnostic Studies and Correlation With DAE Findings
	All patients (n = 218)
Values are n (%) unless otherwise specified. ^aPositive finding that correlated to final DAE findings/location. ^bN = 176 due to information on 42 patients missing or unknown. ^cMissing information. DAE: device-assisted enteroscopy; EGD: esophagogastroduodenoscopy; VCE: video capsule endoscopy; CT: computed tomography; CTE: computed tomography enterography; MRI: magnetic resonance imaging; MRE magnetic resonance enterography; DBE: double-balloon enteroscopy; SBE: single-balloon enteroscopy; SE: spiral enteroscopy.
Endoscopy	Overall (n = 218)	Positive finding^{a, b}
EGD	136 (62.4)	-^c
Ileo-colonoscopy	126 (57.8)	2 (1.6)
Push enteroscopy	21 (9.6)	6 (28.6)
VCE	156 (71.6)	131 (84.0)
Antegrade DAE	10 (4.6)	-^c
Retrograde DAE	2 (0.9)	-^c
Radiology
CT	45 (20.6)	22 (49)
CTE	18 (8.3)	11 (61)
MRI/MRE	2 (0.9)	0 (0)
Unknown	19 (8.7)	-
DAE modality used to find lesion	All patients (n = 218)
Antegrade DBE	122 (56.0)
Retrograde DBE	65 (29.8)
Antegrade SBE	11 (5.0)
Retrograde SBE	1 (0.5)
Antegrade SE	19 (8.7)

Table 3. Prior Diagnostic Studies and Correlation With DAE Findings

All patients (n = 218)

Values are n (%) unless otherwise specified. ^aPositive finding that correlated to final DAE findings/location. ^bN = 176 due to information on 42 patients missing or unknown. ^cMissing information. DAE: device-assisted enteroscopy; EGD: esophagogastroduodenoscopy; VCE: video capsule endoscopy; CT: computed tomography; CTE: computed tomography enterography; MRI: magnetic resonance imaging; MRE magnetic resonance enterography; DBE: double-balloon enteroscopy; SBE: single-balloon enteroscopy; SE: spiral enteroscopy.

Endoscopy

Overall (n = 218)

Positive finding^{a, b}

EGD

136 (62.4)

-^c

Ileo-colonoscopy

126 (57.8)

2 (1.6)

Push enteroscopy

21 (9.6)

6 (28.6)

VCE

156 (71.6)

131 (84.0)

Antegrade DAE

10 (4.6)

-^c

Retrograde DAE

2 (0.9)

-^c

Radiology

45 (20.6)

22 (49)

CTE

18 (8.3)

11 (61)

MRI/MRE

2 (0.9)

0 (0)

Unknown

19 (8.7)

DAE modality used to find lesion

All patients (n = 218)

Antegrade DBE

122 (56.0)

Retrograde DBE

65 (29.8)

Antegrade SBE

11 (5.0)

Retrograde SBE

1 (0.5)

Antegrade SE

19 (8.7)

**Table 4.** Lesion Characteristics
	All patients (n = 218)
Values are n (%) unless otherwise specified. ^aIndicates benign epithelial tumors (e.g., adenoma, hamartoma, Brunner gland lesions). ^bIndicates malignant epithelial tumors (e.g., carcinoid and adenocarcinoma). ^cIndicates mesenchymal tumors (e.g., lipoma, liposarcoma, GIST, leiomyoma, hemangioma, etc.) ^dIndicates lymphoproliferative disorders (e.g., B-cell and T-cell lymphomas). GIST: gastrointestinal stromal tumor.
Lesion location
Duodenum	30 (13.8)
Jejunum	101 (46.3)
Ileum	108 (49.5)
Multi-site	7 (3.2)
Small bowel (unspecified)	0 (0)
Lesion size (mm)
1 - 5	6 (2.8)
5 - 10	61 (28.0)
10 - 20	102 (46.8)
> 20	48 (22.0)
Missing	1 (0.5)
Lesion phenotype
Submucosal	90 (41.3)
Mucosal: sessile	32 (14.7)
Mucosal: pedunculated	72 (33)
Obstructing/invasive	24 (11)
Lesion histology
Benign epithelial^a	81 (37.2)
Malignant epithelial^b	62 (28.4)
Mesenchymal^c	35 (16.1)
Lymphoproliferative^d	3 (1.4)
Inflammatory	17 (7.8)
Normal small bowel tissue	6 (2.8)
Vascular	13 (6.0)
Missing	1 (0.5)

Table 4. Lesion Characteristics

All patients (n = 218)

Frequency (%)

Values are n (%) unless otherwise specified. ^aIndicates benign epithelial tumors (e.g., adenoma, hamartoma, Brunner gland lesions). ^bIndicates malignant epithelial tumors (e.g., carcinoid and adenocarcinoma). ^cIndicates mesenchymal tumors (e.g., lipoma, liposarcoma, GIST, leiomyoma, hemangioma, etc.) ^dIndicates lymphoproliferative disorders (e.g., B-cell and T-cell lymphomas). GIST: gastrointestinal stromal tumor.

Lesion location

Duodenum

30 (13.8)

Jejunum

101 (46.3)

Ileum

108 (49.5)

Multi-site

7 (3.2)

Small bowel (unspecified)

0 (0)

Lesion size (mm)

1 - 5

6 (2.8)

5 - 10

61 (28.0)

10 - 20

102 (46.8)

> 20

48 (22.0)

Missing

1 (0.5)

Lesion phenotype

Submucosal

90 (41.3)

Mucosal: sessile

32 (14.7)

Mucosal: pedunculated

72 (33)

Obstructing/invasive

24 (11)

Lesion histology

Benign epithelial^a

81 (37.2)

Malignant epithelial^b

62 (28.4)

Mesenchymal^c

35 (16.1)

Lymphoproliferative^d

3 (1.4)

Inflammatory

17 (7.8)

Normal small bowel tissue

6 (2.8)

Vascular

13 (6.0)

Missing

1 (0.5)

**Table 5.** Descriptive Characteristics by Histology
	Carcinoid/NET (N = 45)	Hamartoma (N = 45)	Hyperplastic (N = 22)	Total (N = 217)^a	P value
^aChi-square test. ^bKruskal-Wallis test. ^cFisher exact test. ^aNote one patient did not have any histologies indicated and is excluded from this table. Furthermore, descriptive characteristics of the three most common histologies are represented in this table. FH: family history; GI: gastrointestinal; SD: standard deviation.
Gender					0.690^a
Male	26 (57.8%)	21 (46.7%)	13 (59.1%)	117 (53.9%)
Female	19 (42.2%)	24 (53.3%)	9 (40.9%)	100 (46.1%)
Age					< 0.001^b
N	45	42	22	212
Mean (SD)	61.13 (13.59)	40.33 (17.89)	63.32 (12.27)	58.94 (17.25)
Median	64	36.5	65.5	63
Q1, Q3	49.00, 69.00	27.00, 52.00	58.00, 71.00	47.00, 71.00
Range	25.00 - 86.00	14.00 - 87.00	32.00 - 78.00	14.00 - 89.00
BMI at diagnosis					0.013^a
Missing	2	7	1	11
< 18.5	1 (2.3%)	0 (0.0%)	0 (0.0%)	4 (1.9%)
18.5 - 24.9	7 (16.3%)	19 (50.0%)	6 (28.6%)	51 (24.8%)
25 - 29.9	16 (37.2%)	7 (18.4%)	2 (9.5%)	64 (31.1%)
30 - 39.9	16 (37.2%)	9 (23.7%)	11 (52.4%)	69 (33.5%)
> 40	3 (7.0%)	3 (7.9%)	2 (9.5%)	18 (8.7%)
Ethnicity					0.002^c
Missing	2 (0.92%)	2 (0.92%)	1 (0.46%)
Caucasian	26 (60.5%)	36 (83.7%)	12 (57.1%)	148 (71.8%)
African American	14 (32.6%)	4 (9.3%)	9 (42.9%)	50 (24.3%)
Hispanic	0 (0.0%)	3 (7.0%)	0 (0.0%)	4 (1.9%)
Native American	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (0.5%)
Other	3 (7.0%)	0 (0.0%)	0 (0.0%)	3 (1.5%)
Polyposis syndrome					< 0.001^c
Any history	0 (0.0%)	39 (86.7%)	1 (4.5%)	47 (21.7%)
No history	45 (100.0%)	6 (13.3%)	21 (95.5%)	170 (78.3%)
FH of GI malignancies					0.010^c
Any history	9 (20.0%)	14 (31.1%)	5 (22.7%)	38 (17.5%)
No history	36 (80.0%)	31 (68.9%)	17 (77.3%)	179 (82.5%)

Table 5. Descriptive Characteristics by Histology

Carcinoid/NET (N = 45)

Hamartoma (N = 45)

Hyperplastic (N = 22)

Total (N = 217)^a

P value

^aChi-square test. ^bKruskal-Wallis test. ^cFisher exact test. ^aNote one patient did not have any histologies indicated and is excluded from this table. Furthermore, descriptive characteristics of the three most common histologies are represented in this table. FH: family history; GI: gastrointestinal; SD: standard deviation.

Gender

0.690^a

Male

26 (57.8%)

21 (46.7%)

13 (59.1%)

117 (53.9%)

Female

19 (42.2%)

24 (53.3%)

9 (40.9%)

100 (46.1%)

Age

< 0.001^b

212

Mean (SD)

61.13 (13.59)

40.33 (17.89)

63.32 (12.27)

58.94 (17.25)

Median

36.5

65.5

Q1, Q3

49.00, 69.00

27.00, 52.00

58.00, 71.00

47.00, 71.00

Range

25.00 - 86.00

14.00 - 87.00

32.00 - 78.00

14.00 - 89.00

BMI at diagnosis

0.013^a

Missing

< 18.5

1 (2.3%)

0 (0.0%)

4 (1.9%)

18.5 - 24.9

7 (16.3%)

19 (50.0%)

6 (28.6%)

51 (24.8%)

25 - 29.9

16 (37.2%)

7 (18.4%)

2 (9.5%)

64 (31.1%)

30 - 39.9

16 (37.2%)

9 (23.7%)

11 (52.4%)

69 (33.5%)

> 40

3 (7.0%)

3 (7.9%)

2 (9.5%)

18 (8.7%)

Ethnicity

0.002^c

Missing

2 (0.92%)

1 (0.46%)

Caucasian

26 (60.5%)

36 (83.7%)

12 (57.1%)

148 (71.8%)

African American

14 (32.6%)

4 (9.3%)

9 (42.9%)

50 (24.3%)

Hispanic

0 (0.0%)

3 (7.0%)

0 (0.0%)

4 (1.9%)

Native American

0 (0.0%)

1 (0.5%)

Other

3 (7.0%)

0 (0.0%)

3 (1.5%)

Polyposis syndrome

< 0.001^c

Any history

0 (0.0%)

39 (86.7%)

1 (4.5%)

47 (21.7%)

No history

45 (100.0%)

6 (13.3%)

21 (95.5%)

170 (78.3%)

FH of GI malignancies

0.010^c

Any history

9 (20.0%)

14 (31.1%)

5 (22.7%)

38 (17.5%)

No history

36 (80.0%)

31 (68.9%)

17 (77.3%)

179 (82.5%)

**Table 6.** Post-DAE Lesion Management
	All patients (n = 218)
Values are n (%) unless otherwise specified. DAE: device-assisted enteroscopy.
Endoscopic surveillance	49 (22.5)
Surgical resection	82 (37.6)
Medical oncology	15 (6.9)
Unknown	23 (10.6)
No further management	57 (26.1)
Other	3 (1.4)

Table 6. Post-DAE Lesion Management

All patients (n = 218)

Frequency (%)

Values are n (%) unless otherwise specified. DAE: device-assisted enteroscopy.

Endoscopic surveillance

49 (22.5)

Surgical resection

82 (37.6)

Medical oncology

15 (6.9)

Unknown

23 (10.6)

No further management

57 (26.1)

Other

3 (1.4)

**Table 7.** DAE Intervention
	All patients (n = 218)
Values are N (%) unless otherwise specified. DAE: device-assisted enteroscopy.
Tattoo	143 (65.6)
Biopsy	132 (60.6)
Endoscopic resection	83 (38.1)
Clip for marking	7 (3.2)
Other	3 (1.4)
DAE-related complications	2 (0.92)

Table 7. DAE Intervention

All patients (n = 218)

Frequency (%)

Values are N (%) unless otherwise specified. DAE: device-assisted enteroscopy.

Tattoo

143 (65.6)

Biopsy

132 (60.6)

Endoscopic resection

83 (38.1)

Clip for marking

7 (3.2)

Other

3 (1.4)

DAE-related complications

2 (0.92)