Small bowel capsule endoscopy (SBCE) is an established, minimally invasive technique for evaluating small bowel pathology, offering high diagnostic yield across a range of clinical indications. The European Society of Gastrointestinal Endoscopy (ESGE) recommends that at least 75% of patients who require further assessment with Double Balloon Enteroscopy (DBE) should successfully progress as a key performance indicator (KPI). However, little is known about the expected SBCE to DBE conversion rate. This knowledge will help in monitoring performance as well as aiding service provision. Understanding conversion rates may also help clarify which clinical indications are most likely to proceed to DBE, supporting more efficient triage and referral pathways. Our aim is to evaluate the SBCE-to-DBE conversion rate. Secondly, we will assess our DBE compliance against ESGE standards. We also seek to examine how clinical indications influence the likelihood of requiring DBE and to assess whether these patterns have changed over time. By analysing these factors, we aim to provide insight into procedural demand, referral optimisation, and alignment with recognised performance standards.

All SBCE procedures performed between 2018 and 2023 were retrospectively analysed using data extracted from the local PillCam database. Each SBCE report was individually reviewed, and no inclusion or exclusion criteria were applied to ensure complete case capture. Indications were broadly grouped into 5 categories; Iron Deficiency Anaemia (IDA) and suspected bleeding, suspected small bowel Crohn’s (CD), coeliac or enteropathy, polyps or lesions and finally radiology correlation.  Recommendations for DBE were cross-checked against the endoscopy reporting software to confirm procedure completion. Overall and indication-specific SBCE-to-DBE conversion rates were calculated. Odds ratios with 95% confidence intervals were derived using Fisher’s exact test, and year-to-year DBE conversion rates were summarised descriptively and benchmarked against the ESGE 75% performance standard

A total of 3,105 SBCE procedures were performed during the study period. DBE was recommended in 311 (10%). Of these, 176 DBEs were completed, corresponding to an actual SBCE-to-DBE completion rate of 5.7%. This gives a total DBE completion rate of 56.6%, below the ESGE standard of 75%. Yearly analysis demonstrated marked variability in DBE completion performance. KPI compliance ranged from a low of 41.8% in 2020 to a high of 77.4% in 2023, with only 2023 meeting the ESGE KPI threshold. Indication-specific analysis showed significant differences in the likelihood of progressing from SBCE to DBE. Compared with all other indications combined, patients with IDA demonstrated a significantly increased probability of undergoing DBE (OR 3.70, p < 0.001), while those with polyps also showed an elevated likelihood (OR 2.08, p = 0.045). In contrast, suspected Crohn’s disease was associated with a markedly decreased likelihood of DBE (OR 0.16, p < 0.001). Coeliac disease (OR 0.69, p = 0.47) and radiology-driven indications (OR 1.34, p = 0.55) did not significantly influence DBE utilisation. These patterns confirm a strong dependence of DBE conversion on underlying clinical indication.

Overall, our centre did not meet the ESGE 75% KPI for progression from SBCE to DBE, with the most pronounced decline occurring during the COVID-19 period, when elective services were significantly disrupted. As a national referral pathway, the geographical separation from the DBE centre may have played a role in reduced completion rates, potentially amplified by historically limited recognition within smaller referring units of the procedural importance and clinical benefits of DBE. Indication-specific analysis showed a high odds ratio for DBE in iron-deficiency anaemia, consistent with the high diagnostic yield of SBCE in this group, while polyp detection appropriately prompted DBE for therapeutic polypectomy. In contrast, low conversion in suspected Crohn’s disease may reflect reliance on complementary evidence such as biomarkers, faecal calprotectin, and cross-sectional imaging before committing to enteroscopy.  Understanding these conversion patterns is valuable for informing service planning, optimising triage pathways, and strengthening referral practices to ensure timely access to DBE.