Enteroscopy

Wireless capsule endoscopy and double-balloon endoscopy are new methods of enteroscopy that have been introduced in recent years. Wireless capsule endoscopy is an epoch-making examination method that makes possible an endoscopic imaging examination of the entire small intestine without discomfort and without confining patients to a medical facility. Although it is expected to be useful as an initial examination for finding diseases of the small intestine, it cannot be used for biopsy or treatment. One risk associated with the capsule endoscopy technique is entrapment by strictures. Double-balloon endoscopy is based on a new insertion technique in which two balloons, one at the distal end of the endoscope and the other at the distal end of an overtube, are operated in combination, and the endoscope is inserted while simultaneously shortening the intestine. It can be inserted through either the mouth or the anus, allowing the observation of the entire gastrointestinal tract. It features excellent maneuverability even in the distal small intestine, and enables back-and-forth observation, biopsy, and endoscopic treatment at any given site. These two new enteroscopy techniques are expected to lead to innovations in how diseases of the small intestine are approached.     

CURRENT STATUS OF DOUBLE BALLOON ENDOSCOPY

Yamamoto and colleagues have developed a novel insertion method of the endoscope, the ‘double balloon method’ for enteroscopy and, recently, a specialized system for the ‘double balloon method’ has been commercialized by Fujinon. The double balloon endoscopy enables visualization of the entire small bowel and also allows for interventional therapy in the small intestine. This method could be used either from the oral or anal approach. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, hemostasis, balloon dilatation, stent placement, polypectomy, and endoscopic mucosal resection. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.     

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.     

Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.

BACKGROUND & AIMS: A specialized system for a new method for enteroscopy, the double-balloon method, was developed. The aim of this study was to evaluate the usefulness of this endoscopic system for small-intestinal disorders. METHODS: The double-balloon endoscopy system was used to perform 178 enteroscopies (89 by the anterograde approach and 89 by the retrograde approach) in 123 patients. The system was assessed on the basis of the rates of success in jejunal and ileal insertion and the entire examination of the small intestine, diagnostic yields, ability to perform treatment, and complications. RESULTS: Insertion of the endoscope beyond the ligament of Treitz or ileocecal valve was possible in all 178 procedures. It was possible to observe approximately one half to two thirds of the entire small intestine by each approach, and observation of the entire small intestine was possible in 24 (86%) of 28 trials. The source of bleeding was identified in 50 (76%) of 66 patients with GI bleeding, scrutiny of strictures was possible in 23 patients, and a tumor was examined endoscopically in 17 patients. Two complications (1.1%) occurred. Endoscopic therapies in the small intestine including hemostasis (12 cases), polypectomy (1 case), endoscopic mucosal resection (1 case), balloon dilation (6 cases), and stent placement (2 cases) were performed successfully. CONCLUSIONS: Double-balloon endoscopy permits the exploration of the small intestine with a high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.     

Small Bowel Enteroscopy in 1988: Pros and Cons

Endoscopic visualization of the small bowel is now feasible with a recently developed long, small-caliber, transnasal endoscope. Previously, with standard instruments, endoscopic views of the small intestine were limited to the most proximal and distal portions or required laparotomy and intraoperative endoscopy. Small bowel enteroscopy with the new transnasal sondetype flexible endoscope now allows most of the small bowel to be examined as a relatively short, ambulatory procedure. The literature pertaining to endoscopic evaluation of the small intestine is reviewed.     

How to approach the small bowel with flexible enteroscopy

Nowadays, 5 nonsurgical flexible endoscopic techniques are available for small bowel endoscopy: push enteroscopy (PE), balloon-assisted enteroscopy using 2 balloons (double-balloon enteroscopy [DBE]) or 1 balloon (single-balloon enteroscopy [SBE]), balloon-guided enteroscopy (BGE), and spiral enteroscopy (SE). PE is a cost-saving, easy, and fast procedure for the examination of the proximal jejunum, but for a deep small bowel endoscopy, the other flexible enteroscopic techniques are required. BGE does not play a considerable role in deep small bowel endoscopy. DBE is the oldest flexible enteroscopic technique. Actually, the balloon-assisted enteroscopy (BAE) techniques with one balloon (SBE) or two balloons (DBE) are the mainly used techniques. DBE has become established throughout the world for diagnostic and therapeutic examinations of the small bowel and is now used universally in clinical routine work. DBE is still regarded as the gold standard nonsurgical procedure for deep small bowel endoscopy, because it provides the highest rates of complete enteroscopy, which becomes increasingly useful. The recently introduced SE technique represents a promising method but still needs technical improvement. Larger prospective studies on SE and prospective studies comparing the 3 systems (DBE, SBE, SE) are awaited before conclusive assessments can be made.     

Complications of small bowel endoscopy

With the advent of techniques to fully image and intervene on the small intestine, including capsule endoscopy, single- and double-balloon enteroscopy, and spiral enteroscopy, our diagnostic and therapeutic capabilities have increased significantly. These new technologies are not without risk, and these techniques have led to a large body of literature addressing the complications that can arise from these procedures. This chapter will review the complications associated with capsule endoscopy, single- and double-balloon enteroscopy, and spiral enteroscopy.     

Technical modification of the double-balloon endoscopy to access to the proximal side of the stenosis in the distal colon

BACKGROUND: The inability to pass endoscopes beyond strictures is a considerable problem in patients with a colonic stricture. METHODS: In patients with bowel obstruction, we have modified the insertion method for double-balloon endoscopy with a long, transnasal decompression tube. OBSERVATIONS: We have succeeded in reaching the proximal side of the stricture from the oral approach across the entire small bowel in a patient. CONCLUSIONS: This modified double-balloon enteroscopy is useful for patients with bowel obstruction in whom a long decompression tube is already placed.     

Double-balloon enteroscopy in patients with GI bleeding of obscure origin

BACKGROUND: Small-bowel bleeding is difficult to treat and diagnose. The recent introduction of wireless capsule endoscopy permits examination of the entire small intestine, but this method lacks tissue sampling and therapeutic capabilities. Recently, Yamamoto et al established a double-balloon insertion method for enteroscopy that allows examination of the entire small bowel and interventional options. OBJECTIVE: To evaluate double-balloon enteroscopy in patients with obscure GI bleeding. SETTING: Single-center prospective study. PATIENTS: Thirty-one consecutive patients with obscure GI bleeding (13 females, 18 males; mean age 56.4 +/- 3.2 years). Criteria for inclusion in the study were documented iron deficiency anemia (hemoglobin level <10 g/dL or a decrease of >2 g/dL over > or =2 months); upper endoscopy not revealing a site/cause of blood loss; and similarly uninformative lower endoscopy including examination of the terminal ileum. INTERVENTIONS: Endoscopic biopsy or therapy was performed as clinically indicated. MAIN OUTCOME MEASUREMENTS: Diagnostic yield for patients with obscure GI bleeding and patient follow-up. RESULTS: Double-balloon enteroscopy was completed without complications in all patients. Bleeding points were identified in 23 patients (74.2%). In 21 (91.3%) of these 23 patients the cause of blood loss was identified and treated with no further bleeding at 8.5 +/- 0.6 months of follow-up. LIMITATIONS: Small number of patients. CONCLUSIONS: These data suggest that double-balloon enteroscopy is useful for evaluation and treatment of patients with GI bleeding of obscure origin.     

Total enteroscopy with a nonsurgical steerable double-balloon method

BACKGROUND: Deep insertion of an enteroscope by use of a push technique is difficult. A new method of enteroscopy was developed, a double-balloon method, to improve the access to the small intestine. METHODS: The new method uses 2 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 in the small intestine. This method was tried with a standard upper endoscope in 3 patients and with a longer enteroscope in 1 patient. RESULTS: Despite its short length the upper endoscope was successfully inserted as far as 30 to 50 cm beyond the ligament of Treitz in the 3 patients. In the fourth patient the longer enteroscope was successfully inserted beyond the ileo-cecal valve. CONCLUSIONS: The double-balloon method facilitates endoscopic access to the small intestine.     

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).     

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。     

Diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in a series of 100 patients with suspected small bowel diseases

BACKGROUND: Double-balloon enteroscopy is a newly developed endoscopic method allowing non-surgical full-length exploration of the small bowel, biopsies sample and endoscopic treatment of previously inaccessible lesions. AIM: To prospectively assess the diagnostic and therapeutical impact of double-balloon enteroscopy in patients with suspected or documented small bowel disease. PATIENTS AND METHODS: One hundred consecutive patients referring to our centre for suspected small bowel disease underwent double-balloon enteroscopy. Starting insertion route (anal or oral) of double-balloon enteroscopy was chosen according to the estimated location of the suspected lesions basing on the clinical presentation and on the findings, when available, of previous endoscopic or radiological investigations. Major indications for the procedures were acute recurrent or chronic mid-gastrointestinal bleeding (n=71), suspected gastrointestinal tumours (n=10), suspected Crohn's disease (n=6), chronic abdominal pain and/or chronic diarrhoea (n=8), refractory celiac disease (n=5). RESULTS: One hundred and eighteen double-balloon enteroscopy procedures were carried out. Oral and anal route double-balloon enteroscopies were performed in 54 and 28 patients, respectively, while 18 patients underwent a combination of both approaches. Overall diagnostic yield of double-balloon enteroscopy resulted 69%. Most common pathological findings included angiodysplasias (n=39), ulcerations and erosions of various aetiologies (n=21), tumours (n=7) and ileal stenosis in patients with Crohn's disease suspicion (n=2). In the 65% of the patients examined, double-balloon enteroscopy findings influenced the subsequent clinical management (endoscopic, medical or surgical treatment). No major complications related to the procedure occurred. CONCLUSIONS: Our prospective analysis shows that double-balloon enteroscopy is a useful, safe and well-tolerated new method with a high diagnostic and therapeutic impact for the management of suspected or documented small bowel diseases.     

Clinical outcomes of enteroscopy using the double-balloon method for strictures of the small intestine

AIM:To evaluate the clinical outcome of enteroscopy, using the double-balloon method, focusing on the involvement of neoplasms in strictures of the small intestine. METHODS: Enteroscopy, using the double-balloon method, was performed between December 1999 and December 2002 at Jichi Medical School Hospital, 3apan and strictures of the small intestine were found in 17 out of 62 patients. These 17 consecutive patients were subjected to analysis. RESULTS: The double-balloon enteroscopy contributed to the diagnosis of small intestinal neoplasms found in 3 out of 17 patients by direct observation of the strictures as well as biopsy sampling. Surgical procedures were chosen for these three patients, while balloon dilation was chosen for the strictures in four patients diagnosed with inflammation without involvement of neoplasm. CONCLUSION: Double-balloon enteroscopy is a useful method for the diagnosis and treatment of strictures in the small bowel.     

胶囊内镜检查对双气囊小肠镜进镜方式选择的指导作用

目的:探讨胶囊内镜检查对双气囊小肠镜进镜方式选择的指导作用．方法:胶囊内镜检查阴性或可疑病变者20例行双气囊小肠镜检查(均在麻醉下进行),包括经口和经肛进镜方式．根据胶囊内镜时间指数 (胶囊内镜从幽门至病灶的通过时间／幽门至回盲瓣的通过时间)选择首次进镜方式,时间指数>0．50时首先考虑经肛进镜检查,对未发现异常者择期改换方式再行检查．分析按胶囊内镜时间指数选择双气囊小肠镜进镜方式的准确性．结果:胶囊内镜检查阴性者5例,行经口双气囊小肠镜检查,有1例在改为经肛检查后检出病灶．胶囊内镜检查怀疑小肠病变者15例,有 12例(80．0％)经双气囊小肠镜结合活检病理确诊．以时间指数>0．50为标准,4例(分别为0．99, 0．8,0．65和0．59)首选经肛进镜检查,后二者(时间指数分别为0．65和0．59)需换从口侧进镜检查而检出病灶;如以时间指数>0．75为标准,该 2例不再需要改换方式再行检查,另2例病变部位被判断为回肠远端,经肛进镜即可准确到达病灶．结论:胶囊内镜检查可指导对双气囊小肠镜进镜方式的选择,时间指数>0．75提示首选经肛进镜检查．     

Jejunal diverticular bleeding diagnosed by double-balloon enteroscopy: a case report and review of literatures]

Jejunal diverticula is a rare disease and an unusual cause of obscure gastrointestinal hemorrhage. Obscure gasterointestinal bleeding is difficult to treat because the bleeding site cannot be identified by routine endoscopy and contrast studies. A wireless capsule endoscopy is not invasive and can visualize the entire small bowel. However, this method has limitations of incapability of taking biopsies and performing endoscopic interventions such as polypectomy or stent insertion. The double-balloon enteroscopy is being used frequently for the diagnosis and management of various small bowel diseases. We report a case of proximal jejunal diverticular bleeding diagnosed by double-balloon enteroscopy and treated with angiographic embolization.     

Economic aspects and evidence-based decision making in evaluating patients with suspected small bowel disorders

Obscure gastrointestinal hemorrhage is defined as overt or occult bleeding present after normal endoscopic examination of the upper and lower gastrointestinal tracts. Approximately 5% of patients with gastrointestinal hemorrhage can be classified as having obscure bleeding, with most patients found to have responsible lesions in the small intestine. The advent of video capsule endoscopy and deep enteroscopy allows for endoscopic access and therapeutic options in the small intestine. In our current era of cost minimization, reductions in capital equipment expenditures, and a high rate of malpractice claims against clinicians, the decision regarding whether a clinical enterprise should offer small bowel endoscopy using any of the more recent technologies requires an understanding of several factors. This article highlights some of the economic and medicolegal aspects of deep small bowel endoscopy. The following topics will be discussed: costs involved to perform endoscopic imaging of the small bowel; downstream revenue effect resulting from deep enteroscopy; coding, billing, and reimbursement issues; cost-effectiveness studies for diagnostic testing; algorithms for diagnostic evaluation of patients with suspected small bowel pathology; and medicolegal ramifications associated with endoscopic procedures of the small bowel.     

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.     

Acute pancreatitis associated with peroral double-balloon enteroscopy： A case report

A 58-year-old Japanese man had tarry stool and severe anemia. Neither upper nor lower gastrointestinal (GI) endoscopy showed any localized lesions. Thus, the source of his GI bleeding was suspected to be in the small intestine, and he underwent peroral double-balloon enteroscopy (DBE) using EN-450T5 (Fujinon-Toshiba ES System Co., Tokyo, Japan). There were no lesions considered to be the source of GI bleeding. After the procedure, the patient began to experience abdominal pain. Laboratory tests revealed hyperamylasemia and abdominal computed tomography revealed an inflammation of the pancreas and the peripancreas. He was thus diagnosed to have acute pancreatitis. Conservative treatments resulted in both clinical and laboratory amelioration. He had no history of alcohol ingestion, gallstone disease or pancreatitis. Magnetic resonance cholangio-pancreatography demonstrated no structural alterations and no stones in the pancreatobiliary ductal system. As his abdominal pain started after the procedure, his acute pancreatitis was thus thought to have been related to the peroral DBE. This is the first reported case of acute pancreatitis probably associated with peroral DBE.