Small-bowel (SB) bleeding and iron-deficiency anemia (IDA) are the most frequent indications for double-balloon enteroscopy (DBE) (1). Angioectasias are a leading cause of SB bleeding, yet factors influencing their detection remain unclear. This study assessed the diagnostic and therapeutic performance of DBE in SB bleeding/IDA and examined whether antiplatelet or anticoagulant therapy affects the likelihood of identifying angioectasias.

All consecutive DBE procedures performed for SB bleeding/IDA between July 2023 and October 2025 were retrospectively reviewed from our prospectively maintained institutional database. Procedural characteristics, endoscopic findings, therapeutic interventions, route of insertion, need for opposite-route access, panenteroscopy rates, complications, and need for repeat DBE were extracted. Associations between antithrombotic therapy (antiplatelets, anticoagulants) and detection of angioectasias were evaluated using contingency analysis with odds ratios (OR) and 95% confidence intervals (CI).

A total of 178 DBE procedures were performed in 107 patients (median age 67 years, IQR 57–74;39.3% female), of whom 88.8% had prior evaluation with cross-sectional imaging or capsule endoscopy. Procedures were performed via the anterograde (84.3%) or retrograde (15.7%) route;18.0% of patients had surgically altered anatomy. Procedure completion rate was 97.2%, and a definitive clinical impression was achieved in 97.8%. 

Angioectasias were the most common finding (49.4%), followed by inflammation/ulceration (10.1%), Dieulafoy lesions (8.4%), mass/submucosal tumors (3.4%) and SB varices (2.8%); 18.5% of examinations were normal. Opposite-route enteroscopy was required in 16.9% of procedures, and panenteroscopy was achieved in 7.9%, corresponding to 30.8% of patients requiring both routes.

Therapeutic intervention was performed in 71.9% of cases, with 100% technical success and a 0.6% complication rate. At the patient level, 27.1% required at least one repeat DBE. Anticoagulant use was not associated with angioectasia detection (OR 0.92; 95% CI 0.43–2.01), whereas antiplatelet therapy was significantly associated with higher odds of detecting angioectasias (OR 2.10; 95% CI 1.10–4.01; p=0.036).

DBE demonstrated high diagnostic and therapeutic yields with an excellent safety profile in patients investigated for SB bleeding/IDA. Angioectasias were the predominant finding accounting for half of all cases, and were significantly more frequently detected in patients receiving antiplatelet therapy—suggesting that antiplatelets may unmask underlying vascular lesions. In contrast, anticoagulants showed no such association. Despite the complexity of this cohort—reflected by the need for opposite-route access and repeat procedures—DBE remained consistently feasible, effective, and safe. These findings reinforce DBE as a key modality for confirming and treating the causes of small-bowel bleeding.