Small Bowel Obstruction: Prospective Comparison in Diagnosis Among Double Balloon Endoscopy, CT, and Fluoroscopic Enteroclysis, and Enteroscopic Treatment

Abstract

Background: Double balloon endoscopy (DBE) was developed to improve access to the small intestine. This study evaluated the usefulness of this endoscopy for the diagnosis of small-bowel obstruction in comparison with computed tomography (CT) and fluoroscopic enteroclysis, and enteroscopic treatment of small-bowel strictures. Methods: Of 280 patients who underwent DBE between June 2003 and October 2006, 56 (39 men and 17 women, median age 51.0 years) with small-bowel obstruction were enrolled. Contrast-enhanced CT was performed with a multidetector CT scanner. All fluoroscopic enteroclysis was double-contrast roentgenogram. The number of positive findings obtained with each technique was tabulated to calculate diagnostic yield. Endoscopic intestinal biopsies were reviewed histologically. Fifteen patients with small-intestinal strictures underwent 32 balloon dilations. Results: DBE (30 via the oral approach and 76 via the anal approach) enabled endoscopic diagnosis of the lesions deep within the small bowel, which were inaccessible at conventional endoscopy in 48 patients (96%). DBE had the highest diagnostic yield for small-bowel obstruction compared with CT and enteroclysis (P = .00009 and .0003, respectively, McNemar test). Histologic confirmation rate was high or perfect in patients with Peutz-Jeghers syndrome, NSAID-induced diaphragm disease, and primary small-intestinal tumors, but low in Crohn's disease, ischemic enteritis, and metastatic small-intestinal tumors. Of 10 patients with Crohn's strictures, 7 patients recovered by single or repeat enteroscopic balloon dilations, but 3 patients required surgery. Of 5 patients other than those with Crohn's disease, all patients recovered by stricture dilations and remained asymptomatic over the postdilation follow-up period. Retained capsule endoscopes were endoscopically retrieved in 2 patients. Two acute pancreatitis and one exacerbation of obstruction episodes occurred with no mortalities. Conclusions: DBE was relatively safe and useful for the diagnosis and the treatment of small-bowel obstruction. Noteworthy, balloon dilation is considered the first choice in patients with fibrotic and fully remissed tumorous strictures unrelated to Crohn's disease. In a selected group of patients with Crohn's fibrous strictures without active inflammation, this intervention is considered an alternative to surgery.