Push-and-pull enteroscopy using the double-balloon technique/double-balloon enteroscopy

Push-and-Pull enteroscopy/Double balloon enteroscopy (PPE/DBE) allows enteroscopy of the entire small bowel, or at least a substantial part of it. The complication rate is acceptably low. Severe complications such as pancreatitis and perforation were encountered in the literature in approximately 1% of all diagnostic PPE/DBEs. It can be expected that the complication rate of therapeutic PPE/DBEs is higher, comparable with the conventional endoscopy. The diagnostic yield is high, at approximately 75%, as is the therapeutic yield. The option of carrying out endoscopic therapy (in approximately 40%–50% of cases in the Western hemisphere) is an important aspect. Angiodysplasias are the main bleeding source, at least in Western countries. Using the PPE/DBE device, endoscopic treatments such as endoscopic hemostasis using injection and argon plasma coagulation, polypectomy, endoscopic resection, balloon dilation, and foreign-body extraction have become feasible even in the small intestine and can generally be performed safely and without relevant technical problems. Medical therapy can be started in up to 20% of cases—e.g., after a new or changed diagnosis of Crohn's disease. Surgical therapy is required in 10–20% of cases, due to malignant tumors or complex stenoses, for example. The main indication is mid-gastrointestinal bleeding.     

Usefulness of EUS with double-balloon enteroscopy for diagnosis of small-bowel diseases

BACKGROUND: Until recently, EUS of the small bowel has been performed only in limited regions because of difficulties in endoscopically approaching the small bowel. Double-balloon enteroscopy (DBE) now permits investigation of the entire small bowel. OBJECTIVE: To evaluate the usefulness of EUS with DBE for diagnosis of small-bowel diseases. DESIGN: Pilot study. SETTING: All patients were examined at Hiroshima University Hospital. PATIENTS: EUS with DBE was performed in 20 consecutively analyzed patients (14 men, 6 women; mean age, 47.6 +/- 3.8 years). DBE was performed to investigate obscure GI bleeding (n = 12), small-bowel diseases suggested by other modalities (n = 7), recurring ileus (n = 1), or follow-up (n = 1). INTERVENTIONS: Endoscopic biopsies were performed as clinically indicated. MAIN OUTCOME MEASUREMENTS: EUS image quality for various types of small-bowel diseases and comparison with abdominal US. RESULT: Protruding lesions were detected in 7 examinations, ulcerative lesions in 7, and no abnormalities in 7. EUS could be performed in 20 of 21 examinations. These images were adequately detailed evaluations and with more detail than US images in 16 examinations. LIMITATION: Small nonblinded study. CONCLUSIONS: EUS with DBE offers high-resolution cross-sections of small-bowel lesions and may contribute to the diagnosis of small-bowel diseases.     

A pedunculated polyp-shaped small-bowel lymphangioma causing gastrointestinal bleeding and treated by double-balloon enteroscopy

We report a rare case of a small-bowel lymphangioma causing massive gastrointestinal (GI) bleeding that we successfully diagnosed and treated using double-balloon enteroscopy (DBE). An 81-year-old woman suffering from repeated GI bleeding of unknown origin underwent a capsule endoscopy at a previous hospital. She was suspected of having bleeding from the jejunum, and was referred to our department for diagnosis and treatment. An oral DBE revealed a 20 mm × 10 mm, regularly surfaced, white to yellowish, elongated, pedunculated jejunal polyp with small erosions at 10 cm distal to the ligament of Treiz. Since no other source of bleeding was identified by endoscopy in the deep jejunum, an endoscopic polypectomy (EP) was performed for this lesion. A subsequent histopathological examination of the resected polyp showed clusters of lymphatic vessels with marked cystic dilatation in the submucosa and the deep layer of the lamina propria mucosae. These characteristics are consistent with the typical features of small-bowel lymphangioma with erosions. Although clipping hemostasis was performed during EP, re-bleeding occurred. Finally, a complete hemostasis was achieved by performing an additional argon plasma coagulation.     

Laparoscopic-assisted double-balloon enteroscopy for small-bowel polyp surveillance and treatment in patients with Peutz-Jeghers syndrome

BACKGROUND: Surveillance and treatment of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS) can be challenging and may require intraoperative enteroscopy. While initial reports that used double-balloon enteroscopy (DBE) for the resection of small-bowel polyps in patients with PJS appear promising, complete enteroscopy when using this technique may require multiple procedures or may not be possible at all. OBJECTIVE: To develop a single-procedure approach to the surveillance and the treatment of small-bowel polyps in patients with PJS. DESIGN: Retrospective review. SETTING: Single, North American tertiary-care center. PATIENTS: Individuals with PJS and small-bowel polyps identified by other modalities. INTERVENTIONS: DBE was combined with laparoscopy as a single-procedure surveillance and therapeutic strategy for small-bowel PJS polyps. MAIN OUTCOME MEASUREMENTS: Completion of enteroscopy, number of polyps resected, procedure duration, complications. RESULTS: Three patients with a history of PJS and known small-bowel polyps underwent laparoscopic-assisted DBE (LADBE). Complete enteroscopy was performed, and all polyps larger than 0.5 cm were resected endoscopically. No cases of cancer or dysplasia were noted; procedure times lasted from 1 to 4 hours. Postoperative complications included ileus in 2 patients. LIMITATIONS: Small sample size, single-center experience. CONCLUSIONS: LADBE holds promise as a new technique that can be used as both a surveillance and a therapeutic tool for small-bowel polyps in patients with PJS.     

Evaluation of deep small bowel involvement by double-balloon enteroscopy in Crohn's disease

OBJECTIVES: Double-balloon enteroscopy (DBE) enables inspection of deep small bowel, and total small bowel examination can be performed by either antegrade or retrograde DBE. The aim of this study was to evaluate ileal involvement, which cannot be achieved using conventional colonoscopy, by DBE in patients with Crohn's disease. METHODS: From December 2003 to September 2005, a total of 44 patients with Crohn's disease underwent 53 examinations using DBE. RESULTS: Forty patients with Crohn's disease, seven women and 33 men, underwent DBE, and the ileum was investigated in 38 patients. There were 25 cases of ileitis, 2 of colitis, and 13 of ileocolitis. Jejunal lesions were found in two and ileal lesions proximal to the terminal ileum were found in 24 patients with Crohn's disease. DBE was superior to radiological study to detect aphthae, erosions, and small ulcers in the ileum. Small bowel stricture was demonstrated in six and nine patients with DBE and small bowel barium study (SBBS), respectively. An additional mucosal finding was demonstrated in one of the eight patients who underwent wireless capsule endoscopy, and one patient had a capsule removed by DBE that had become lodged because of an ileal stricture. One ileal perforation because of overtube balloon pressure occurred in 53 examinations of patients with Crohn's disease (1.9%). CONCLUSION: DBE is useful to evaluate small bowel lesions in patients with Crohn's disease; however, special attention should be paid to mesenteric longitudinal ulcers during insertion and the overtube balloon should not be inflated if a clear intestinal view is not possible.     

双气囊小肠镜在小肠克罗恩病中的诊断价值研究

目的 探讨双气囊小肠镜在小肠克罗恩病(CD)诊断中的价值.方法 回顾性总结141例临床怀疑小肠CD行双气囊小肠镜检查患者的临床资料,以病理诊断结合内镜表现和临床随访结果为最终诊断结果,对比分析小肠CD双气囊小肠镜、CT小肠成像以及胶囊内镜的检出率和确诊率.结果 双气囊小肠镜检出小肠CD 128例,检出率为90.8％( 128/141),最终经病理及临床随访确诊126例,确诊率为98.4％ (126/128);CT小肠成像检出小肠CD 19例,检出率为76.0％( 19/25),最终经病理及临床随访确诊17例,确诊率为89.5％ (17/19);胶囊内镜镜检出小肠CD 15例,检出率为60.0％( 15/25),最终经病理及临床随访确诊14例,确诊率为93.3％ (14/15).双气囊小肠镜组小肠CD检出率和确诊率均高于胶囊内镜和CT小肠成像.结论 双气囊小肠镜在小肠CD诊断中具有较好的应用价值,对存在内镜检查禁忌证者CT小肠成像可作为首选辅助检查手段.     

Performance of antegrade double-balloon enteroscopy: comparison with push enteroscopy

BACKGROUND: Double-balloon enteroscopy (DBE) is a novel procedure for the diagnosis of small-bowel pathology. The aim of this retrospective study was to compare the performance and the diagnostic value of antegrade DBE with those of push enteroscopy (PE). METHODS: We reviewed endoscopic and histologic findings in 118 patients examined by PE or antegrade DBE during a period 1980 to 2004. The maximal length of insertion under plain radiograph was compared between patients examined by PE and those examined by antegrade DBE. Diagnostic yield was compared among patients stratified by indication for enteroscopy and the duodenal pathology. RESULTS: Ninety-one patients were examined by PE and 27 patients by antegrade DBE. Length of insertion from the ligament of Treitz was significantly greater in antegrade DBE (median, 92 cm; range, 40-144 cm) than in PE (median, 22 cm; range, 0-98 cm; p < 0.0001). In 90 nonbleeding patients with inflammatory or miscellaneous diseases or polyposis, the diagnostic yield was not different between PE and antegrade DBE (64% vs. 82%, p = 0.13). However, it was higher in antegrade DBE (79%) than in PE (31%, p = 0.012) in nonbleeding patients without duodenal pathology. In bleeding patients, the diagnostic yield was 40% in antegrade DBE and 36% in PE (p = 0.61). CONCLUSIONS: Antegrade DBE is superior to PE in exploration of the small intestine and in diagnostic yield for small-intestinal pathology.     

Impact of double-balloon enteroscopy findings on the management of Crohn's disease

Abstract

Objective. It is estimated that 10%–30% of Crohn's disease (CD) patients have small-bowel lesions, but the exact frequency and clinical relevance of these findings are unknown. Double-balloon enteroscopy (DBE) enables endoscopic visualization of the small bowel. The aim of this study was to evaluate the use of DBE for detecting small-bowel lesions in CD patients suspected of having small-bowel involvement. Furthermore, the clinical impact of adjusting treatment in these patients was assessed. Material and methods. A prospective study was performed in a tertiary referral center. CD patients suspected of small-bowel involvement and in whom distal activity had previously been excluded were included. All patients underwent DBE, followed by step-up therapy in patients with small-bowel lesions. The presence of small-bowel lesions during DBE was noted and clinical outcome was assessed after adjusting therapy. Results. Thirty-five patients (70%) showed small-bowel lesions; these lesions could not be assessed by conventional endoscopy in 23 (46%). At 1-year follow-up, step-up therapy in 26 patients (74%) led to clinical remission in 23 (88%). This was confirmed by a significant decrease in Crohn's disease activity index and mucosal repair on second DBE. Conclusions. DBE showed a high frequency of small-bowel lesions in known CD patients with clinically suspected small-bowel activity. Most of these lesions were not accessible for conventional endoscopy. Adjusting treatment in patients with small-bowel CD involvement led to clinical remission and mucosal repair in the majority of cases.     

胶囊内镜结合双气囊内镜检查在小肠疾病诊断中的作用

目的 探讨胶囊内镜结合双气囊内镜检查在小肠疾病诊断中的作用.方法 连续调查299例因不明原因消化道出血或腹痛、腹泻等原因而行胶囊内镜检查者,对胶囊内镜阴性或诊断不确定者建议双气囊内镜检查.分析胶囊内镜后双气囊内镜检查者诊断和随访资料.结果 296例完成胶囊内镜检查,发现阳性138例(46.6%),可疑阳性68例(23.0%),阴性90例(30.4%).45例胶囊内镜可疑阳性者和7例阴性者接受双气囊内镜检查,分别检出31例和1例小肠病变.双气囊内镜可能存在假阴性结果8例,未发现假阳性者;胶囊内镜可能存在假阴性结果2例,并有8例假阳性.在胶囊内镜结果提示下,90.3%(28/31)患者经单侧双气囊内镜检查即发现病灶.平均随访期为17个月,93.5%的双气囊内镜明确诊断者得到有效治疗.二种检查方法耐受性好,无严重不良反应发生.结论 胶囊内镜对小肠病变检出率高,但其诊断不确定性也较高.双气囊内镜能明确大部分胶囊内镜可疑阳性者.胶囊内镜结合双气囊内镜检查的诊断策略能提高小肠疾病诊断率、指导治疗并改善患者预后.