Antegrade Single Balloon Enteroscopy Research Articles

Polyp Endotherapy for Multiple Jejunal Lipomas Presenting as Small Bowel Intussusception: “Loop and Let Go Technique”

AbstractA 46-year-old woman presented with abdominal pain, vomiting, and intermittent constipation for the last 2 days. She had similar history of recurrent symptoms for the last 6 months. Abdominal examination showed mild central abdominal tenderness and generalized abdominal fullness and no palpable mass. A diagnosis of intestinal obstruction was considered. Nasogastric aspiration was performed with intravenous (IV) antibiotics and IV fluids. Computed tomography (CT) scan of the abdomen showed “bowel in bowel” or “target” sign appearance of jejunum with a submucosal hypodense lesion (suggestive of lipoma) acting as the lead point. There were two more submucosal lipomas of sizes approximately 3 cm each in the distal jejunal loops. A diagnosis of jejunal lipomas causing small bowel intussusception was made. The patient improved with conservative management. Exploratory laparotomy was planned with an intent to resect the small bowel. The patient did not provide consent for the same and so the option of enteroscopy-guided polyp endotherapy was offered to the patient. An antegrade single balloon enteroscopy was done (SIF-Q180, Olympus Medical Systems, United States). Three submucosal lesions with smooth overlying mucosa were noted in the mid and distal jejunum consistent with lipomas. The base of the lesions was ligated tightly using endoloop to make them ischemic and detach. Notable changes in color and mucosal appearance were noted after the application of endoloop. Since all the lipomas detected on cross-sectional radiologic imaging have been tackled via antegrade route, a retrograde enteroscopy was not attempted further. After 2 days, the patient was discharged in stable condition. Follow-up cross-sectional imaging at 3 months showed no residual lipomas, and she remained symptom-free at the end of 6 months.

Diagnostic yield and technical performance of the novel motorized spiral enteroscopy compared with single-balloon enteroscopy in suspected Crohn's disease: a prospective study (with video)

Both single-balloon enteroscopy (SBE) and the novel motorized spiral enteroscopy (NMSE) are effective techniques for device-assisted enteroscopy (DAE). To date, no study has prospectively compared both modalities in suspected Crohn's disease (CD). Patients with suspected CD undergoing either SBE or NMSE between March 2021 and December 2021 in a high-volume tertiary center were prospectively compared for technical success (ability to reach the lesion), diagnostic yield, depth of maximal insertion (DMI), procedure time, and total enteroscopy rates. One hundred seventy-seven patients (37.2% female; aged 7-75 years) with suspected CD underwent 201 DAEs. Technical success was 83% (SBE 81.5% vs NMSE 87.3%, P= .61) and impacted subsequent management in 92% (SBE 88.5% vs NMSE 97.8%, P= .2). Technical success with antegrade NMSE was significantly higher (81.4%) than antegrade SBE (33.3%, P= .007) for lesions in the proximal ileum and beyond. There was no significant difference in the diagnostic yield (SBE 80.8% vs NMSE 83.6%, P= .65). Median procedure time was significantly lower in both antegrade (NMSE, 40 minutes [range, 10-75]; SBE, 60 minutes [range, 20-180]; P< .0001) and retrograde (NMSE, 25 minutes [range, 20-60]; SBE, 60 minutes [range, 20-180]; P< .0001) NMSE. Median DMI was higher with antegrade NMSE (NMSE, 400 cm [range, 70-600]; SBE, 180 cm [range, 60-430]; P< .0001). The total enteroscopy rate was higher with NMSE (37% vs .7% with SBE, P< .0001). All adverse events were mild. Both NMSE and SBE are safe and effective for small-bowel evaluation in suspected CD. NMSE is superior to SBE with regard to deeper small-bowel evaluation with complete small-bowel coverage and shorter procedure time.

Endoscopic management of small bowel obstruction caused by intragastric balloon using antegrade single-balloon enteroscopy.

A 44-year old woman with type 2 diabetes mellitus who underwent intragastric balloon (Spatz3) insertion 1 year ago presented with acute abdominal pain for 3 days. Abdominal examination showed mild tenderness at the epigastrium. Laboratory investigation showed a white blood cell count of 12,630 /mm3. An abdominal computed tomography (CT) scan revealed a distally migrated intragastric balloon in the mid-jejunum causing a small bowel obstruction ([Fig. 1]). After a discussion regarding treatment options, she decided to undergo endoscopic removal using antegrade single balloon-assisted enteroscopy.

Evaluation of the diagnostic and therapeutic utility of retrograde through-the-scope balloon enteroscopy and single-balloon enteroscopy.

BACKGROUNDRetrograde single balloon enteroscopy (SBE) is a minimally invasive procedure which is less frequently performed compared with antegrade SBE. There are few studies on the retrograde through–the-scope enteroscopy (TTSE), a novel technique for evaluation of the small bowel.AIMTo compare the clinical utility and safety of retrograde TTSE with retrograde SBE.METHODSClinical data and complications of retrograde TTSE (2014-2018) and retrograde SBE (2011-2018) performed in a community hospital were reviewed and presented as mean ± SD or frequency (%) and compared using proper statistical tests. Technical success was defined as insertion of the enteroscope > 20 cm beyond ileocecal valve.RESULTSData obtained from 54 retrograde SBE in 49 patients and 27 retrograde TTSE in 26 patients were studied. The most common indication for retrograde enteroscopy was iron deficiency anemia (41 patients) followed by gastrointestinal bleeding (37 patients), and chronic diarrhea (7 patients). The duration of retrograde SBE procedure (91.9 ± 34.2 min) was significantly longer compared with retrograde TTSE (70.5 ± 30.7 min) (P = 0.04). Technical success was comparable in TTSE [23/27 (85.2%)] and SBE [41/54 (75.9%) (P = 0.33)]. The mean depth of insertion beyond the ileocecal valve in retrograde SBE (92.5 ± 70.0 cm) tended to be longer compared with retrograde TTSE (64.6 ± 49.0 cm) (P = 0.08). No complication was observed in this study.CONCLUSIONBoth retrograde TTSE and retrograde SBE are feasible and safe. Retrograde TTSE takes a shorter time and has a comparable technical success with SBE. TTSE has a lower capacity of small bowel insertion.

Gastrointestinal: Small bowel lymphangioma diagnosed by single‐balloon enteroscopy

A 46-year-old woman was referred with 3 months of episodic abdominal pain, melena, fatigue and shortness of breath. The patient's fecal occult blood was positive, and the complete blood count revealed severe anemia suggestive of gastrointestinal bleeding. Blood transfusion was performed to maintain her hemoglobin around 90 g/L. Following admission, the patient was investigated with esophagogastroduodenoscopy (EGD) and colonoscopy, but the location of bleeding was not identified. Video capsule endoscopy (CE) showed red blood in the jejunum, but the etiological factor remained unknown. The patient was futher referred for a single-balloon enteroscopy (SBE) investigation. Based on the location of the lesion on CE, antegrade SBE was performed with the patient under general anesthesia. A circumferential submucosal lesion with thickened and yellowish-white mucosal folds was identified in the proximal part of the jejunum. Many bleeding points could be seen on the surface of the lesion (Figure 1). The lesion appeared consistent with a typical lymphangioma. Dilated lymphatic vessels were evident in endoscopic biopsy specimen, which confirmed the lesion to be small-bowel lymphangioma (Figure 2). The patient was then referred for surgical resection of the lesion. The tumor was found at 15 cm distal to the ligament of Treitz and was resected successfully. The surgical specimen was of a soft, yellow-white lesion and was measured at 60 × 50 mm. The cut surface contained tiny multicystic spaces with milky fluid. Histological examination revealed a localized area of numerous and variable-sized dilated lymphatic channels in the mucosa and submucosa. The final diagnosis was simple lymphangioma with bleeding into the lymphatic vessels. The patient's melena resolved immediately after surgery and did not recur. Lymphangiomas are usually found in childhood and adult cases are rare. The etiology of lymphangiomas is probably a primary malformation of the lymphatic system. Histologically, lymphangiomas are classified into three types: simple, cavernous or cystic. Small-bowel lymphangioma is a benign tumor of the lymphatic system, and it is very rare. It is reported that Lymphangiomas comprise only 3% of benign small bowel tumors. Lymphangioma is usually discovered incidentally during examination or operation for an unrelated complaint. However, they are rarely reported as the cause of significant GI bleeding or acute abdominal pain. Single-balloon enteroscopy (SBE) has established itself as an effective tool in the diagnosis and management of small bowel diseases since its availability in 2006. It is reported that SBE system is easier to perform and may provide higher quality images superior than double-balloon enteroscopy. This is the first case report of small-bowel lymphangioma diagnosed through single-balloon enteroscopy. Surgery is the treatment for small bowel lymphangiomas, surgeons usually aim for complete removal of the tumor with surrounding organs of potential invasion, because there is a possibility of recurrence and invasion to surrounding organs. Contributed by

Use of Capsule Small Bowel Transit Time to Determine the Optimal Enteroscopy Approach.

BackgroundCapsule small bowel transit time (SBTT) is used to select the most effective enteroscopy approach when targeting capsule endoscopy (CE) findings. Aim of this study was to determine if capsule SBTT can be used to guide the choice of enteroscopy technique for reaching CE abnormalities.MethodsSingle center, retrospective study involving 60 patients. Data were abstracted from medical records of patients with abnormal CE who proceeded to enteroscopy which included push enteroscopy (PE) single balloon enteroscopy (SBE) and double balloon enteroscopy (DBE).ResultsNinety five findings were documented on CE with presumed identification of 56 (59%) of these abnormalities by enteroscopy. Majority were angioectasias on CE (42%) and enteroscopy (59%). Optimal cutoff values for selection of enteroscopy procedure were: 0-21% SBTT for PE (80% sensitivity, 74% specificity, 83% PPV); 0 - 36% SBTT for antegrade SBE (93% sensitivity, 40% specificity, 82% PPV); 0 - 57% SBTT for antegrade DBE (75% sensitivity, 80% specificity, 75% PPV); and 74 - 100% SBTT for retrograde DBE (88% sensitivity, 78% specificity, 78% PPV).ConclusionCapsule SBTT may be used to guide the selection of enteroscopy approach. PE, antegrade SBE, antegrade DBE and retrograde DBE are optimal when abnormalities on CE are seen at ≤ 21%, ≤ 36%, ≤ 57% and ≥ 74% SBTT respectively.

Bleeding Meckelʼs Diverticulum with a Negative Meckelʼs Scan - Uncommon Feature of an Uncommon Entity

Purpose: Case: A 30-year old male presented with a 13-month history of obscure GI bleeding. He initially presented elsewhere after a single episode of maroon colored stools. He had been previously healthy, and used NSAIDs rarely. He was adopted and of Korean descent; his family history was unknown. He denied easy bruising or epistaxis. Initial workup elsewhere revealed iron-deficiency anemia. EGD and colonoscopy were negative. He was advised to avoid NSAIDs, which he did. Two weeks later, he had recurrent bleeding. A capsule enteroscopy, single balloon enteroscopy (SBE), tagged red blood cell scan and Meckel's scan were negative. At our institution, a repeat antegrade SBE showed a single non-bleeding jejunal vascular ectasia that was cauterized. He was well for 9 months, then again developed maroon stools. He denied NSAID use. Workup included a SBE that was unremarkable, a triple-phase CT enterography (CTE) showing a Meckel's diverticulum, a Meckel's scan which was again negative, and a capsule enteroscopy revealing a mid-ileal ulcer. Due to ongoing bleeding, a retrograde double balloon enteroscopy (DBE) was done and revealed a large mid-ileal diverticulum with a 2 cm ulcer at its rim containing a flat pigmented spot, treated endoscopically. Persistent bleeding led to surgical resection of the diverticulum. Pathology confirmed a Meckel's diverticulum, with circumferential ulceration around its neck and a thrombosed artery in the ulcer base. Histologic sampling of the entire diverticulum failed to reveal ectopic gastric mucosa. Discussion: Meckel's diverticulum is the most common congenital anomaly of the GI tract. It affects 2% of the population, but only 2% develop complications, often before age 2. Complications include bleeding (most commonly), obstruction, diverticulitis, intussusception and perforation. Up to 90% of bleeding diverticula contain ectopic gastric mucosa. Our patient had a triple-phase CTE demonstrating a Meckel's diverticulum, and a DBE localizing it as the bleeding source, despite negative Meckel's scans. Histologic evaluation of the surgical specimen failed to reveal ectopic gastric mucosa, ruling out acid-mediated ulceration. The pattern of ulceration suggested the diverticulum had bled from repetitive inversion and eversion of the diverticulum into the ileal lumen, leading to ulceration in the neck. This putative mechanism has not been reported in the literature. This case highlights that a Meckel's diverticulum may be a source of GI bleeding despite absence of ectopic gastric mucosa.

First successful antegrade single-balloon enteroscopy in a 3-year-old with occult GI bleeding

Balloon enteroscopy is an emerging technique to allow access to the small intestine for both diagnostic and therapeutic purposes. To date, there have been few published data documenting the safety and efficacy of balloon enteroscopy in small children. To describe our experience with single-balloon enteroscopy (SBE) in a 37-month-old toddler with occult GI bleeding. A single case report. A free-standing, academic children's hospital in Denver, Colorado. The patient was a 37-month-old, 13.5-kg toddler with persistent heme-positive stools, severe microcytic anemia, and hypoalbuminemia. Previous workup was significant for eosinophilic inflammation in the antrum and a video capsule study showing erythematous lesions in the small bowel. An antegrade SBE was performed with the child under general endotracheal anesthesia, with biopsy specimens obtained from identified lesions in the jejunum and ileum. Complications and successful treatment of symptoms were the primary endpoints. The procedure was performed successfully in 85 minutes, passing an estimated 200 cm beyond the pylorus, without complications. Identification of the lesions as consistent with eosinophilic enteropathy led to successful treatment with an elimination diet and corticosteroids. The primary limitation of this study is that it is a single case report. Therefore, it is difficult to make a generalized statement regarding the safety and efficacy of balloon enteroscopy in toddlers of this size. Antegrade SBE can be a well-tolerated and effective procedure to evaluate occult GI bleeding in children as young as 3 years of age. Further study is needed to better establish safety parameters for balloon enteroscopy in small pediatric patients.