Enteroscopy in small bowel Crohn’s disease: A review

Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn’s. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial’s in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.     

Current status of single-balloon enteroscopy: Insertability and clinical applications

The single-balloon enteroscopy (SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy (DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. However, many methods have been proposed to improve the depth of insertion with the SBE system, involving several techniques and endoscopic accessories. SBE is used for investigating not only small bowel diseases, but also diseases of the pancreatobiliary and colonic structures. SBE is a necessary advancement for many endoscopic procedures and applications in modern clinical practice. In our review, we summarized the current literature concerning the insertability of SBE and described the technical aspects of improving the rate of deep insertion in SBE procedures. In addition, the recent applications of SBE to diseases besides those of the small bowel are described.     

Current state of double balloon endoscopy: The latest approach to small intestinal diseases

Recent developments of capsule endoscopy and double balloon endoscopy (DBE) have made endoscopic examination of the entire small bowel practical, and changed the diagnostic algorithm for small bowel diseases. Double balloon endoscopy uses two balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops of intestine. Total inspection by DBE is usually achieved by combination of sequential oral and anal intubations; success rates are reported to be 40–80%. Indications for DBE include scrutiny for obscure gastrointestinal bleeding, small bowel tumor, small bowel stricture and following up evaluation of previously diagnosed small bowel diseases. Because DBE has an accessory channel and good maneuverability in the distal small intestine, it enables endoscopic treatment, including hemostasis, balloon dilation, polypectomy, mucosal resection, retrieval of foreign bodies and endoscopic retrograde cholangiopancreatography (in the case of post-operative anastomoses). Double balloon endoscopy is also useful for cases of difficult colonoscopy, providing success rates of total colonoscopy between 88–100%. Although it has been a few years since its development, the usefulness of DBE is now well recognized. This challenging procedure has become popular rapidly and is currently used in many countries.     

气囊辅助式小肠镜检查相关胰腺炎和高淀粉酶血症的临床研究

目的探讨单气囊小肠镜（SBE）、双气囊小肠镜（DBE）检查与胰腺炎、高淀粉酶血症并发症的相关性。方法连续收集2011年9月至2012年12月间56例行SBE和DBE检查患者的临床资料,按气囊辅助式小肠镜类型及进镜途径进行分组（即分成SBE经口组、SBE经肛组、DBE经口组和DBE经肛组）并整理数据,统计分析气囊辅助式小肠镜类型及进镜途径对镜检相关胰腺炎、高淀粉酶血症并发症发生率的影响。结果SBE经口组19例,发生镜检相关高淀粉酶血症12例（63．16％）、胰腺炎1例;SBE经肛组12例,发生镜检相关高淀粉酶血症2例（16．67％）,无镜检相关胰腺炎发生;DBE经口组15例,发生镜检相关高淀粉酶血症11例（73．33％）,无镜检相关胰腺炎发生;DBE经肛组10例,无镜检相关高淀粉酶血症、胰腺炎发生。术后高淀粉酶血症发生率,SBE经口组与SBE经肛组比较（P=0．009）、DBE经口组与DBE经肛组比较（P=0．001）差异均有统计学意义,而SBE经口组与DBE经口组比较（P=0．415）、SBE经肛组与DBE经肛组比较（P=0．558）差异无统计学意义。结论气囊辅助式小肠镜检查术后较易并发高淀粉酶血症,经口途径较经肛途径更易并发,而是否易发与气囊辅助式小肠镜类型无关;至于气囊辅助式小肠镜检查与术后胰腺炎的相关性,由于样本量太少,未能得出有价值的临床结论。     

Antegrade Double Balloon Enteroscopy for Continued Obscure Gastrointestinal Bleeding Following Push Enteroscopy: Is There A Role?

Background  

The benefit of double balloon endoscopy (DBE) over push enteroscopy (PE) for the proximal small bowel in patients with obscure gastrointestinal bleeding remains unclear.     

Double Balloon Enteroscopy Detects Small Bowel Mass Lesions Missed by Capsule Endoscopy

BACKGROUND: Small bowel mass lesions (SBML) are a relatively common cause of obscure gastrointestinal bleeding (OGIB). Their detection has been limited by the inability to endoscopically examine the entire small intestine. This has changed with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE) into clinical practice. STUDY AIM: To evaluate the detection of SBML by DBE and CE in patients with OGIB who were found to have SBML by DBE and underwent both procedures. METHODS: A retrospective review of a prospectively collected database of all patients undergoing DBE for OGIB at seven North American tertiary centers was performed. Those patients who were found to have SBML as a cause of their OGIB were further analyzed. RESULTS: During an 18 month period, 183 patients underwent DBE for OGIB. A small bowel mass lesion was identified in 18 patients. Of these, 15 patients had prior CE. Capsule endoscopy identified the mass lesion in five patients; fresh luminal blood with no underlying lesion in seven patients, and non-specific erythema in three patients. Capsule endoscopy failed to identify all four cases of primary small bowel adenocarcinoma. CONCLUSIONS: Double balloon enteroscopy detects small bowel mass lesions responsible for OGIB that are missed by CE. Additional endoscopic evaluation of the small bowel by DBE or intraoperative enteroscopy should be performed in patients with ongoing OGIB and negative or non-specific findings on CE.     

Enteroscopy

Until the end of the 20th century, push enteroscopy (PE) was the most commonly used method for the endoscopic investigation of the small bowel. However, PE has been almost completely replaced by double balloon enteroscopy (DBE). Undoubtedly the major endoscopic breakthrough of the last decade, DBE has contributed to the better diagnosis and understanding of diseases of the small bowel, opening-up this obscure part of the gastrointestinal tract to visualisation. Modern diagnostic and therapeutic DBE allows for a deeper and more thorough evaluation of the small bowel than PE, enabling the detection of more pathological lesions. In addition, DBE has for the first time enabled endoscopists to observe the entire small intestine, and has provided endoscopic interventions such as cauterisation of bleeding lesions, polypectomy, placement of small bowel stents, and foreign-body extraction.     

Device-assisted enteroscopy: A review of available techniques and upcoming new technologies

The advent of video capsule endoscopy into clinical routine more than 15 years ago led to a substantial change in the diagnostic approach to patients with suspected small bowel diseases, often indicating a deep enteroscopy procedure for diagnostical confirmation or endoscopic treatment. Device assisted enteroscopy was developed in 2001 and for the first time established a practicable, safe and effective method for evaluation of the small bowel.Currently with double-balloon enteroscopy, single-balloon enteroscopy and spiral enteroscopy three different platforms are available in clinical routine.Summarizing, double-balloon enteroscopy seems to offer the deepest insertion depth to the small bowel going hand in hand with the disadvantage of a longer procedural duration. Manual spiral enteroscopy seems to be a faster procedure but without reaching the depth of the DBE in currently available data. Finally,single-balloon enteroscopy seems to be the least complicated procedure to perform. Despite substantial improvements in the field of direct enteroscopy,even nowadays deep endoscopic access to the small bowel with all available methods is still a complex procedure, cumbersome and time-consuming and requires high endoscopic skills. This review will give an overview of the currently available techniques and will further discuss the role of the upcoming new technology of the motorized spiral enteroscopy(PowerSpiral).     

Small Bowel Enteroscopy and Intraoperative Enteroscopy for Obscure Gastrointestinal Bleeding

Intraoperative endoscopy (IOE) is accepted as the ultimate diagnostic procedure for completely evaluating the small bowel in patients with obscure gastrointestinal (GI) bleeding. Small bowel enteroscopy (SBE) has been reported useful in the nonsurgical evaluation of the small intestine in these patients, but findings may be limited because of incomplete small bowel intubation and a lack of tip deflection. Twenty-three patients underwent 25 SBE exams and subsequently had 25 IOE exams during surgical exploration for continued bleeding. Patients' bleeding histories averaged 2 yr, with an average transfusion requirement of 27 units. Findings on IOE were the same as with SBE in 17/22 (77%) of examinations. We conclude that SBE and IOE are comparable in depth of insertion and ability to detect small vascular ectasias. Both procedures missed pathology due to limited visibility and the evanescent nature of ectasias. Long-term success in abolishing bleeding with these combined techniques can be expected in 55% of these patients. SBE should precede surgery, since the finding of diffuse ectasias precludes any benefit from operative intervention.     

Dünndarmendoskopie

Since the introduction of capsule endoscopy and later balloon enteroscopy in clinical practice, endoscopic examination of the small bowel has dramatically improved. For the first time, it is possible to diagnose the whole small bowel without the necessity of laparotomy and intraoperative enteroscopy. The methods revolutionized the field of small bowel diagnostic and therapy and become part of daily clinical practice. This article provides a review of small bowel enteroscopic methods.     

DIAGNOSIS AND TREATMENT OF SMALL BOWEL DISEASES WITH A NEWLY DEVELOPED SINGLE BALLOON ENDOSCOPE

Background: Recent advances in capsule endoscopy (CE) and double balloon endoscopy (DBE) have enabled an endoscopic approach to small bowel diseases. However, CE is simply a diagnostic tool and DBE is fairly complicated to handle. Methods: We developed a single balloon endoscopy (SBE) in cooperation with Olympus Medical Systems. The single balloon enteroscope consists of an endoscope and a splinting tube. In this system, a balloon is attached to the splinting tube, but not to the scope itself. The single‐person insertion method was effective for SBE cases, but two persons were needed for DBE. The patients we examined had undergone upper and lower gastrointestinal endoscopy and were suspected of having small intestinal diseases. We examined a total of 30 cases (nine women, 21 men; range 19–78 years), and carried out a total of 48 examinations. Results: In fifteen cases, the cause of bleeding was diagnosed as either ulcer, angiodysplasia, Crohn's disease, inflammatory polyp, or metastatic cancer, but in eight cases, the cause was not identified. Four obstruction cases comprised ulcers, adhesion, and jejunal volvulus. For treatment, clippings were performed for bleeding in three patients, polypectomy for two, reversal of volvulus for one, and balloon dilation for ilial stenosis in one. The entire small intestine was observed in 71% of patients when the intention was to examine the whole bowel. No complications were encountered. Conclusions: The newly developed SBE is useful for diagnosis and treatment of small bowel diseases.     

Small bowel enteroscopy

Over the past decade, the advent of capsule endoscopy and balloon-assisted enteroscopy has revolutionized the approach to small intestinal diseases. The small bowel is no longer out of reach, and has fallen within the diagnostic and therapeutic realm of the gastrointestinal endoscopist. Double-balloon enteroscopy was the first type of balloon-assisted endoscopy and is the method for which there are the most data. Single-balloon enteroscopy has since been introduced as an alternative balloon-assisted method, followed more recently by the development of spiral overtube-assisted enteroscopy. The purpose of the present article is to review these methods of small bowel enteroscopy and to discuss the latest developments. While the investigation of small bowel diseases cannot be addressed without considering the central role of capsule endoscopy, a detailed assessment is beyond the scope of the present article, and capsule endoscopy will only be discussed as it pertains to enteroscopy.     

Conservative approach in Peutz-Jeghers syndrome: Single-balloon enteroscopy and small bowel polypectomy

AIM: To assess the usefulness of the balloon assisted enteroscopy in preventing surgical intervention in pa-tients with Peutz-Jeghers syndrome (PJS) having a small bowel large polyps. METHODS: Seven consecutive asymptomatic pts(age 15-38 years) with PJS have been collected; six under-went polypectomy using single balloon enteroscopy(Olympus SIF Q180) with antegrade approach using push and pull technique. SBE system consists of the SIF-Q180 enteroscope, an overtube balloon control unit(OBCU Olympus Balloon Control Unit) and a dispos-able silicone splinting tube with balloon(ST-SB1). All procedures were performed under general anesthesia. Previously all pts received wireless capsule endos-copy(WCE). Prophylactic polypectomy was reservedmainly in pts who had polyps 15 mm in diameter. The balloon is inflated and deflated by a balloon control unit with a safety pressure setting range from-6.0 kPa to +5.4 kPa. Informed consent has been obtained from pts or parents for each procedure.RESULTS: Six pts underwent polypectomy of small bowel polyps; in 5 pts a large polyp 15 mm(range 20-50 mm in diameter) was resected; in 1 patient with WCE negative, SBE was performed for previous surgi-cal resection of gastrointestinal stromal tumors. In 2 pts endoscopic clips were placed due to a polypectomy. No surgical complication have been reported. SBE with resection of small bowel large polyps in PJS pts was useful to avoid gastrointestinal bleeding and emergency laparotomy due to intestinal intussuscep-tions. No gastrointestinal tumors were found in sub-sequent enteroscopic surveillance in all seven pts. In order surveillance, all pts received WCE, upper en-doscopy, ileocolonoscopy every 2 years. No pts had extraintestinal malignant lesions. SBE was performed when WCE was positive for significant polyps( 15 mm).CONCLUSION: The effective of prophylactic polyp-ectomy of small bowel large polyps( 15 mm) could be the first line treatment for conservative approach in management of PJS patients.     

胶囊内镜与单气囊小肠镜对可疑小肠疾病的诊断价值

目的比较胶囊内镜与单气囊小肠镜对小肠疾病的诊断价值。方法 2009年6月-2011年12月共有37例疑诊为小肠疾病的患者接受了胶囊内镜(CE)和单气囊小肠镜(SBE)检查。比较两种检查方法对小肠疾病的检出情况。结果在37例患者中,CE检查发现阳性病变28例,总体诊断率为75.68%(28/37),SBE检查发现阳性病变33例,总体诊断率为89.19%(33/37),两者之间差异无统计学意义(P=0.221)。CE和SBE检查结果不一致,CE检查阳性而SBE检查阴性3例,CE检查阴性而SBE检查阳性8例,CE和SBE检查均阴性1例。CE全小肠检查完成率为94.59%(35/37);SBE全小肠检查完成率为57.14%(4/7)。两种检查方法均未发生严重并发症。结论胶囊内镜和单气囊小肠镜对小肠疾病的诊断价值相当。     

Spiral enteroscopy: Prime time or for the happy few?

Spiral enteroscopy is the newest of the deep enteroscopy techniques. The current technique employs an overtube with a raised spiral at the distal end to pleat the small intestine and achieve deep small bowel intubation. Although spiral enteroscopy is a novel technique, the learning curve is comparable to the balloon enteroscopy techniques. There is some evidence of improved speed of spiral enteroscopy procedures with superior control compared to the balloon endoscopy technologies. Altered surgical anatomy deep enteroscopy has been shown to have similar safety and efficacy to competitive technologies, particularly in cases of Roux-en-Y ERCP cases. Spiral enterosopy is safe and effective for deep small bowel enteroscopy and diagnostic yield and therapeutic yields are similar to alternate technologies. There are bright future applications of the technology with enteroscopes and an integrated spiral. Spiral enteroscopy is an advanced technique that can be performed by any skilled endoscopist.     

Small bowel tuberculosis diagnosed by the combination of video capsule endoscopy and double balloon enteroscopy

Small bowel tuberculosis is sometimes encountered in oriental countries, and because its symptoms are vague and present a nonspecific pattern, confirmative diagnosis is difficult to achieve. In 2001, two new innovative endoscopic techniques for the small bowel, video capsule endoscopy and double balloon enteroscopy, were introduced, thus advancing the diagnostic technology for small bowel disorders. Our asymptomatic patient with small bowel tuberculosis was diagnosed definitively using the combination of video capsule endoscopy and double balloon enteroscopy. The number of such cases will increase when those procedures become more widely used. At present, the endoscopic view of small bowel tuberculosis is difficult to differentiate from Crohn's disease and drug-induced enteropathy, but from now on it will be possible to distinguish them utilizing endoscopic and fluoroscopic images. On the basis of the characteristics of small bowel tuberculosis with its endoscopic images, referring to our case report and previous literature, we report a topical diagnostic procedure, the combination of video capsule endoscopy and double balloon enteroscopy.     

Exploring the Small Bowel: Update on Deep Enteroscopy

Deep enteroscopy allows for the diagnosis and treatment of small bowel disorders that historically required operative intervention. There are a variety of endoscopic platforms using balloons and rotational overtubes to facilitate small bowel intubation and even allow for total enteroscopy. Obscure gastrointestinal bleeding is the most common indication for deep enteroscopy. By visualizing segments of the small bowel not possible through standard EGD or push enteroscopy, deep enteroscopy has an established high rate of identification and treatment of bleeding sources. In addition to obscure bleeding, other common indications include diagnosis and staging of Crohn’s disease, evaluation of findings on capsule endoscopy and investigation of possible small bowel tumors. Large endoscopy databases have shown deep enteroscopy to be not only effective but safe. Recent research has focused on comparing the diagnostic rates, efficacy, and total enteroscopy rates of the different endoscopic platforms.     

Diagnosis and treatment of small bowel diseases are advanced by capsule endoscopy and double-balloon enteroscopy

In 2001, new endoscopic procedures for the small bowel, capsule endoscopy (CE) and double-balloon enteroscopy (DBE), were introduced into regular clinical practice. These methods were significant breakthroughs for imaging examination of the small bowel. The methods have different characteristics with regard to their approach into the target organ; however, common to both is the feature of enabling rapid total observation of the small bowel. CE is the first safe, non-invasive well-tolerated procedure and can be performed in any condition. The examination time is about 8 h and the patient can spend the time freely. CE can demonstrate active bleeding or neoplasm in the small bowel, which other modalities cannot detect. DBE, which was developed by Yamamoto, employs two balloons combined with an overtube and allows deeper insertion into the small bowel, and can be a modality for examination of the entire small bowel with combined oral and anal approaches. This modality enables biopsy specimens to be taken, polyps to be resected and hemostatic procedures to be performed throughout the small bowel. The understanding of small bowel disease is being extended by using CE and DBE for diagnosis. CE is considered to be superior for the first examination of the small bowel and DBE is useful for detailed examination and endoscopic therapy. Further clinical study of unknown small bowel disorders using these two modalities and algorithms for the management of small bowel disorders are required.     

Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy using balloon-assisted enteroscope

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy involves challenging procedures for ERCP endoscopists. In these patients, the anatomical structure of the intestine is substantially altered, and an endoscope needs to be inserted into the long afferent limb. Moreover, the papilla is observed in the opposite view from the normal anatomy. Recently, a balloon-assisted enteroscope (BAE) has been developed and made available for use in daily practice. The two types of BAE are single-balloon enteroscope (SBE), which is inserted with one balloon attached to the overtube using a balloon-assisted method, and double-balloon enteroscope (DBE), which is inserted with two balloons, one attached to the overtube and the other attached to the tip of the enteroscope. In addition, short-type DBE (short-DBE) and short-type SBE (short-SBE) with a working length of approximately 150 cm, which could be used with various ERCP accessories, are commercially available or under development. Notably, the success rate of ERCP through coordinated manipulation with a balloon was remarkably improved with the use of BAE, even in patients with surgically altered anatomy. Here, we report the current status and procedures of ERCP in patients with surgically altered anatomy.     

双气囊小肠镜与胶囊内镜诊断小肠出血病因比较

目的比较双气囊小肠镜和胶囊内镜在小肠出血中的诊断准确率和实用价值。方法24例原因不明的可疑小肠出血患者分别接受双气囊小肠镜和胶囊内镜检查。双气囊小肠镜首选进镜方式分为经口或经肛2种，首选方式检查后未发现病灶者，日后改换进镜方式再行检查。胶囊内镜采用以色列GIVEN公司产品。2种检查方法分别由专门医师独立操作并诊断，最后进行汇总比较。结果24例患者中21例通过小肠镜检查发现病灶，总检出率为87．5％。24例患者行胶囊内镜检查后，有阳性发现者11例(45．8％)，另13例无异常发现。双气囊小肠镜检查发现的阳性病灶均经活检病理和手术探查证实，其病因诊断准确率为87．5％，胶囊内镜诊断准确率为25％。在耐受性评估方面，胶囊内镜和全麻下经口进镜的耐受性最佳，以后依次为非麻醉经肛方式和非麻醉经口方式。所有小肠镜和胶囊内镜检查者中未见操作相关的严重不良反应。结论①经口和经肛方式结合能使双气囊小肠镜完成对全小肠的检查。②双气囊小肠镜在不明原因小肠出血的病因诊断方面明显优于胶囊内镜检查。③胶囊内镜在小肠多节段病变和长段病变的诊断上仍有一定价值。④胶囊内镜和全麻下经口双气囊小肠镜检查是一项易为患者接受的、安全的检查方法。