Patient burden and patient preference: Comparing magnetic resonance enteroclysis,capsule endoscopy and balloon‐assisted enteroscopy

Background and Aim: We aimed to prospectively determine patient burden and patient preference for magnetic resonance enteroclysis, capsule endoscopy and balloon‐assisted enteroscopy in patients with suspected or known Crohn's disease (CD) or occult gastrointestinal bleeding (OGIB). Methods: Consecutive consenting patients with CD or OGIB underwent magnetic resonance enteroclysis, capsule endoscopy and balloon‐assisted enteroscopy. Capsule endoscopy was only performed if magnetic resonance enteroclysis showed no high‐grade small bowel stenosis. Patient preference and burden was evaluated by means of standardized questionnaires at five moments in time. Results: From January 2007 until March 2009, 76 patients were included (M/F 31/45; mean age 46.9 years; range 20.0–78.4 years): 38 patients with OGIB and 38 with suspected or known CD. Seventeen patients did not undergo capsule endoscopy because of high‐grade stenosis. Ninety‐five percent (344/363) of the questionnaires were suitable for evaluation. Capsule endoscopy was significantly favored over magnetic resonance enteroclysis and balloon‐assisted enteroscopy with respect to bowel preparation, swallowing of the capsule (compared to insertion of the tube/scope), burden of the entire examination, duration and accordance with the pre‐study information. Capsule endoscopy and magnetic resonance enteroclysis were significantly preferred over balloon‐assisted enteroscopy for clarity of explanation of the examination, and magnetic resonance enteroclysis was significantly preferred over balloon‐assisted enteroscopy for bowel preparation, painfulness and burden of the entire examination. Balloon‐assisted enteroscopy was significantly favored over magnetic resonance enteroclysis for insertion of the scope and procedure duration. Pre‐ and post‐study the order of preference was capsule endoscopy, magnetic resonance enteroclysis and balloon‐assisted enteroscopy. Conclusion: Capsule endoscopy was preferred to magnetic resonance enteroclysis and balloon‐assisted enteroscopy; it also had the lowest burden. Magnetic resonance enteroclysis was preferred over balloon‐assisted enteroscopy for clarity of explanation of the examination, bowel preparation, painfulness and burden of the entire examination, and balloon‐assisted enteroscopy over magnetic resonance enteroclysis for scope insertion and study duration.     

双气囊小肠镜与胶囊内镜在小肠出血应用中的对比研究

目的比较双气囊小肠镜与胶囊内镜在小肠出血中的病变检出率、病因诊断率、耐受性和安全性,初步探讨双气囊小肠镜对小肠出血的内镜下治疗。方法2006年4月至2009年10月烟台毓璜顶医院消化内科收治的可疑小肠出血患者159例,其中81例患者行双气囊小肠镜检查,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。对活动性出血病灶行内镜下止血治疗。另78例患者行胶囊内镜检查。两组患者分别由专门医师独立操作并诊断,最后进行汇总分析,对比双气囊小肠镜与胶囊内镜的临床应用价值。结果双气囊小肠镜组的病变检出率为95.06%,病因诊断率为82.72%,23例检查时见病变活动性出血,行内镜下止血治疗,21例止血成功,内镜止血成功率为91.30%;胶囊内镜组的病变检出率82.05%,病因诊断率为66.67%。双气囊小肠镜组的病因检出率及病因诊断率均显著高于胶囊内镜组,差异有统计学意义(P0.05)。在耐受性方面,胶囊内镜的耐受性最好,双气囊小肠镜的耐受性依次为:全麻下经肛进镜、全麻下经口进镜、非麻醉经肛进镜、非麻醉经口进镜。所有患者均未发生严重并发症。结论双气囊小肠镜对小肠出血的病因诊断明显优于胶囊内镜,并且可行内镜下止血治疗,是一项安全、有效的临床诊疗方法。     

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.     

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。     

Deep enteroscopy-indications,diagnostic yield and complications

Since its introduction in 2001 capsule endoscopy opened up the small bowel for diagnostic approaches followed by double balloon enteroscopy which enabled the endoscopic community to perform therapeutic interventions in the whole small intestine.In this review the scientific developments related to indications,diagnostic yield and complications of the last years between the competing devices double ballon enteroscopy,single balloon enteroscopy and spiral enteroscopy are illustrated.     

SMALL BOWEL PSEUDOMELANOSIS AND ORAL IRON THERAPY

Small bowel pseudomelanosis is a rarely reported clinical entity characterized by brown pigmentation of small bowel mucosa. The authors describe two cases, both with iron deficiency anemia, one of an 81‐year‐old female patient submitted for capsule endoscopy that revealed a brown pigmentation of all small bowel mucosa and another of an 81‐year‐old male whose retrograde double‐balloon enteroscopy revealed a diffuse brown pattern of small bowel mucosa. Ileal biopsies confirmed intense iron deposition in the macrophages of the lamina propria. Both patients were on oral iron therapy and the second one had a previous double‐balloon enteroscopy, 2 years earlier, which revealed only ileal angiodysplasias. These two cases demonstrate the importance of two new endoscopic methods for diagnosis of small bowel pseudomelanosis, the rarity of such an entity and its close relation with oral iron therapy.     

Successful treatment with balloon dilatation using a double‐balloon enteroscope for a stricture in the small bowel of a patient with Crohn's disease

The requirement for endoscopic access to a stricture is a major limitation of the endoscopic dilatation for the treatment of strictures in the gastrointestinal tract. We have developed the double‐balloon enteroscopy method that enables visualization of the entire small bowel. In addition, double‐balloon enteroscopy has a potential for the interventional therapy including dilatation of strictures. We present here a case of jejunal strictures in a 47‐year‐old woman with Crohn's disease successfully treated with a balloon catheter in combination with double‐balloon enteroscopy. Balloon dilation with double‐balloon enteroscopy is a promising method for the treatment of small bowel strictures in Crohn's disease.     

The patient with recidivent obscure gastrointestinal bleeding

Obscure gastrointestinal (GI) bleeding is defined as visible or invisible GI blood loss, the source of which can not be identified by standard endoscopy (oesophagogastroduodenoscopy and colonoscopy). Nowadays, GI bleeding is divided into upper, mid- and lower bleeding. Mid-GI bleeding covers the section from the Treitz ligament to the ileocaecal valve. The new diagnostic methods of capsule endoscopy and double balloon enteroscopy have revolutionised the diagnostic approach in recent years. As a result, previous radiological and nuclear medicine techniques (small bowel X-ray, scintigraphy and angiography), but also endoscopic techniques, such as the push enteroscopy and intraoperative endoscopy, are becoming less important. After standard endoscopy and persistent blood loss it is advisable to first have these procedures repeated by an experienced examiner under optimal conditions. Nevertheless, no source of bleeding is identified by this method in 5% of cases. It is then recommended to use capsule endoscopy and, depending on the findings, double balloon enteroscopy with the option of intervention. In patients with unstable circulation an invasive procedure (intraoperative endoscopy) may be required.     

Occult intestinal haemorrhage due to lipoma of the small bowel detected with the combined use of the new endoscopic techniques. A report of two cases

We report two unusual cases of occult intestinal bleeding due to lipoma of the small bowel. Both the patients underwent several inconclusive endoscopic and radiological procedures before the diagnosis of these lesions that was possible using video capsule endoscopy and double balloon enteroscopy. In the first case, the finding of capsule endoscopy was confirmed using enteroscopy, allowing us to diagnose the ileal mass. In the second and more recent case, we used double balloon enteroscopy for the further characterisation and management of the ileal lipoma. Lipoma is a very rare cause of intestinal bleeding and we describe the management and the outcome of our patients.     

Endoscopic ultrasonography and small‐bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small‐bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device‐assisted enteroscopy have quickly become the reference standard for the diagnosis of small‐bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up‐to‐date overview of the latest advances in endoscopic ultrasonography and small‐bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.     

小肠肿瘤诊断:双气囊小肠镜与其他检查手段的对比研究

目的比较双气囊小肠镜与小肠稀钡灌注和胶囊内镜检查在小肠肿瘤诊断中的诊断率和准确率。方法对59例临床怀疑小肠肿瘤患者行双气囊小肠镜检查。其中有34例和17例患者分别同期行插管法小肠稀钡灌注或胶囊内镜检查。检查分别由专职医师独立操作并诊断，最后进行汇总比较。结果34例小肠稀钡灌注检查者中，19例诊断为小肠肿瘤或怀疑小肠肿瘤，诊断率为55．9％，最终经双气囊小肠镜确诊为12例，诊断准确率为63．2％（12／19例）；在15例小肠稀钡灌注阴性者中，双气囊小肠镜发现肿瘤3例。17例胶囊内镜检查者中，8例检查结果为小肠肿瘤或怀疑小肠肿瘤，诊断率为47．1％，最终经双气囊小肠镜确诊为4例，诊断准确率为4／8例；在9例胶囊内镜阴性者中，双气囊小肠镜发现小肠肿瘤2例。59例患者中，经一侧进镜检查后（经口或经肛）发现小肠肿瘤36例，完成双侧检查后发现肿瘤16例。7例患者在双侧检查后未发现任何病变。双气囊小肠镜对小肠肿瘤的检出率为88．1％，并经病理和临床随访确诊。上述三项检查中未见明显的与操作相关的并发症。结论双气囊小肠镜在小肠肿瘤诊断率及准确率方面明显优于小肠稀钡灌注和胶囊内镜检查。     

EXPERIENCES OF BILIARY INTERVENTIONS USING SHORT DOUBLE‐BALLOON ENTEROSCOPY IN PATIENTS WITH ROUX‐EN‐Y ANASTOMOSIS OR HEPATICOJEJUNOSTOMY

Background: The efficacy of double‐balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux‐en‐Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux‐en‐Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.     

Enteroskopische Techniken

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 entire small bowel without the need for laparotomy and intraoperative enteroscopy. These methods revolutionized the field of small bowel diagnostics and therapy and have become part of daily clinical practice. This article provides a review of small bowel enteroscopy techniques.     

Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications

Enteroscopy, defined as direct visualization of the smallbowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past severalyears. The need for endoscopic access to improvediagnosis and treatment of small bowel disease hasled to the development of novel technologies one ofwhich is noninvasive, the video capsule, and a type of invasive technique, the deviceassisted enteroscopy.In particular, the device-assisted enteroscopy consiststhen of three different types of instruments all able toallow, in skilled hands, to display partially or throug-hout its extension (if necessary) the small intestine.Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowelenteroscopy, focusing on indications, modifications toimprove imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endo-scopic skills and determining their role in the diagnosisand treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved.Studies are underway to determine the best strategy toapply new enteroscopy technologies for the diagnosisand management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocar cinomaor gas trointestinal stromal tumors. Complete entero-scopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and the rapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective ran-domized studies are needed to guide diagnostic testing and the rapy with these new endoscopic techniques.     

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.     

Neuroendocrine liver metastases: contributions of endoscopy and surgery to primary tumor search

Neuroendocrine tumors (NETs) are diagnosed with increasing frequency and patients often present with liver metastases at the time of diagnosis. Apart from treatment of the metastases, resection of the primary tumor at an early phase is recommended to prevent complications, although it may be difficult to locate, especially in patients with functionally inactive NETs. Small and multifocal tumors in the jejunum and ileum represent a particular challenge. Primary hepatic neuroendocrine carcinoma is extremely rare and is diagnosed only after exclusion of other primary tumors. Therefore, some uncertainty may remain, as small non-hepatic primary tumors may escape detection. Diagnostic work-up in these patients includes biochemical assays and imaging modalities (also comprising specific techniques of scintigraphy and positron emission tomography). This editorial highlights the contributions of endoscopy and operative exploration to the search for the primary tumor. Besides esophago-gastro-duodenoscopy, endoscopic ultrasonography, colonoscopy and bronchoscopy, special endoscopic techniques such as balloon enteroscopy or capsule endoscopy are used with growing experience. Compared with balloon enteroscopy, capsule endoscopy is non-invasive and better tolerated, but it cannot localize a lesion precisely and does not allow biopsy or removal of lesions. Before proceeding to surgery, a discussion of the findings by a tumor board should be a standard procedure. Improvements in diagnostic tools have created new perspectives for the detection of obscure primary tumors in patients with neuroendocrine liver metastases, and these searches are best coordinated by a multidisciplinary team.     

Evaluation and outcomes of patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding(OGIB) is defined as recurrent or persistent bleeding or presence of iron deficiency anaemia after evaluation with a negative bidirectional endoscopy. OGIB accounts for 5% of gastrointestinal bleeding and presents a diagnostic challenge. Current modalities available for the investigation of OGIB include capsule endoscopy, balloon assisted enteroscopy, spiral enteroscopy and computed tomography enterography. These modalities overcome the limitations of previous techniques. Following a negative bidirectional endoscopy, capsule endoscopy and double balloon enteroscopy remain the cornerstone of investigation in OGIB given their high diagnostic yield. Longterm outcome data in patients with OGIB is limited, but is most promising for capsule endoscopy. This article reviews the current literature and provides an overview of the clinical evaluation of patients with OGIB, available diagnostic and therapeutic modalities and longterm clinical outcomes.     

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.     

A Case of Enteropathy-Type T-Cell Lymphoma Diagnosed by Small Bowel Enteroscopy: A Perspective on Imaging-Enhanced Endoscopy

Enteropathy-type T-cell lymphoma (ETL) or enteropathy-associated T-cell lymphoma is a very rare malignant intestinal tumor. ETL is usually diagnosed by surgery. Endoscopic findings of ETL are not well known, and there are few reports of findings from endoscopy that has been performed only using white light. Additionally, there are no definite treatment guidelines for ETL. Therefore, we report a case of ETL diagnosed by enteroscopy with imaging-enhanced endoscopy and also review recently developed treatment options.     

ULTRATHIN ENDOSCOPE‐ASSISTED ERCP FOR INACCESSIBLE PERIDIVERTICULAR PAPILLA BY A SINGLE‐BALLOON ENTEROSCOPE IN A PATIENT WITH ROUX‐EN‐Y ANASTOMOSIS

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux‐en Y (R‐Y). A 73‐year‐old man who had total gastrectomy with R‐Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre‐cutting, the ultraslim endoscope was replaced with a conventional forward‐viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure‐related complication.