Enteroscopy in children and adults with inflammatory bowel disease

Inflammatory bowel disease(IBD) includes Crohn's disease(CD), ulcerative colitis and unclassified entities. CD commonly involves the terminal ileum and colon but at the time of diagnosis it can be confined to the small bowel(SB) in about 30% of the patients, especially in the young ones. Management of isolated SB-CD can be challenging and objective evaluation of the SB mucosa is essential in differentiating CD from other enteropathies to achieve therapeutic decisions and to plan the follow-up. The introduction of cross-sectional imaging techniques and capsule endoscopy(CE) have significantly expanded the ability to diagnose SB diseases providing a non-invasive test for the visualization of the entire SB mucosa. The main CE limitations are the low specificity, the lack of therapeutic capabilities and the impossibility to take biopsies. Device assisted enteroscopy(DAE) enables histological confirmation when traditional endoscopy, capsule endoscopy and cross-sectional imaging are inconclusive and also allows therapeutic interventions such as balloon stricture dilation, intralesional steroid injection, capsule retrieval and more recently stent insertion. In the current review we will discuss technical aspect, indications and safety profile of DAE in children and adults with IBD.     

Detection of Neuroendocrine Tumors of the Small Bowel by Double Balloon Enteroscopy

Background Neuroendocrine tumors (NET) account for one-third of all small bowel neoplasms. The search for the primary tumor in NET is important, even though it is difficult to localize, as its surgical excision leads to a better prognosis, even in metastasized stages of the disease. The objective of this study was to evaluate the use of double balloon enteroscopy (DBE) for the detection of the primary tumor in patients with NET. Methods Twelve consecutive patients (eight women, four men) with suspected carcinoid syndrome, either metastatic to the liver (n = 5), symptoms of a neuroendocrine tumor with elevated tumor markers (n = 5), or obscure gastrointestinal bleeding (n = 2) underwent DBE for the search of the primary tumor or the source of bleeding. All patients underwent abdominal sonography and a computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), ileocolonoscopy, and octreotide scintigraphy prior to DBE. Capsule endoscopy was performed in four patients. Results A total of 17 DBE were performed in the 12 patients. The CT scan and sonography of the abdomen as well as EGD and ileocolonoscopy were unable to detect the primary tumor in any patient. A submucosal tumor of the ileum or the jejunum could be detected by DBE was detected in seven patients (58%) (anal route, n = 4; oral route, n = 3). In four of these patients (33%) this finding could be confirmed by the surgical resection of a NET. In two patients (17%) with a submucosal ileum protrusion suspicious for NET, laparotomy and intraoperative endoscopy did not confirm the tumor. Conclusions In this study, the diagnostic yield of DBE for primary tumor search in patients with metastatic or suspected NET was 33%. Although endoscopic small bowel investigation by DBE seems to enrich the diagnostic possibilities for the diagnosis of small bowel-NET, at the present time DBE should only be performed in selected cases, possibly based on a positive previous work-up. Michael Bellutti and Lucia C. Fry contributed equally to this paper.     

Single balloon enteroscopy: Technical aspects and clinical applications

The small bowel has long been considered a black box for endoscopists because of its long length and the presence of multiple complex loop. Most of the small bowel is inaccessible by traditional endoscopic means. In addition, radiographic studies have significant limitations with regard to diagnostic yield, and surgery is an invasive alternative. This limitation was overcome through the development of balloon enteroscopy that becomes established throughout the world for diagnostic and therapeutic examinations of the small bowel. The single-balloon enteroscope (SBE) system (Olympus, Tokyo, Japan) was introduced into the commercial market in 2007. Several study demonstrated its efficacy and safety. Early reports on the use of singleballoon enteroscopy have suggested a high diagnostic yield and similar therapeutic potential to that of the double-balloon endoscope. SBE is viable technique for in the management of small bowel disease. Technically, it is easy to perform, may be efficient, and in the literature data available, seems to provide high diagnostic and therapeutic yield.     

Factors associated with reduced insertion depth at double balloon enteroscopy: A retrospective,multivariate analysis

Background

Deep small bowel insertion during double balloon enteroscopy can be difficult to achieve.

Aims

To determine the factors influencing depth of insertion during double balloon enteroscopy.

Methods

History of abdomino-pelvic surgery, route of insertion, type of enteroscope, age, sedation or general anaesthesia used and gender were considered as potential influencing factors; procedures were categorised accordingly and maximal depth of insertion calculated.

Results

At multivariate analysis, maximal depth of insertion was significantly associated with history of abdominal-pelvic surgery (P < 0.001), rectal approach (P = 0.011), gender (P = 0.02) and use of the therapeutic enteroscope (P = 0.047). Mean maximal depth of insertion was 266 ± 12 cm, 255 ± 9 cm (P = 0.50), 197 ± 10 cm (P < 0.0001), 160 ± 12 cm (P < 0.01) and 103 ± 33 cm (P < 0.15) when 0, 1, 2, 3 and 4 influencing factors were present, respectively.

Conclusion

Maximal depth of insertion was significantly influenced by history of abdomino-pelvic surgery, insertion route, gender and type of enteroscope used.     

术中内镜应用的价值：附10例小肠出血的诊断

本文报告我院1986年至1993年内外科配合行术中内镜检查对10例小肠出血病变作出诊断.这些小肠出血病变包括血管畸形和小血管瘤、小平滑肌肉瘤、小肠转移性癌和炎症性疾病,对于这些病变采用常规剖腹探查术难以得出诊断.文章结合临床分析和文献复习对术中内镜的检查方法和临床评价进行了讨论.     

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.     

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.     

Ileo-ileal invagination – a cause of recurrent mid-gastrointestinal bleeding: Diagnostic and endoscopic therapy by means of push-and-pull enteroscopy

The types of lesions that cause bleeding in the small bowel are similar to those found in other areas in the gastrointestinal tract, such as vascular malformations, ulcers and inflammatory lesions, neoplasms and other less common lesions like Meckel's diverticulum.

This report describes three patients with suspected mid-gastrointestinal bleeding with no significant past medical history. Before presenting to our unit the diagnostic work-up such as oesophagogastroduodenoscopy, colonoscopy and radiological small bowel imaging such as conventional enteroclysis or magnet resonance imaging enteroclysis had been performed without detecting any bleeding source. Capsule endoscopy suspected an angiodysplasia in the terminal ileum in one patient, in the other two patients a polyp in the region of the ileum as the potential bleeding source was diagnosed. In all three patients, a polyp with an ulcerated tip was found with the anal push-and-pull enteroscopy. An endosocpic resection was performed in all three cases without complication with the exception of one. In this patient a perforation occured 3 days after resection and was treated surgically without further complications. Histology revealed in all three cases, a polypoid diaphragmatic invagination of the small bowel with a vast area of chronic ulceration on the tip of this pseudopolyp with infiltration of the muscularis propria.

In summary, the present paper describes the rare cases of erosive pseudopolyps after ileo-ileal invagination treated with endoscopic resection by means of push-and-pull enteroscopy.     

Enteroscopy for the early detection of small bowel tumours in at-risk celiac patients

BackgroundA subset of celiac patients shows a high risk for small bowel malignancies.AimsTo select celiac patients considered at risk and evaluate the diagnostic yield of enteroscopy in this context.MethodsCeliac patients were enrolled from a tertiary referral centre during the period June 2011–June 2013, based on the following criteria: (i) patients diagnosed when aged 50+ and with poor response to gluten-free dieting; (ii) low dietary compliance; (iii) alarm symptoms. The patients underwent small bowel capsule endoscopy and/or double-balloon enteroscopy. Control populations were represented by the 165 non-celiac patients undergoing capsule endoscopy for obscure gastrointestinal bleeding, and the 815,362-strong population of the Italian province of Varese as a registered cohort.ResultsFifty-three patients (19% males, mean age 43.6 ± 17.4 years) were evaluated. Two jejunal adenocarcinomas and one ileal neuro-endocrine tumour were diagnosed by enteroscopy (the diagnostic yield for malignancies in the selected population being 5.7%). In the non-celiac controls the detection rate of small bowel tumours by capsule endoscopy was 0.6% (P = 0.04). When compared to the registered population, the relative risk for intestinal malignancy was 1282 (95% CI, 407–4033; P < 0.0001).ConclusionsCapsule endoscopy and double-balloon enteroscopy can be considered for early disease management of a subset of celiac patients.     

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。     

双气囊电子小肠镜在小肠病变中的诊断价值

目的评价双气囊电子小肠镜对小肠病变的诊断价值、有效性及安全性。方法对65例行双气囊电子小肠镜检查可疑小肠病变患者的临床资料进行回顾性分析。结果 65例患者进行双气囊电子小肠镜检查,42例发现病灶,总体检出阳性率为64.6%,前三位病变为炎性病变、美克尔憩室和肿瘤。其中慢性腹痛阳性率为54.2%,不明原因消化道出血阳性率为80.0%,不全性肠梗阻阳性率为90.9%,腹泻阳性率为100.0%。并发症发生回肠末段穿孔1例,一过性心率下降1例,无消化道出血、急性胰腺炎及其他严重心肺功能障碍发生。结论双气囊电子小肠镜对小肠病变具有较高的临床诊断价值,安全性及有效性较好,是目前小肠病变最好的检查方法之一,但仍具有一定风险。     

血清尿素氮与肌酐比值对小肠出血者小肠镜检查进镜途径的指导价值

目的:探讨血清尿素氮(blood urea nitrogen,BUN)与肌酐(creatinine,Cr)比值(BUN/Cr)对小肠出血患者行小肠镜检查时进镜途径选择的指导价值。方法:2015年1月—2019年10月期间,因潜在小肠出血在空军特色医学中心接受双气囊小肠镜检查,并在出血48 h内行BUN和Cr检测的105...     

小肠克罗恩病54例临床特征分析

目的分析小肠克罗恩病患者的临床资料,增进对小肠克罗恩病的认识。方法回顾性归纳2004年01月至2008年12月期间南方医院小肠克罗恩病患者的临床表现、消化道内镜、腹部影像学及病理等相关资料。结果小肠克罗恩病患者共54例,青壮年好发[发病年龄(28.9±11.8)岁],病程较长[(35.6±46.6)月],临床表现以腹痛、营养不良、黑便等为主,并发症以肠梗阻、瘘管形成、消化道大出血等多见。小肠克罗恩病主要以黏膜破损、肠腔狭窄等为主要病变形态,节段、跳跃式分布于小肠各部位,空肠、回肠(回肠末端除外)、回肠末端(和/或回盲瓣)受累比例为48.6%、77.1%、62.9%。23例(42.6%)具有上皮样细胞、非干酪性坏死性肉芽肿等特征性病理发现。结论小肠克罗恩病临床表现多样,小肠段内镜探查是小肠克罗恩病的首选手段;目前小肠克罗恩病诊断仍较困难,需结合临床表现、影像学和消化内镜证据以及病理、追踪资料等综合判断。     

多层CT小肠造影与单气囊小肠镜对小肠梗阻的诊断价值

目的探讨多层CT小肠造影(MSCTE)与单气囊小肠镜(SBE)在小肠梗阻性病变的诊断价值。方法收集2009年6月-2013年2月临床和/或腹部X线平片疑为小肠梗阻的患者30例。所有患者先行MSCTE检查,根据检查结果选择经口或经肛SBE检查。分析两种检查方法对小肠梗阻性病变的诊断率。结果①MSCTE检查诊断小肠梗阻的灵敏度为85.19%,特异度为66.67%,阳性预测值为95.83%,阴性预测值为33.33%。SBE检查分别为81.48%、100%、100%和37.50%。②MSCTE和SBE检出病变一致性为53.33%(16/30)。③根据MSCTE检查结果选择经口或经肛SBE检查,MSCTE检查阳性指导SBE选择进镜方式正确率高于MSCTE检查阴性(95.83%vs33.33%,P<0.05)。结论 MSCTE和SBE对小肠梗阻的诊断率相当,二者联合应用可提高对小肠梗阻性病变的诊断率。MSCTE检查结果可以指导SBE选择进镜方式。     

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。     

双气囊电子小肠镜检查小肠疾病62例

目的:评价双气囊小肠镜对小肠疾病诊断价值及其安全性和操作性能,增加小肠疾病的检出率.方法:2005-08/2006-12期间62例有消化道症状,经胃镜、结肠镜、全消化道钡餐、腹部CT等检查无阳性发现的患者应用双气囊电子小肠镜检查,结合手术、病理结果、观察、分析其阳性率、检查范围、并发症等,所有检查均在静脉麻醉下完成.结果:62例患者中仅有5例发生轻度呼吸抑制、血压下降等麻醉相关的并发症:检查过程除了咽喉损伤、黏膜擦伤外无严重并发症发生.62例患者通过双气囊小肠镜检查发现有病变者53例,病变检出率85.5%;其中肿瘤性疾病10例,占18.9%(10/53);炎症性疾病包括炎症性肠病和非特异性糜烂、溃疡20例,占37.7%(20/53);血管性疾病7例,占13.2%(7/53);寄生虫病6例,占11.3%(6/53);其他10例,占18.9%(10/53);未发现病灶9例.结论:双气囊小肠镜可直视检查全消化道腔内病变,对消化道特别是小肠病变检出率高,是诊断和治疗小肠疾病的有力工具.     

Clinical Utility of Double-Balloon Enteroscopy for Small Intestinal Bleeding

Until the development of wireless capsule endoscopy (CE) and double-balloon enteroscopy (DBE), it was extremely difficult to examine the entire small intestine. To assess the usefulness of DBE for diagnosing suspected small intestinal bleeding, we retrospectively compared the diagnoses and treatments of cases before and after its introduction at one hospital. Between September 2003 and December 2005, 21 consecutive patients with suspected small intestinal bleeding underwent DBE at Tokai University Hospital (group A), and subsequently 2 were excluded from the study after being diagnosed with bleeding from a diverticulum and an angiodysplasia in the ascending colon, respectively. For comparison, inpatients who were negative for gastrointestinal bleeding on colonoscopy and gastroscopy between May 1998 and August 2003 were reviewed and 27 consecutive patients who had not undergone DBE were selected as the control group (group B). All patients had been diagnosed negative for a source of bleeding on more than one colonoscopy and gastroscopy. There were no significant differences between the two groups in terms of age, gender, history of blood transfusion, blood hemoglobin value on admission, or symptoms. The diagnostic yield of DBE in identifying the source of bleeding was 78.9%: six cases of small intestinal ulcers, five cases of angiodysplasia, two cases of hard submucosal tumor (SMT), one case of small pulsating SMT, and one case of small intestinal cancer. DBE was also used to successfully treat three cases of angiodysplasia with argon plasma coagulation. In the control group, conventional investigations, including enteroclysis, angiography, Meckel scan, scintigraphy with technetium-labeled red blood cells, and/or push enteroscopy, were performed in 88.9%, 29.6%, 29.6%, 55.6%, and 25.9%, respectively. The overall diagnostic yield of the conventional approaches was only 11.1% (P < 0.01), comprising a Meckel's diverticulum, a polyp, and an angiodysplasia. We conclude that DBE can be used to diagnose suspected small intestinal bleeding and to treat some cases, such as angiodysplasia.