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Analysis of atrioventricular inflows depression keeps coming back abilify 15mg for sale, hepatic veins and inferior vena cava can also be used to assess cardiac rhythm. Primum atrial septal defect is the simplest form of the atrioventricular septal defects (see below). Secundum atrial septal defect, which are the most common, are usually isolated, but may be related to other cardiac lesions (such as mitral, pulmonary, tricuspid or aortic atresia) and are occasionally found as part of syndromes (including Holt-Oram syndrome in which there is hypoaplasia of the thumb and radius, triphalangeal thumb, abrachia, and phocomelia). Prevalence Secundum atrial septal defects, which represent about 10% of congenital heart defects, are found in about 1 per 3,000 births. Diagnosis Although the in utero identification of secundum atrial septal defect has been reported, the diagnosis remains difficult because of the physiological presence of the foramen ovale and only unusually large defects can be recognized with certainty. Prognosis Atrial septal septal defects are not a cause of impairment of cardiac function in utero, as a large right-to-left shunt at the level of the atria is a physiological condition in the fetus. They are classified into perimembranous, inlet, trabecular or outlet defects depending on their location on the septum. Perimembranous defects (80%) involve the membranous septum below the aortic valve, but also extend to variable degrees into the adjacent portion of the septum. The inlet defects are on the inflow tract of the right ventricle and thus affect the implantation of the septal chordae of the tricuspid valve. The trabecular defects occur in the muscular portion of the septum, and the outlet defects are in the infundibular portion of the right ventricle. Prevalence Ventricular septal defects, which represent 30% of all congenital heart defects, are found in about 2 per 1,000 births. Diagnosis Echocardiographic diagnosis depends on the demonstration of a dropout of echoes in the ventricular septum. Since most ventricular septal defects are perimembranous and subaortic, a detailed view of the left outflow tract is the best picture to image them. While evaluating the ventricular septum in search of defects, multiple views should be used. Overall, small isolated ventricular septal defects are difficult to detect prenatally, and both false positive and false negative diagnoses have been made. Ventricular Septal Defects In dubious cases, Color Doppler may be useful, in that many ventricular septal defects are associated with a demonstrable left to right shunt. Prognosis Ventricular septal defects are not associated with hemodynamic compromise in utero because the right and left ventricular pressures are very similar and the degree of shunting should be minimal. Large defects present with congestive heart failure at 2-8 weeks of life and require medical treatment (digoxin and diuretics). Rarely very large defects, associated with massive left to right shunt, can be associated with congestive heart failure soon after birth.
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Referral centers with special expertise in fetal echocardiography have indeed reported both false positive and false negative diagnoses great depression test answer key buy abilify 20 mg fast delivery. There is a typical association between conotruncal anomalies and 22q11 deletion, a condition associated with long term implications, including immune deficits, neurological development and speech, that may not be apparent in neonatal life. Associated cardiac lesions are present in about 50% of cases, including ventricular septal defects (which can occur anywhere in the ventricular septum), pulmonary stenosis, unbalanced ventricular size ("complex transpositions"), anomalies of the mitral valve, which can be straddling or overriding. There are three types of complete transposition: those with intact ventricular septum with or without pulmonary stenosis, those with ventricular septal defects and those with ventricular septal defect and pulmonary stenosis. Prevalence Transposition of the great arteries is found in about 1 per 5,000 births. Diagnosis Complete transposition is probably one of the most difficult cardiac lesions to recognize in utero. In most cases the four-chamber view is normal, and the cardiac cavities and the vessels have normal appearance. A clue to the diagnosis is the demonstration that the two great vessels do not cross but arise parallel from the base of the heart. The most useful echocardiographic view however is the left heart view demonstrating that the vessel connected to the left ventricle has a posterior course and bifurcates into the two pulmonary arteries. Conversely, the vessel connected to the right ventricle has a long upward course and gives rise to the brachio-cephalic vessels. Difficulties may arise in the case of huge malalignment ventricular septal defect with overriding of the posterior semilunar root. This combination makes the differentiation with double outlet right ventricle very difficult. Corrected transposition is characterized by a double discordance, at the atrio-ventricular and ventriculo-arterial level. The left atrium is connected to the right ventricle, which is in turn connected to the ascending aorta. Conversely, the right atrium is connected with the right ventricle, which is in turn connected to the ascending aorta. The derangement of the conduction tissue secondary to malalignment of the atrial and ventricular septa may result in dysrhythmias, namely complete atrioventricular block. For diagnostic purposes, the identification of the peculiar difference of ventricular morphology (moderator band, papillary muscles, insertion of the atrioventricular valves) has a prominent role. Demonstration that the pulmonary veins are connected to an atrium which is in turn connected with a ventricle that has the moderator band at the apex is an important clue, that is furthermore potentially identifiable even in a simple four-chamber view. Diagnosis requires meticulous scanning to carefully assess all cardiac connections, by using the same views described for the complete form.
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Generally phenotypic variations are due to hormonal differences between the sexes depression symptoms irritability order abilify in india. Low levels of circulating androgens in utero can cause disturbances in male sexual development, resulting in congenital abnormalities of the male reproductive tract. Later in life, this may cause reduced fertility, sexual dysfunction, decreased muscle formation and bone mineralisation, disturbances of fat metabolism, and cognitive dysfunction. Testosterone levels decrease slightly as a process of ageing: signs and symptoms caused by this decline can be considered a normal part of ageing. However, low testosterone levels are also associated with obesity and several chronic diseases, and some symptomatic patients may benefit from testosterone treatment. A quick reference document (pocket guidelines) is available, both in print and in a number of versions for mobile devices, presenting the main findings of the Male Hypogonadism Guidelines. These are abridged versions which may require consultation together with the full text versions. The recommendations provided in the current guidelines are based on a systematic literature search and review performed by the panel members. MedLine, Embase and Cochrane databases were searched to identify original articles and review articles. The expert panel reviewed these records and selected articles with the highest level of evidence in accordance with a rating schedule adapted from the Oxford Centre for Evidence-Based Medicine levels of evidence. The incidence of low testosterone and symptoms of hypogonadism in men aged 40-79 varies form 2. Hypogonadism is more prevalent in older men, in men with obesity, those with co-morbidities, and in men with a poor health status. Androgens are crucial for the development of male reproductive organs, such as the epididymis, vas deferens, seminal vesicle, prostate and penis. In addition, androgens are needed for puberty, male fertility, male sexual function, muscle formation, body composition, bone mineralisation, fat metabolism, and cognitive functions . Testosterone is needed for the stabilisation of the Wolffian ducts, resulting in formation of the epididymis, vas deferens and seminal vesicle. Under the influence of intratesticular testosterone, the number of gonocytes per tubule increases threefold during the foetal period . In addition, testosterone is needed for development of the prostate, penis and scrotum. Intratesticular testosterone is needed to maintain the spermatogenic process and to inhibit germ cell apoptosis .
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The endoscope is introduced through the mouth and advanced into the small bowel as far as possible until looping limits forward progression mood disorder nos symptoms discount abilify 20mg online. If the endoscope cannot be advanced further all forms of enteroscopy deserve consideration. Foremost, with these maneuvers, patient position can be changed mucosal inspection should be accomplished during both and abdominal pressure can be applied. If a variableinsertion and withdrawal because minor mucosal abrasions stiffness colonoscope is used, stiffening of the instrument caused by instrumentation can mimic vascular or in? The endoscope is then varies and depends on many factors including the type of advanced to the second or third portion of the duodenum, enteroscopy being performed, the approach (antegrade and loop reduction is then performed. The balPush enteroscopy may be performed with dedicated enloons are intended to anchor the endoscope in position teroscopes or by using colonoscopes. Push enteroscopes during insertion to allow for pleating of the bowel over are longer versions of standard endoscopes with a working the endoscope shaft, reducing loop formation and allowlength of 200 to 250 cm, external diameters of 10. The most commonly used system is er, the length of the instrument does not necessarily correan enteroscope with a 9. Addirepeated, and the device is advanced through the intestine tional available overtubes used with the smaller diameter in 40-cm increments (Fig. A circumferential white marking onto the enteroscope, a soft latex balloon is attached to on the enteroscope 140 cm proximal to the balloon reprethe tip of the enteroscope. This is to prevent approach, the endoscope and overtube are advanced to the overtube from shearing off the enteroscope balloon the duodenum past the major papilla, and the overtube during insertion or withdrawal (Fig. The overby pressing buttons on the front panel of the Olympus tube is then advanced into the ileum with its balloon balloon control unit or on a remote control. The overtube is backloaded onto the enteroscope, the chance of loop formation in the stomach and allows and the enteroscope is advanced as far as possible into for better contact of the spiral helix to the small intestine the small bowel, then anchored by using its? Subsequently, the overtube is advanced with ally due to loop formation in the stomach. The overcountered by continued slow clockwise rotation of the tube balloon is then in? This reduction maneuver along with application of to allow pleating of the small bowel over the enteroscope external abdominal pressure or splinting can be used to and overtube. The enteroscope is then re-advanced while advance the overtube-enteroscope unit into the small inkeeping the overtube balloon in? When resistance to further clockwise overtube of the proximal bowel that has been pleated on the overrotation is encountered and deeper advancement is not tube. When the enteroscope cannot be advanced further, thought to be possible, the enteroscope can be uncoupled its tip is again?
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In patients with deep ology as congenital bipolar depression not typical otherwise specified generic abilify 20 mg with amex, primary, or secondary; identifies vein obstruction, venous claudication can be present. It is usually and characterizes the pathophysiology as reflux, obpitting and varies markedly with the time of day and struction, both, or neither. It begins in the perimalleolar area and useful for venous severity scoring because many of its ascends the leg. Bilateral leg edema can be caused by components are relatively static and others use detailed congestive heart failure, hypoalbuminemia secondalphabetical designations. An adjunctive scoring system ary to nephrotic syndrome or severe hepatic disease, (Table 2) allows for a standardized clinical evaluation, myxedema caused by hypothyroidism, and drugs such the assessment of clinical severity, and evaluation of the as dihydropyridine calcium channel blockers and thiresponse to treatment [39-41]. Non-pitting leg edema by lipedema, which is caused by fat deposition, should also be considered. Stemmer?s sign is one of A complete history and physical examination are imthe clinical features of lymphedema. Non-invasive and invasive diagnostic testing must asVaricose veins are dilated, bulging, superfcial veins, sist the diagnosis. Comprehensive overviews with varicose veins are often asymptomatic but still have been published previously . Venous volume, C2 Varicose veins venous refilling times, maximum venous outflow, C3 Edema b segmental venous capacitance, and ejection fraction C4 Changes in skin and subcutaneous tissue can be determined [43,44]. There are four basic types of (A) Pigmentation or eczema plethysmography: impedance plethysmography, strain(B) Lipodermatosclerosis or atrophie blanche gauge plethysmography, photoplethysmography, and C5 Healed ulcer air plethysmography. Appropriate timing of image An No venous location identifed acquisition based on venous flling time is required to Pathophysiologic classifcation (P) acquire optimal images and avoid artifacts in a certain Pr Refux venous system. In addition, these techniques do not P Obstruction, thrombosis provide functional information. Next, a tourniquet or manual compression over the superficial veins is placed and the veins are obDiagnosis of venous obstruction served after the patient is asked to stand. Filling of the the diagnosis of venous obstruction can be inferred varicose veins > 20 seconds indicates that the varicose from the absence of flow, blunted augmentation, the veins are caused by superfcial venous insufciency. In presence of an echogenic thrombus within the vein, or contrast, the varicose veins will dilate promptly in the failure of the vein to collapse by a compression maneupresence of deep (or combined) venous insufciency . Small veins, Diagnosis of venous refux such as calf veins, usually do not show spontaneous Venous refux is detected by the direction of fow. An absence of spontaneous significant reverse flow toward the foot is considered flow may indicate an obstruction either proximal or venous refux (Fig. Although reverse fow constant high velocity fow without signifcant respiracan be detected without the provocation maneuver, the tory changes indicates a proximal stenosis or occlusion Valsalva maneuver or augmentation by compressing (Fig.
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The diagnosis of spina bifida has been greatly enhanced by the recognition of associated abnormalities in the skull and brain depression symptoms worse in morning purchase abilify now. These abnormalities are secondary to the Arnold-Chiari malformation and include frontal bone scalloping (lemon sign), and obliteration of the cisterna magna with either an "absent" cerebellum or abnormal anterior curvature of the cerebellar hemispheres (banana sign). These easily recognizable alterations in skull and brain morphology are often more readily attainable than detailed spinal views. A variable degree of ventricular enlargement is present in virtually all cases of open spina bifida at birth, but in only about 70% of cases in the mid-trimester. Encephaloceles are recognized as cranial defects with herniated fluid-filled or brain-filled cysts. They are most commonly found in an occipital location (75% of the cases) but alternative sites include the frontoethmoidal and parietal regions. In encephalocele the prognosis is inversely related to the amount of herniated cerebral tissue; overall the neonatal mortality is about 40% and more that 80% of survivors are intellectually and neurologically handicapped. In spina bifida the surviving infants are often severely handicapped, with paralysis in the lower limbs and double incontinence; despite the associated hydrocephalus requiring surgery, intelligence may be normal. Fetal therapy There is some experimental evidence that in utero closure of spina bifida may reduce the risk of handicap because the amniotic fluid in the third trimester is thought to be neurotoxic. Ventriculomegaly (lateral ventricle diameter of 10 mm or more) is found in 1% of pregnancies at the 18-23 week scan. Therefore the majority of fetuses with ventriculomegaly do not develop hydrocephalus. Etiology this may result from chromosomal and genetic abnormalities, intrauterine hemorrhage or congenital infection, although many cases have as yet no clear-cut etiology. Diagnosis Fetal hydrocephalus is diagnosed sonographically, by the demonstration of abnormally dilated lateral cerebral ventricles. Certainly before 24 weeks and particularly in cases of associated spina bifida, the head circumference may be small rather than large for gestation. A transverse scan of the fetal head at the level of the cavum septum pellucidum will demonstrate the dilated lateral ventricles, defined by a diameter of 10 mm or more. The choroid plexuses, which normally fill the lateral ventricles are surrounded by fluid. A distinction is usually made between mild, or borderline, ventriculomegaly (diameter of the posterior horn 10-15 mm) and overt ventriculomegaly or hydrocephalus (diameter greater than 15 mm). Prognosis Fetal or perinatal death and neurodevelopment in survivors are strongly related to the presence of other malformations and chromosomal defects. Although mild, also referred to as borderline, ventriculomegaly is generally associated with a good prognosis, affected fetuses form the group with the highest incidence of chromosomal abnormalities (often trisomy 21). In addition in a few cases with apparently isolated mild ventriculomegaly there may be an underlying cerebral maldevelopment (such as lissencephaly) or destructive lesion (such as periventricular leukomalacia).
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Active Crohn?s disese with perianal fistula 2) complex fistula is defined as a fistula located above the denetate line with multiple openings depression test cesd buy genuine abilify on-line, and/or Discussion: with abscess formation, and/or with rectovaginal fistula, Perianal fistula is an abnormal connection 3 and/or with anorectal stricture. Perianal fistula could be as an initial the natural history of fisulizing Crohn?s presentation of Crohn?s disease and preceding intestinal disease in Olmsted County, Minnesota. Hemostasis was achieved surrounded with normal mucosa in the rectum at 5 cm successfully (Figure 2-4). Surg Rectal Dieulafoy?s is an unusual source of rectal Laparosc Endosc Percutan Tech 2008;18:398-9. Majority of Dieulafoy?s lesion Recurrent massive haematemesis from Dieulafoy occur in a lesser curvature of stomach within 6 cm of vascular malformations-a review of 101 2 the gastroesophageal junction. A 59-year-old woman presented with mucous erythema, friable mucosa with ulceration and mucosal bloody diarrhea for a year. Colonoscopy revealed diffuse improved significantly after corticosteroids treatment. Severe bridging fibrosis of the colon in a man Discussion: with inflammatory bowel disease. Indian J by bridging of regenerative mucosal tissue from one wall Gastroenterol 2012;31:39. This condition carries no malignant potential and can be found in other colitis conditions including ischemic 2 colitis, infective colitis, and colonic tuberculosis. A 52-year-old man presented with bowel habit ulcerative mass with friable mucosa and easily contacts change. He lost weight about 5 kgs Computed narrowed but scope could pass through this lesion t o m o g r a p h y o f t h e a b d o m e n d e m o n s t r a t e d (Figure 2-3). Biopsy of the lesion showed complex circumferential thickened wall of the hepatic flexure of neoplastic sheets with occasional glandular formation colon, about 5. Those lining cells pericolonic fat stranding, suggestive of carcinoma (T3) contained markedly pleomorphic nuclei. Colonoscopy revealed a circumferential was well-differentiated adenocarcinoma (Figure 4). Fuji Intelligent patients with rightand left-sided colon cancer: Chromo Endoscopy and staining technique for differences in epidemiology, perioperative the diagnosis of colon tumor. He had no previous history of visible findings showed a tortuous dilated vein extending from gastrointestinal bleeding. Rectal varices are collateral vessels that connect the superior hemorrhoidal veins (inferior References mesenteric and portal circulation) with the middle and 1. Anorectal varices-their inferior hemorrhoidal veins (pudendal vein and systemic frequency in cirrhotic and non-cirrhotic portal circulation). A 46-year-old man with a history of bowel Crohn?s disease with ileocolic obstruction was clinically resection secondary to severe Crohn?s disease, entertained.
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The pressure value that is estimated to be in the range of the systolic use of dipyridamole was optional in the trial and varied and diastolic pressures anxiety pregnancy cheap abilify 20 mg without prescription. In the early post-operative period, an among centers; thus, it is no longer part of the standard arterial catheter is necessary to monitor blood pressure propanti-coagulation and anti-platelet algorithm. After the arterial catheter is removed, the arterial blood Anti-coagulation and anti-platelet therapy may need to pressure is most reliably assessed using Doppler and a sphygbe adjusted for some clinical conditions. Pressure values obtained using the Doppler infection, especially bacteremia, are associated with a method may be measured at any point during the cardiac cycle higher incidence of stroke due to increased endothelial acand should not necessarily be considered the actual systolic, 97 diastolic, or mean pressure values. Therefore, increased anti-platelet therapy may be warranted during systemic bacArterial blood pressure should be controlled with vasoterial infections. The pump speed should not be adsupport that may be severe and require that anti-coagulation justed to achieve a desired arterial blood pressure. The goal 98?101 is to maintain the mean arterial blood pressure in the range therapy be reduced or discontinued. There are anecdotal reports pressure in the desired range will optimize cardiac support. Eventuies during outpatient visits to determine if the patient?s ally, the patient?s demonstration of understanding and compepump is set at the proper speed. The fundamental features of an effective patient education program have been 10,11,107,108 V. They must also Avoid power interruption or inadvertent power lead be prepared to respond appropriately to alarm symbols and disconnection that would lead to loss of support. Loss of power will cause the pump to speed optimization and device monitoring present stop. Pump cessation may have serious consequences, espeunique challenges compared with pulsatile devices. Owing to this critical result in ventricular collapse or inlet obstruction and dependence on a continuous power supply, patient training initiate arrhythmias. Changes in ventricular shape and function and percutaneous lead from movement at the exit site. Movement of the percutaneous lead will disrupt the sub-cutanethe patient?s physiologic response to changing pump ous tissue ingrowth in the velour lining of the lead, resulting speeds will determine the appropriate speed setting. The lead should be immobimate that should be used for trending and not as a lized in the operating room with a stabilization belt or precise measurement of cardiac output. A patient?s ability to accomplish this goal in itoring and optimizing support compared with pulsatile deday-to-day life can greatly depend on the effectiveness of vices. Thus, education tics, it is not possible to cover all possible scenarios for should routinely emphasize to the patient that proper exit device management for all devices. Patients should be prompted to the presence of high afterload pressure and low pump speed. It is important to view each of these device parameters in the larger context of the patient?s overall condition.
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If one or more of the deflated balloons moves from your stomach into your intestines and cause a blockage also known as an obstruction anxiety or panic attacks generic abilify 10 mg with visa, they must be surgically taken out. Based on laboratory testing, this type of travel might cause the balloon to deflate. If the balloons deflate you may need to have an endoscopy to have them removed early from your stomach. If the balloon does not inflate completely, you will require an endoscopy to have them taken out of your stomach early. Patients either had the Obalon Balloon System placed for 6 months and received diet and exercise coaching for 12 months or just received diet and exercise coaching for 6 months. The patients who received the Obalon Balloon System and the diet and exercise coaching were chosen by chance (like flipping a coin). By chance, 198 patients received the Obalon Balloon System plus diet and exercise coaching and 189 patients received only diet and exercise coaching. Patients who just received diet and exercise coaching for 6 months were given the choice to have the Obalon Balloon System put in after they completed the first 6 months of diet and exercise coaching. All of the balloons lasted for 6 months except for 1 balloon that was found deflated at the time of removal. Patients were asked if they ever had weight loss surgery or if they could promise to stay on a diet and exercise program. They were not allowed to be in the clinical study if they ever had weight loss surgery, or said that they would not or could not follow the Obalon diet and exercise program, or if they were pregnant or breastfeeding. The balloons were put in and taken out in the clinical study in the same way and on the same times that your balloons will be put in and taken out. All clinical study patients had three-week follow up visits for 12 months where the doctor?s staff collected information on weight loss and side effects. The patients also got the diet and exercise program to help them to eat smaller amounts of food, reduce total calories and exercise regularly. Risks of the Obalon System the information in this section is based on a study of the Obalon balloons in 336 patients. It is unknown what adverse events may develop and how many patients may develop them. The harm possible from them and their frequencies are unknown based on this clinical trial. It is unknown whether they will happen and how often they will happen with more widespread use of the Obalon balloon: Possible Serious Side Effect Harm (Possible Serious Adverse Event) Any of the balloons could deflate and move from your Patient had a balloon that deflates stomach into your intestines, causing a blockage (also and moves into the intestines called intestinal obstruction), requiring surgery to remove the balloons and relieve the blockage. Any of the balloons could deflate and move from your Patient had decreased feeling stomach into your intestine (also called balloon of fullness or some abdominal migration causing blockage, or intestinal obstruction), pain and did not inform their requiring surgery to remove the balloons and relieve the doctor blockage.
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Acta Gastroenterol Belg 2003;66: enteroscopy in patients with suspected small-bowel disorders anxiety disorder treatment best abilify 15mg. Antegrade is more effeccompared with standard endoscopy for the evaluation of smalltive than retrograde enteroscopy for evaluation and management of bowel polyps in persons with familial adenomatous polyposis (with suspected small-bowel disease. Long-term outcome after endoscopy compared to push enteroscopy: 1-year follow-up study. Long-term outcome of patients in patients with non-stricturing small bowel Crohn?s disease. Am J treated with double balloon enteroscopy for small bowel vascular Gastroenterol 2006;101:954-64. Double-balloon enteroscopy and yield of capsule endoscopy compared to other diagnostic modalities capsule endoscopy have comparable diagnostic yield in smallin patients with obscure gastrointestinal bleeding. Complications of singleballoon endoscopy for the diagnosis and treatment of smallballoon enteroscopy: a prospective evaluation of 166 procedures. Novel single-balloon enterodouble-balloon enteroscopy: comparison with push enteroscopy. Prospective multicenter trial enteroscopy) of the small bowel: feasibility and diagnostic and thercomparing push-and-pull enteroscopy with the singleand doubleapeutic yield in patients with suspected small bowel disease. Clinical evaluation of a newly bowel using the double-balloon technique: results of a prospective developed single-balloon enteroscope. The clinical utility of singlediagnosis and the management of small-bowel diseases: an initial balloon enteroscopy: a single-center experience of 172 procedures. Single-balloon enteroscopy: reof double-balloon enteroscopy in a large cohort of patients with sults from an initial experience at a U. The European experience with apeutic impact of single-balloon enteroscopy: series of 106 cases. Long-term outcomes after balloon endoscopy for achieving total enteroscopy: a randomized, double-balloon enteroscopy for obscure gastrointestinal bleeding. Initial experience with double-balloon enteroteroscopy in small-bowel diagnostics: a randomized multicenter trial. Gastrointest Endosc 2001;53: training initiative: results of a prospective study evaluating the Dis216-20. Balloon-assisted enteroscopy: different high definition, confocal, and standard endoscopes [abtechnology and troubleshooting. Gastrointest Endosc antegrade approach in 3 consecutive patients by first time users of 2005;61:826-32. Curr Opin Gastroenterol 2000;16: gleand double-balloon enteroscopy by using a novel method to 121-5. Diagnostic yield of push-type encenter trial comparing oral double-balloon enteroscopy and oral teroscopy in relation to indication. Complications of double between double-balloon enteroscopy and spiral enteroscopy.