Obstructing small bowel bezoars due to an agar diet: diagnosis using double balloon enteroscopy

Primary small bowel bezoars are rare and may cause acute abdomen due to small bowel obstruction (SBO). A 70-year-old Japanese woman presented to the emergency room with abdominal pain, nausea and vomiting. The patient reported that she had eaten a large amount of highly-concentrated, agar dissolved in boiling water two days prior to presentation. Double balloon enteroscopy (DBE) revealed that white-colored, hard bezoars were clogged in the jejunum. At surgery, many bezoars were found impacted in the distal jejunum, and enterotomy was performed. The bezoars were elastic hard, crystallized objects. These bezoars were considered to have formed from highly-concentrated, dissolvable agar.     

Comparison of double balloon enteroscopy and small bowel series for the evaluation of small bowel lesions]

BACKGROUND/AIMS: The role of double balloon enteroscopy (DBE) is still evolving. The aim of this study was to compare the diagnostic yield of DBE with that of small bowel series (SBS). METHODS: We enrolled patients with suspected small bowel disease consecutively, and performed both DBE and SBS in all patients. RESULTS: Eighteen patients (M:F=12:6, 14-82 years) were included. Indications for small bowel evaluation were obscure gastrointestinal bleeding (10), abdominal pain (5), diarrhea (2) and abnormal CT finding (1). Of 10 obscure gastrointestinal bleeding patients, 6 showed the same findings in both studies. However, 4 showed negative findings in SBS while DBE detected erosions or ulcerations. Of 5 abdominal pain patients, 3 showed the same results in both studies. However, 2 demonstrated different results. One was suspected of early Crohn's disease in SBS, but proved to be normal in DBE, and the other was suspected of malignancy in SBS but was suspected of benign ulcers in DBE. Of 2 chronic diarrhea patients, one was diagnosed as Crohn's disease in both studies. The other was suspected of tuberculosis in SBS but diagnosed as lymphangiectasia by DBE with biopsy. One patient with jejunal wall thickening in CT proved to be normal in both DBE and SBS. There were no serious complications associated with DBE and SBS. CONCLUSIONS: DBE is better than SBS in terms of diagnostic accuracy. DBE may become an important method for the evaluation of small bowel diseases.     

单气囊小肠镜在小肠疾病诊断中的应用

目的评价单气囊小肠镜（SBE）在小肠疾病诊断中的安全性、检查范围及临床价值。方法对2009年6月至9月间行SBE检查的疑有小肠疾病患者的临床资料进行回顾性分析,总结检查完成情况、操作时间以及并发症发生情况等。结果30例患者共行35例次SBE检查。单纯经口检查15例;单纯经肛检查10例;经口＋经肛检查5例,均完成对接检查。共26例明确诊断,疾病检出率为86．7％（26／30）。经口进镜检查平均用时49．7min,经肛进镜检查平均用时48．6min。所有患者检查过程中生命体征处于安全范围,无心脑血管并发症发生,无剧烈腹痛及出血、穿孔等并发症出现。结论SBE是一种安全、可靠的检查手段,用于诊断小肠疾病具有较好的临床价值。     

Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease

BACKGROUND: Double-balloon enteroscopy (push-and-pull enteroscopy) is a new method that allows complete visualization, biopsy, and treatment in the small bowel. This study evaluated the feasibility and the diagnostic and the therapeutic yield of double-balloon enteroscopy (push-and-pull enteroscopy) in comparison with current imaging methods. METHODS: Between March 2003 and November 2004, 248 consecutive double-balloon enteroscopies (push-and-pull enteroscopies) were performed in a prospective study in 137 patients with suspected small-bowel disease (60 women, 77 men; mean age 56.6 +/- 17.8 years), most with chronic GI bleeding (66%). The examinations were carried out after negative evaluations with other methods or to allow biopsy or treatment in patients with known small-bowel findings. RESULTS: There were no relevant technical problems or severe complications. On average, 240 +/- 100 cm of the small bowel was visualized by using the oral route and 140 +/- 90 cm was visualized by using the anal route. The investigation time averaged 73.5 +/- 25 minutes. The overall diagnostic yield was 80% (109/137 patients). The main diagnosis was angiodysplasia (40/109; 37%); erosions and ulcerations of various etiologies were found in 27% (29/109). Polyps and tumors were identified, including malignancy, in 25% (27/109). Other findings were detected in a further 11%. No relevant pathology was found in 20%. Subsequent treatment was influenced by the results in 104 patients (76%): endoscopic therapy in 57 (41.5%), medical treatment in 23 (17%), and surgery in 24 (17.5%). CONCLUSIONS: Double-balloon enteroscopy (push-and-pull enteroscopy) is safe and easily conducted. Visualization and tissue sampling are possible in the entire small bowel by using the oral and anal approaches, and treatment is possible in the same way as in standard endoscopy, avoiding open surgery. If further prospective studies confirm its value, double-balloon enteroscopy (push-and-pull enteroscopy) may become a standard method of diagnostic and therapeutic endoscopy in the small bowel.     

双气囊小肠镜在诊断小肠克罗恩病中的价值

目的 探讨双气囊小肠镜在诊断小肠克罗恩病中的价值.方法 对65例临床怀疑小肠克罗恩病的患者进行检查,并与先前进行的插管法小肠钡灌肠和胶囊内镜检查结果进行对比分析.结果 65例患者行双气囊小肠镜检查诊断为小肠克罗恩病58例,并经病理和临床随访确诊.其中45例患者首选从肛门进镜行小肠镜检查,确认克罗恩病34例（75.6%）,另11例后从口腔进镜,发现病变者8例（72.7%）;20例首选经口进镜,检出克罗恩病11例（55%）,另9例患者日后经肛进镜检查中检出5例（55.6%）.先前进行的46例小肠钡灌肠检查中,24例诊断或疑似小肠克罗恩病,诊断率为52.2%,与小肠镜结果比较,符合小肠克罗恩病诊断例数为18例,诊断正确率为75%（18/24）.22例胶囊内镜检查者中,14例诊断或疑似小肠克罗恩病,诊断率为63.6%,最终经双气囊小肠镜确诊的病例数为11例,诊断准确率为78.6%（11/14）.结论 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;双气囊小肠镜是小肠克罗恩病诊断的较为理想的方法,并能对病变范围和严重程度作出正确判断,插管法小肠钡灌肠是一项决定小肠镜进镜方式选择上有价值的筛选性手段.     

Improvements in small bowel carcinoid diagnosis and staging: 18F-DOPA PET,capsule endoscopy and double balloon enteroscopy

Carcinoid tumours are rare, slow growing tumours, originating from cells of the neuroendocrine system. Staging of the disease is of paramount importance to determine the optimal treatment strategy but is notoriously difficult. A case of a 45-year-old male who presented with abdominal pain and flushes is presented. An abdominal computerised tomography-scan was performed which showed a solitary liver lesion, consisting of neuroendocrine tumour cells. Further staging with ¹⁸F-DOPA PET, capsule endoscopy and double balloon enteroscopy revealed the localisation of the primary tumours in the small bowel, and the patient subsequently underwent surgery. The recent introduction of ¹⁸F-DOPA PET, capsule endoscopy and double balloon enteroscopy in the diagnosis and staging of carcinoid tumours has made significant contributions to the management of this disease.     

Examining the whole bowel,double balloon enteroscopy: Indications,diagnostic yield and complications

Double balloon enteroscopy(DBE) is an advanced type of endoscopic procedure which brings the advantage of reaching the whole small bowel using anterograde or the retrograde route. This procedure is both diagnostic and interventional for a variety of small intestinal diseases, such as vascular lesions, tumors, polyps and involvement of inflammatory bowel diseases.Main indication is the diagnosis and treatment of mid-gastrointestinal bleeding according to the recent published data all over the world. The complication rates seem to be higher than conventional procedures but growing experience is lowering them and improving the procedure to be safe and well tolerated. This review is about the technique, indications, diagnostic importance and complications of DBE according to the literature growing since 2001.     

Endoscopic characterization of the small bowel in patients with portal hypertension evaluated by double balloon endoscopy

BACKGROUND: The endoscopic abnormalities present in the small bowel (SB) of patients with portal hypertension (PH) are not well understood. This study sought to evaluate endoscopic findings of the SB in patients with PH by double balloon endoscopy (DBE). METHODS: We evaluated the endoscopic findings of SB in 15 patients with PH and 49 controls without liver disease or PH. A total of 24 and 90 procedures were performed for PH patients and control patients, respectively, through oral and/or anal approaches. RESULTS: Fourteen of the 15 patients exhibited villous abnormalities, including edema (73%), atrophy (40%), and reddening (47%) of villi. Vascular lesions, such as angiodysplasia-like abnormalities (67%), dilated/proliferated vessels (93%), and varices (7%), were observed in all patients with PH. Although they were associated with ascites, these abnormalities did not correlate with any laboratory findings. None of these abnormalities was observed in controls. Definitive or suspected bleeding sources were identified in 9 of 13 patients with both PH and obscure gastrointestinal bleeding (OGIB), which was similar to the incidence in controls with OGIB. Although the frequency of postprocedure fever (>37.5 degrees C) was higher in patients with PH in comparison to controls (29% vs. 2%, P < 0.01), endoscopic treatment under DBE was performed on 3 PH patients without serious complications. CONCLUSIONS: Endoscopic abnormalities of the SB may be prevalent in patients with PH. Although postprocedure fever of DBE may occur more commonly in patients with PH, DBE is useful as both a diagnostic and therapeutic tool to evaluate the SB.     

双气囊内镜对小肠息肉的内镜诊治研究

目的 探讨双气囊内镜(DBE)对小肠息肉镜下治疗的可行性及安全性.方法 回顾分析我院自2003年11月～2009年6月接受DBE检查并检出小肠息肉的所有病例,总结和分析小肠息肉的内镜诊断及治疗情况,并评价其安全性.结果 360例患者,共进行566例次DBE检查及治疗,其中检出小肠息肉患者66例(Peutz-Jeghers综合征患者50例,其他小肠息肉患者16例).66例患者共接受122例次DBE镜下治疗(经口 74次,经肛48次).镜下切除小肠息肉共计1 012枚(直径5～10 mm 95枚、1～30mm 599枚,直径31～50 mm 274枚,直径大于50 mm 44枚).66例患者在DBE检查及治疗前86例次有不同的临床症状(不完全肠梗阻36例、消化道出血32例、腹痛及腹部不适18例),其中78例次(90.7%)经内镜治疗后临床症状均明显缓解或消失,另有8例次因小肠息肉巨大(7例)或发现息肉恶变(2例)转外科手术治疗.发生较严重的并发症共6例次(小肠穿孔3例,术后有3例出现引起血红蛋白水平下降的消化道出血).结论 DBE能安全有效地切除小肠多发息肉,可在一定范围内代替外科手术治疗,为小肠息肉患者提供了一种安全有效的微创治疗方法,具有重要的临床应用价值.     

A facilitated method for endoscopic interventions at the bile duct after Roux-en-Y reconstruction using double balloon enteroscopy

Endoscopic retrograde cholangiography (ERC) after Roux-en-Y reconstruction and modified BII surgery or duodenopancreatectomy is considerably more difficult than ERC under normal anatomic conditions. If the common bile in the afferent loop cannot be reached by a common lateral-viewing duodenoscope because of excessive intestinal length, it has recently become possible to use double balloon enteroscopy (DBE) for ERC to reach the common bile duct. Cannulating the bile duct via DBE in these postoperative settings remains one of the most difficult ERCP manipulations because of the lack of an Albarran lever and the use of extra long ERCP accessories. Here, we report on a facilitated method for endoscopic interventions at the bile duct in postoperative settings with a long afferent loop using DBE. For facilitation of interventions the enteroscope can be exchanged for a 110-cm-long conventional gastroscope after incision of the overtube in three quarters of its circumference. Care has to be taken that the pressure line for the balloon remains intact. The huge benefit of this facilitated method is the use of standard endoscopic material like guides, catheters and papillotomes.     

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.     

Clinical impact of videocapsule and double balloon enteroscopy on small bowel bleeding: Results from a large monocentric cohort in the last 19 years

BackgroundSuspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center.MethodsWe retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE–DBE concordance, hemoglobin (Hb) values before and after DBE, and complications.Results807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1–5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients.ConclusionVCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.     

双气囊小肠镜在小肠疾病诊断中的应用

目的评价双气囊小肠镜对小肠疾病的诊断价值。方法19例经B超、CT、胃镜、肠镜等常规检查不能明确病凼的患者,其中腹痛待查5例,腹泻待查2例,不明原因的消化道出血7例,腹痛伴有黑便2例,腹痛伴有腹泻3例,接受双气囊小肠镜检查,评价其病变检出率、并发症及患者的耐受性等。结果19例患者经口进镜2例,经肛进镜5例,接受经口＋经肌检查12例。19例患者中15例发现阳性病灶,总体病因确诊率78．9％;不明原因消化道出血病因确诊率71．4％,腹痛、腹泻的病因确诊率分别为80％和50％,2例腹痛伴有黑便者及3例腹痛伴有腹泻者均获得病因学诊断,未见操作相关的严重不良反应和并发症,结论双气囊小肠镜是一种对小肠疾病诊断价值较高、安全可靠的检查手段。     

Computed tomographic enteroclysis with air and virtual enteroscopy: protocol and feasibility for small bowel evaluation

Background and aimsWe describe our optimized protocol for computed tomographic enteroclysis using air as the contrast material and report an early assessment of its clinical performance.MethodsThirty-one examinations of computed tomographic enteroclysis with air were performed in 30 patients in our hospital from September 2008 to September 2010. The volume of injected air and intra-intestinal pressure were monitored in 16 cases. The data were reviewed for ratios of successful whole small bowel depictions out of the total number of examinations for patients without stenosis. Efforts were made to confirm depicted abnormal findings when possible by other imaging techniques, intra-operative findings, histopathological findings, and subsequent history.ResultsThe injected air volume and final intra-intestinal pressure were 2925 ± 686 ml and 24.5 ± 7.1 cm H₂O in cases without stenosis. In 19 examinations with anterograde air injection for patients without stenosis, whole small bowel depiction was achieved in 16 (84.2%). Computed tomographic enteroclysis with air was useful for detecting strictures (in Crohn's disease, malignant lymphoma, metastatic carcinoma), Meckel's diverticulum, and for excluding other obstructive conditions in ileus.ConclusionsComputed tomographic enteroclysis with air has a potential to enable the exploration of the whole small bowel, thereby providing information of small bowel lesions that complements other techniques.