Balloon Enteroscopy Research Articles

Evaluation of Deep Remission with Through-The-Scope Catheter-Based Endoscopic Ultrasound during Double Balloon Enteroscopy in Small Bowel Crohn’s Disease

Evaluation of deep remission in Crohn's disease (CD) can be challenging when the disease is confined to the small intestine. The aim of this study was to evaluate the effectiveness of through-the-scope (TTS) endoscopic ultrasound (EUS) during Double-balloon enteroscopy (DBE) in distinguishing small-bowel CD patients in endoscopic remission from those with active disease. Patients who underwent DBE-EUS were divided into groups of endoscopic remission and endoscopic activity according to segmental Simple Endoscopic Score for Crohn's Disease (SES-CD). Thickness of small intestinal wall layers and other parameters were evaluated by EUS. EUS using the ultrasonic catheter probe via DBE showed that the total wall thickness (TWT) and submucosal thickness (SMT) of the small intestine in the active group were significantly greater than those in the remission group (TWT 3.84±1.02 vs 2.42±0.25mm, SMT 1.23±0.34 vs 0.79±0.13mm, respectively, p<0.001). Cut-off values of 2.65 mm for TWT and 0.95 mm for SMT can distinguish active small-bowel CD from inactive disease (Sensitivity 91.5%, Specificity 80.8% and Sensitivity 70.2%, Specificity 88.6%, respectively). The correlation analysis revealed a significant positive correlation between TWT and SES-CD (r=0.930, p<0.001). Furthermore, TWT was strongly correlated with FC (r=0.861, p<0.001) and CDAI (r=0.805, p<0.001). Similar results were observed for SMT. EUS using an ultrasonic catheter probe during DBE is effective in evaluation of both mucosal and transmural healing in small-bowel CD patients. DBE-EUS could become an important tool in the management of patients with small-bowel CD.

Prospective multicenter study to identify optimal target population for motorized spiral enteroscopy

Motorized spiral enteroscopy (MSE) enhances small bowel exploration, but the optimal target population for this technique is unknown. We aimed to identify the target population for MSE by evaluating its efficacy and safety, as well as detecting predictors of efficacy. A prospective multicenter observational study was conducted at 9 tertiary hospitals in Spain, enrolling patients between June 2020–2022. Analyzed data included demographics, indications for the procedure, exploration time, depth of maximum insertion (DMI), technical success, diagnostic yield, interventional yield, and adverse events (AE) up to 14 days from enteroscopy. Patients with prior gastrointestinal surgery, unsuccessful balloon enteroscopy and small bowel strictures were analyzed. A total of 326 enteroscopies (66.6% oral route) were performed in 294 patients (55.1% males, 65 years ± 21). Prior abdominal surgery was present in 50% of procedures (13.5% gastrointestinal surgery). Lower DMI (162 vs 275 cm, p = 0.037) and diagnostic yield (47.7 vs 67.5%, p = 0.016) were observed in patients with prior gastrointestinal surgery. MSE showed 92.2% technical success and 56.9% diagnostic yield after unsuccessful balloon enteroscopy (n = 51). In suspected small bowel strictures (n = 49), the finding was confirmed in 23 procedures (46.9%). The total AE rate was 10.7% (1.8% classified as major events) with no differences related to prior gastrointestinal/abdominal surgery, unsuccessful enteroscopy, or suspected small bowel strictures. The study demonstrates that MSE has a lower diagnostic yield and DMI in patients with prior gastrointestinal surgery but is feasible after unsuccessful balloon-enteroscopy and in suspected small bowel strictures without safety concerns.

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.

Double balloon enteroscopy versus single balloon enteroscopy: A comparative study.

Device assisted enteroscopy (DAE) like the double balloon enteroscopy (DBE) and single balloon enteroscopy (SBE) are postulated to ease small bowel examination and performance of therapy. However, studies comparing the effectiveness of these 2 modalities have yielded varying results. The aim of this study is to compare the efficacy and safety of SBE and DBE. We retrospectively reviewed records of patients who underwent DBE (n = 82) or SBE (n = 45) for small bowel exam in our unit from January 2014 to January 2022. Our primary outcomes were to compare the technical success and diagnostic success rates between DBE and SBE. Our secondary outcomes were to compare the therapeutic success, and complication rates. The main indications were suspected GI bleeding (DBE 41.5% vs SBE 48.9%), iron deficiency anemia (DBE 9.8% vs SBE 4.4%) and small bowel lesions (DBE 28.0% vs SBE 44.4%) detected either from prior capsule endoscopy or radiological imaging. Majority of the enteroscopy exam was by antegrade approach (DBE 67.1% vs SBE 77.8%). We found no significant difference in the technical success (DBE 95.1% vs SBE 97.8%, P = .46), diagnostic success (DBE 69.5% vs SBE 77.8%, P = .36) and the therapeutic success rate (DBE 63.2% vs SBE 54.3%, P = .09) between the groups. Complications occurred in 1 case from each group (mucosal tear). None of the complications were major. In patients who underwent enteroscopy, the diagnostic and therapeutic performance of SBE is similar to DBE. Both procedures were safe with low complication rates.

Peroral cholangioscopy-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy for Roux-en-Y anastomosis.

Peroral cholangioscopy-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy for Roux-en-Y anastomosis.

Clinical Decision Making in Inflammatory Bowel Disease Mimics: Practice Management from Inflammatory Bowel Disease LIVE.

Since 2009, inflammatory bowel disease (IBD) specialists have utilized "IBD LIVE," a weekly live video conference with a global audience, to discuss the multidisciplinary management of their most challenging cases. While most cases presented were confirmed IBD, a substantial number were diseases that mimic IBD. We have categorized all IBD LIVE cases and identified "IBD-mimics" with consequent clinical management implications. Cases have been recorded/archived since May 2018; we reviewed all 371 cases from May 2018-February 2023. IBD-mimics were analyzed/categorized according to their diagnostic and therapeutic workup. Confirmed IBD cases made up 82.5% (306/371; 193 Crohn's disease, 107 ulcerative colitis, and 6 IBD-unclassified). Sixty-five (17.5%) cases were found to be mimics, most commonly medication-induced (n = 8) or vasculitis (n = 7). The evaluations that ultimately resulted in correct diagnosis included additional endoscopic biopsies (n = 13, 21%), surgical exploration/pathology (n = 10, 16.5%), biopsies from outside the GI tract (n = 10, 16.5%), genetic/laboratory testing (n = 8, 13%), extensive review of patient history (n = 8, 13%), imaging (n = 5, 8%), balloon enteroscopy (n = 5, 8%), and capsule endoscopy (n = 2, 3%). Twenty-five patients (25/65, 38%) were treated with biologics for presumed IBD, 5 of whom subsequently experienced adverse events requiring discontinuation of the biologic. Many patients were prescribed steroids, azathioprine, mercaptopurine, or methotrexate, and 3 were trialed on tofacitinib. The diverse presentation of IBD and IBD-mimics necessitates periodic consideration of the differential diagnosis, and reassessment of treatment in presumed IBD patients without appropriate clinical response. The substantial differences and often conflicting treatment approaches to IBD versus IBD-mimics directly impact the quality and cost of patient care.

Role of Novel Motorized Enteroscopy in the Evaluation of Small Bowel Diseases: A Systematic Review and Meta-analysis.

Motorized spiral enteroscopy (MSE) has recently been introduced for small bowel evaluation. In this systematic review and meta-analysis, we aim to evaluate the safety and efficacy of MSE for evaluation of small bowel diseases. A literature search was performed in Embase, PubMed, Medline databases for studies evaluating MSE between January -2010 and October-2022. The primary outcome of the study was diagnostic yield with MSE. Secondary outcomes included technical success, procedure duration, depth of maximum insertion (DMI), rate of pan-enteroscopy and adverse events. 10 studies with 961 patients [581 (60.5%) males] were included in the analysis. 1068 MSE procedures were performed by antegrade route in 698, retrograde route in 215 and bidirectional in 155 patients. Technical success was achieved in 94.9% (95% CI 92.9% to 96.4%) procedures. The pooled diagnostic yield of MSE was 73.7% (95% CI 70.7% to 76.4%). Pooled rate of pan-enteroscopy by antegrade route was 21.9% (95% CI 18.1% to 26.1%), retrograde route was 6.9% (95% CI 2.4% to 18.3%) and combined route was 61.2% (95% CI 52.4% to 69.3%). Pooled rate of major adverse events was 1.9% (95% CI 1.2% to 3.2%). MSE is a safe and effective tool for evaluating small bowel disorders. High diagnostic yield and low rate of adverse events make it a potential alternative to balloon enteroscopy. However, comparative trials are required in the future.

Successful cholangioscopy-guided biopsy using a novel thin cholangioscope under balloon enteroscopy in a patient with Roux-en-Y gastrectomy.

Successful cholangioscopy-guided biopsy using a novel thin cholangioscope under balloon enteroscopy in a patient with Roux-en-Y gastrectomy.

Efficacy of a novel drill dilator in overcoming severe biliary strictures with balloon enteroscopy.

Efficacy of a novel drill dilator in overcoming severe biliary strictures with balloon enteroscopy.

A165 MALIGNANT TUMORS OF THE SMALL BOWEL DIAGNOSED BY DOUBLE BALLOON ENTEROSCOPY: A FIFTEEN-YEAR EXPERIENCE OF A MEDICAL CENTER IN MID-TAIWAN

Abstract Background The malignant tumors of the small bowel are relatively rare, and their pre-operative diagnosis is usually difficult Aims This study was aimed to investigate the clinical characteristics of patients with malignant small bowel tumors who underwent double balloon enteroscopy. Secondary end points were to evaluate the usefulness and safety of double balloon enteroscopy for the diagnosis of patients with suspected small bowel tumors derived from other previous procedures. Methods From January 2008 to June 2023, we retrospectively analyzed consecutive patients who underwent double balloon enteroscopy at a medical center in mid-Taiwan over a 15-year period (Figure 1). Results Double balloon enteroscopy were performed in 1001 patients. Small bowel tumors were diagnosed in 141 patients (141/1001; 14.1%), of which 76 patients (53.9%) (43 males, a mean age of 61.89 years) had malignant tumors : 37 had gastrointestinal stromal tumors (49.4%), 16 had adenocarcinoma (20.8%), 10 had metastatic cancer (13.1%), 7 had lymphoma (9.2%), 3 had angiosarcoma (3.9%), 2 had carcinoid (2.6%), and 1 had desmoid tumor (1.3%) (Figure 2). The indications for double-balloon enteroscopy in patients with malignant small bowel tumors were obscure gastrointestinal bleeding (68.4%). The concordance rate of diagnoses based on double balloon enteroscopy with diagnoses based on small bowel barium study, computed tomography, and capsule endoscopy among patients with small bowel tumors was 54.1%, 65.9% , and 76.9%, respectively. (Figure 3, 4) . Therapeutic plans were changed to surgery in 67.1 % of patients with malignant small bowel tumors. Additionally, treatment was added on chemotherapy in 25.6% of patients with malignant small bowel tumors after the results of double-balloon enteroscopy. Conclusions Approximately 14.1% of patients who underwent double balloon enteroscopy had small bowel tumors, 53.9% of small bowel tumors are malignant. The most common indication for double balloon enteroscopy in patients with malignant small bowel tumors was obscure gastrointestinal bleeding. Double balloon enteroscopy is a very useful modality in diagnosing malignant small bowel tumors and has an important impact on therapeutic plans and clinical results. Figure 1. The Prevalence Rate of Small Bowel Tumor Figure 2. Malignant tumor Figure 3. Location Distribution of Small Bowel Tumors Figure 4. The clinical manifestations of Malignancy Tumors Funding Agencies None Intestinal Disorders

Endoscopic ultrasound-guided antegrade treatment versus balloon enteroscopy endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis.

The safety and technical success of endoscopic ultrasound-guided antegrade treatment (EUS-AG) compared to balloon enteroscopy-assisted endoscopic cholangiopancreatography (BE-ERCP) for choledocholithiasis in Roux-en-Y gastrectomy has not been well documented. We performed a systematic review and meta-analysis to assess the safety and efficacy of the 2 procedures. A systematic search of multiple databases was undertaken through January 25, 2024, to identify relevant studies comparing the 2 procedures. Standard meta-analysis methods were employed using a random-effects model. For each outcome, risk-ratio (RR), 95% confidence interval (CI), and P-values were generated. P<0.05 was considered significant. Heterogeneity was assessed using the I 2 statistic. Three studies with 795 patients (95 in the EUS-AG group and 700 in the BE-ERCP group) were included. The technical success rate was similar between EUS-AG and BE-ERCP (RR 1.08, 95%CI 0.84-1.38; P=0.57; I 2=56%). The overall rate of adverse effects was higher in the BE-ERCP group than in the EUS-AG group (RR 1.95, 95%CI 1.21-3.15; P=0.006; I 2=0 %). Rates of clinical success, pancreatitis, perforation, and bile peritonitis were similar between the 2 procedure techniques. Our analysis showed no distinct advantage in using one technique over the other for patients with Roux-en-Y anatomy in achieving technical and clinical success. However, the incidence of adverse effects was greater in the BE-ERCP group than in the EUS-AG group.

Inspection of intraductal papillary mucinous neoplasm via the papilla using a novel slim pancreatoscope under balloon enteroscopy.

Inspection of intraductal papillary mucinous neoplasm via the papilla using a novel slim pancreatoscope under balloon enteroscopy.

Oral Drug for Small Intestinal Angiodysplasia Bleeding: Every Cloud Has a Silver Lining!!

AbstractBecause of both difficulties in accurate diagnosis and appropriate management, small bowel bleeding due to angiodysplasia remains a challenging and perplexing issue in clinical practice. Advancement in small bowel endoscopy including capsule endoscopy as well as balloon enteroscopy has expanded the domain of endoscopic hemostatic interventions in the small bowel. This has led on to marked improvement in immediate homeostasis rates in patients with small bowel angiodysplasias (SBA) bleeding. However, high recurrent bleeding rates are an important limitation of endoscopic interventions. Therefore, there is an unmet need of an effective therapeutic as well as prophylactic pharmacotherapy that can alter the course of the disease. Long-acting octreotide as well as thalidomide has been used in patients with SBA bleeding with encouraging results, but the evidence on their efficacy is not robust. In news and views of this issue, we discuss a randomized controlled study that investigates the efficacy and safety of thalidomide for the treatment of recurrent bleeding due to SBA.

Balloon enteroscopy: a modern view of the problem

Balloon enteroscopy: a modern view of the problem

Emergent approach to small bowel tumors: diagnosis and treatment.

This study presents the diagnosis and treatment of rare small bowel tumors through clinical cases. Patients treated between 2000 and 2023 were included in the study. The clinical records of the patients were analyzed retrospectively. A total of 34 patients were included in the study. Of these patients, 26 (75.5%) were male and eight (23.5%) were female. The mean age of the patients was 62.1 years. The most common symptoms and signs were abdominal pain (76.4%), bloating (38.2%), and nausea and vomiting (17.6%). Diagnostic methods included computed tomography (CT) (82.3%), upper gastrointestinal double balloon enteroscopy (35.2%), and capsule endoscopy (5.8%). Diagnoses included adenocarcinoma in 13 cases, gastrointestinal stromal tumors (GISTs) in 12 cases, and neuroendocrine tumors (NETs) in two cases. Small bowel tumors frequently present with abdominal pain, bloating, and nausea and vomiting. CT and endoscopic procedures are the primary diagnostic tools. Small bowel cancers are often diagnosed late due to subtle clinical findings and the limitations of endoscopic imaging. Targeted screening strategies may be beneficial for certain at-risk and symptomatic patient groups. Early surgical intervention offers significant advantages for diagnosed patients.

Protein-losing enteropathy: is it Crohn's disease?

Case of a 24-year-old woman presenting due to edema in lower extremities. The patient had had infectious mononucleosis three weeks prior and had medical history of suspicion of Crohn's disease (CD) (due to a non-specific ileocolitis in a colonoscopy/EnteroRM). No ongoing medication. Laboratory evaluation unveiled hypoproteinemia with severe hypoalbuminemia, no renal abnormalities. A PLE was assumed, with post-infectious or CD being the most likely culprits. Alternative causes were extensively excluded. A videocapsule revealed white-tipped or granular villi, some white nodular villi and diffuse edema of the mucosa, and multiple extensive erosions and superficial ulcers in the jejunum and proximal ileum, not suggestive of CD. A push enteroscopy revealed unspecific histopathology. After incomplete response to enteral nutrition, corticotherapy was initiated resulting in sustained improvement. A follow-up Ileocolonoscopy and double balloon enteroscopy revealed no abnormalities. Six months post-treatment, the patient remains asymptomatic, with unremarkable laboratory results and no need for medication.

Evaluation of small bowel wall thickness with double balloon enteroscopy

Objectives: Double balloon enteroscopy (DBE) is an endoscopic method used for the evaluation of small bowel segments. Its advantage over other small bowel evaluation methods is that it allows treatment in addition to the detection of lesions. In this study, we evaluated the results of patients with small bowel abnormalities, especially wall thickness, on radiologic imaging who underwent double-balloon enteroscopy.&#x0D; Methods: The data of patients who were found to have wall thickness and stenosis in the small intestine on radiological imaging and who underwent DBE between January 2007 and December 2018 at Ankara City Training and Research Hospital were retrospectively analyzed. Patients with inadequate endoscopic images or medical records were excluded from this study.&#x0D; Results: The study included 112 patients. Of the patients, 69 (61.6%) were male and 43 (38.4%) were female. The mean age of the population was 45.59 ± 17 years. Abdominal pain was the main presenting symptom. The procedure was performed anterograde (oral) in 79 patients, retrograde (anal) in 25 patients, and both approaches in 8 patients. Various complications developed after 20 procedures, and no mortality was observed. Radiologically, small bowel wall thickness was most commonly detected on computed tomography, and the majority of the lesions detected were in the jejunum (63.9%). In 48 DBE procedures, no lesion was detected in the small intestine. The ulcer was the most common lesion detected during DBE (25.6%), and the majority were detected in the ileum. Crohn's disease was the most common pathology detected in the samples. Malignancy was the second most common pathology, and jejunal lymphoma was the most common malignancy.&#x0D; Conclusion: DBE should be used more frequently in clinical practice to evaluate radiologically detected small bowel lesions because of the possibility of biopsy and its high diagnostic accuracy.

Small Intestinal Polyp Burden in Pediatric Peutz-Jeghers Syndrome Assessed through Capsule Endoscopy: A Longitudinal Study.

The management of pediatric Peutz-Jeghers Syndrome (PJS) focuses on the prevention of intussusception complicating small intestinal (SI) polyposis. This hinges on the accurate appraisal of the polyp burden to tailor therapeutic interventions. Video Capsule Endoscopy (VCE) is an established tool to study SI polyps in children, but an in-depth characterization of polyp burden in this population is lacking. Methods: We performed a retrospective longitudinal cross-sectional analysis of VCE studies in pediatric PJS patients at our institution (CMKC) from 2010 to 2020. Demographic, clinical, and VCE findings reported by three reviewers in tandem were accrued. Polyp burden variables were modeled as functions of patient and study characteristics using linear mixed models adjusted for clustering. Results: The cohort included 15 patients. The total small bowel polyp count and largest polyp size clustered under 30 polyps and <20 mm in size. Luminal occlusion correlated closely with the estimated polyp size. Polyp distribution favored proximal (77%) over distal (66%) small bowel involvement. The adjusted largest polyp size was greater in males. Double Balloon Enteroscopy was associated with a decreased polyp burden. Conclusions: The polyp burden in pediatric PJS patients favors the proximal third of the small intestine, with relatively small numbers and a polyp size amenable to resection through enteroscopy. Male gender and older age were related to an increased polyp burden.

S1819 Predictors of Recurrent AVM-Related Bleeding in Patients With Advanced CKD Receiving Balloon Enteroscopy

S1819 Predictors of Recurrent AVM-Related Bleeding in Patients With Advanced CKD Receiving Balloon Enteroscopy

S1700 Examining the Impact of a GI Hospitalist Model on the Outcomes of Double Balloon Enteroscopy: A Single Center Retrospective Study

S1700 Examining the Impact of a GI Hospitalist Model on the Outcomes of Double Balloon Enteroscopy: A Single Center Retrospective Study