Management Of Small Bowel Diseases Research Articles

Double balloon enteroscopy: a 3-year experience at a tertiary care center.

To evaluate the indications, diagnostic yield, therapeutic interventions, complications and safety of double balloon enteroscopy (DBE) in clinical practice. The medical records of the patients who underwent DBE at the Turkiye Yuksek Ihtisas Hospital between October 2007 and January 2010 were examined to note the demographic data, indications for the examination, results of previous non-invasive small bowel imaging and endoscopic procedures and the results of DBE including findings, endoscopic interventions, complications and pathological reports. A total of 139 procedures were performed in 118 patients. DBE was performed 81 times through mouth and 26 times through anus and additionally both approaches were used 16 times in the same patients. Panenteroscopy was successfully performed in 13 of 16 patients (87.5%) in whom it was attempted. The most common indication was obscure gastrointestinal bleeding (28.8%). DBE had an overall diagnostic and/or therapeutic contribution in 63 (53.4%) patients. The main pathologies detected on DBE were polyps (12.7%), infammation (10.7%) and vascular lesions (3.4%). Complications were recognized in four cases (3.4%) but no major complication occured. Our retrospective analysis showed that DBE is a useful, safe and well-tolerated method with a diagnostic and therapeutic impact for the management of small bowel diseases.

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

Double‐balloon endoscopy in clinical practice: Where are we now?

Double-balloon endoscopy (DBE) was developed in 2000 for the diagnosis and treatment of small bowel diseases. Although use rates still differ between Eastern and Western countries, DBE quickly reached a broad global diffusion. Together with capsule endoscopy (CE), DBE represented 'a revolution' for the management of small bowel diseases because of its therapeutic capabilities. At present, the main indications for DBE in clinical practice are obscure gastrointestinal bleeding, Crohn's disease and familial polyposis. In the setting of obscure gastrointestinal bleeding, DBE seems to have similar diagnostic performances as capsule endoscopy, but it allows for a more definitive diagnosis and the treatment of identified lesions. The main contribution of DBE in the management of Crohn's disease patients is its therapeutic capabilities. Indeed, several recently published studies have suggested that endoscopic dilation of small bowel strictures can delay or, in the near future, could even replace surgical interventions. Also, for patients with familial polyposis syndromes, DBE can represent a viable alternative to small bowel surgery. The complication rate of DBE appears to be low; major complications, such as pancreatitis, bleeding and perforation, have been reported in approximately 1% of all diagnostic DBE whereas the complication rate for therapeutic procedures is about 5%.

Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications

Enteroscopy, defined as direct visualization of the small bowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past several years. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies one of which is non-invasive, the video capsule, and a type of invasive technique, the device-assisted enteroscopy. In particular, the device-assisted enteroscopy consists then of three different types of instruments all able to allow, in skilled hands, to display partially or throughout its extension (if necessary) the small intestine. Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocarcinoma or gastrointestinal stromal tumors. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

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 single-balloon 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.

Double-balloon enteroscopy: The diagnosis and management of small bowel diseases

Double-balloon enteroscopy is a novel endoscopic technique developed to investigate small bowel diseases. The aim of this study was to evaluate the diagnostic and therapeutic impact of double-balloon enteroscopy in patients with suspected or documented small bowel disease who were referred to our tertiary center, which was the first to introduce the double-balloon enteroscopy system in Turkey. This is a single-center prospective study. A total of 216 double-balloon enteroscopy procedures (168 antegrade, 48 retrograde) were done in 188 patients who were referred to our center for suspected small bowel disease. The main outcome measurements were complications, insertion depth and duration, and diagnostic and therapeutic rates. Indications included obscure gastrointestinal system bleeding, iron deficiency anemia, abnormality on radiographic evaluation, abdominal pain, diarrhea, and suspected celiac disease. A diagnosis was established in 130 (69%) patients. The most common pathologic findings included angiodysplasias (29%), ulcerations (16%) and Crohn's disease (9%). Mean time±standard deviation to perform the examination using the antegrade route was 116.4±7.17 min, and the average±standard deviation insertion length was 310.65±90.3 cm (beyond the pylorus). Therapeutic interventions were performed in 66 patients (56 angiodysplasias, 4 ulcers, 4 strictures, and 2 polyps), and the success rate was 97%. No serious complication was observed, although pancreatitis occurred in 6 of 48 (12.5%) patients who were followed up for post-procedure pancreatic enzyme levels. Our prospective analysis suggests that double-balloon enteroscopy is a feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders.

The clinical utility of single-balloon enteroscopy: a single-center experience of 172 procedures

Single-balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small-bowel disease. Although there is substantial literature addressing double-balloon enteroscopy and its impact on the diagnosis and management of small-bowel disease, there are limited data available on the clinical utility of SBE. To evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center. Single-center, retrospective study. Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio. A total of 161 patients were referred for SBE from January 2006 to August 2008. Demographic, clinical, procedural, and outcome data were collected and analyzed. A total of 161 patients underwent a total of 172 procedures. Antegrade and retrograde approaches were used in 83% and 17% of subjects, respectively. The average insertion depth using the antegrade approach was 132 cm beyond the ligament of Treitz (range 20-400 cm). The average insertion depth using the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). The average procedure time was 40 minutes overall, 38 minutes (range 12-90) antegrade and 48 minutes (range 28-89) retrograde. Fluoroscopy was used in 20 cases (12%). Diagnostic yield was 58% (99/172); 42% (72/172) were therapeutic cases. There were no significant complications. Single-center, retrospective study. SBE demonstrated a high diagnostic yield and frequently provided useful therapeutic intervention. It seems to be a safe and effective method for performing deep enteroscopy.

Double-balloon enteroscopy in the elderly: safety, findings, and diagnostic and therapeutic success

Double-balloon enteroscopy (DBE) is an important tool in the evaluation and management of small-bowel disease. Limited data are available on the safety, findings, and outcomes of DBE in elderly patients. To determine the safety and efficacy of DBE in elderly patients. Single-center, retrospective analysis of prospectively collected database. Open-access, tertiary care referral center. A total of 176 patients undergoing DBE (216 procedures) for evaluation of small-bowel disease between August 2007 and August 2008. Argon plasma coagulation of bleeding small-bowel lesions. DBE complication rate, diagnostic/therapeutic success of DBE. An age cutoff of 75 years and older was used to designate patients as elderly. Data on complications, indications, findings, and diagnostic and therapeutic success of DBE were compared between age groups. The mean age of patients was 66 +/- 16.4 years (range 20-95 years). DBE was performed in 185 patients, including 60 patients age 75 years and older and 110 patients younger than age 75. An overall complication rate of 0.9% was seen for DBE in this study, with no significant difference between age groups. No major complications were observed in elderly patients. Elderly patients were more likely to have angioectasias (39% vs 23%; P = .01) and were more likely to require endoscopic therapy during DBE (46.8% vs 29.2%; P = .01). Single-center, retrospective study. DBE is safe in elderly patients. Elderly patients are more likely to have angioectasias and to require endoscopic therapy during DBE.

Cardiac Pacemaker and Wireless Capsule Endoscopy Interference: Case Report in a Patient with Gastric Vascular Ectasias

Wireless capsule endoscopy is a new endoscopic tool for the diagnosis and management of small bowel diseases. The main indication at present is the evaluation of GI bleeding of obscure origin, Crohn’s disease, coeliac disease and small bowel tumors. Studies suggest that capsule endoscopy is associated with few adverse events. Whether cardiac pacemaker may interfere with capsule endoscopy is still a controversial issue. We here report a case showing that there is a possibility of interference between the two procedures, cardiac pacemaker affecting the proper functioning of capsule endoscopy and that this is related to the distance between the pacemaker and the recorder.

Single-balloon Enteroscopy

Single-balloon enteroscopy has emerged as a viable alternative to double-balloon enteroscopy in the management of small bowel disease. Technically, it is easier to perform, may be more efficient, and in the limited literature available, seems to provide similar diagnostic and therapeutic yield when compared with double-balloon enteroscopy. This review provides up-to-date views on this emerging technology and its application.

Small bowel enteroscopy: territory conquered, future horizons

To review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies, video capsule, and double balloon endoscopy. Newer devices, single balloon and spiral endoscopy, are just entering clinical use. With new technologies come the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease. Identification of small bowel lesions has dramatically improved. However, small bowel angulations, peristalsis, and bilious fluid in the lumen can result in false readings or missed lesions. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly bleeding. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require patience and significant skill. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

Five years' experience with capsule endoscopy in a single center.

Capsule endoscopy (CE) is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding (OGIB) has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases. Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn's disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.

Single Balloon Enteroscopy in Comparison to Capsule Endoscopy in the Diagnosis and Management of Small Bowel Disease

Single Balloon Enteroscopy in Comparison to Capsule Endoscopy in the Diagnosis and Management of Small Bowel Disease

Single-Operator Double Balloon Enteroscopy in the Management of Small Bowel Diseases

Background: Double Balloon Enteroscopy (DBE) has increasingly been used as a new tool in the diagnosis and treatment of small bowel diseases. However, the need for two expert operators and long duration of each procedure has limited its clinical usage and cost effectiveness. We described the technique of single-operator DBE (SODBE) in the successful management of small bowel diseases. Methods: The technique of SODBE involved the use of an over-tube/enteroscope holder thus allowing alternative control of over-tube and enteroscope by a single operator. We prospectively studied 25 patients between March 2005 and November 2005 using this new technique in patients with suspected small bowel diseases. The indications for SODBE were obscure GI bleeding in 18 patients, clarification of previous findings and biopsies in 5 patients and recurrent abdominal pain in 2 patients. Results: A total of 33 procedures were done by a single operator. Eleven, 6 and 8 patients had SODBE done through oral, anal and combined routes respectively. The duration taken for each procedure ranged from 20 minutes to 120 minutes. Small bowel diseases were detected in 17 patients. The diagnoses were NSAIDS ulcers/erosions, jejunal polyps, jejunal diverticulosis, Crohn's disease, GIST, lymphoma and angiodysplasia in 4, 3, 3, 2, 1, 1 and 1 patients respectively. In 2 patients who had complete small bowel examination, gastric antral vascular ectasia (GAVE) was detected. Jejunal polypectomies were done in 2 patients and argon plasma coagulation was used for hemostasis in 1 patient with angiodysplasia. No complication was reported in all the diagnostic and therapeutic SODBE. Conclusions: SODBE, a modified technique of performing DBE has been shown to be effective in the management of small bowel diseases. It allowed a single operator to perform DBE cost-effectively. It will be useful especially in places with limited trained operators and clinical situations requiring urgent enteroscopy such as overt small bowel bleeding.

Double-balloon enteroscopy in the diagnosis and the management of small-bowel diseases: an initial experience in 40 patients

Double-balloon enteroscopy (DBE) is a new technique, recently described by its innovator, and it is seen to be beneficial in the diagnosis and management of small-bowel disease. To evaluate this new technique in consecutive patients with suspected small-bowel disease. Single-center prospective study. Tertiary referral hospital, conducted from July to December 2004. Forty consecutive patients with suspected small-bowel disease referred for DBE, mean age of 58 years (range, 14-89 years), 17 men. Endoscopic biopsies or therapy was performed as clinically indicated. Significant diagnostic input and therapeutic intervention based on clinical outcomes. Indications included obscure GI bleeding (18), iron deficiency anemia (6), anemia of chronic disease (4), acute obscure GI bleeding (4), abdominal pain with other symptoms (4), Crohn's disease (3), and abdominal pain alone (1). Nineteen patients (47.5%) had a small-bowel finding, with 30 of 40 (75%) of the patients having a significant diagnostic input. Intervention was performed in 13 (32.5%) patients with success in 10 (77%). The only variable significantly associated with therapeutic success was a previous history of blood transfusions (p < 0.01). This was the only independent predictor identified by multiple logistic regression analysis (Odds ratio 13.5: 95% confidence interval [1.5, 120]). One perforation from contact diathermy occurred. In 10 attempts at total enteroscopy, none were successful. Nonblinded nonrandomized study. These early data suggest DBE to be effective in the diagnosis and the therapy of small-bowel disease, particularly those patients with a history of blood transfusion.

Capsule Imaging

Capsule endoscopy was conceived in the late 1980s by an electrico-optical engineer and first used in human beings clinically during the last 5 years. Already it has changed the management of small bowel diseases and is beginning to be used in the esophagus. Developments are under way to use the capsule in a wider range of clinical conditions. The literature has advanced from case series to outcome studies. The utility of capsule endoscopy is reviewed here.

Diagnosis and management of small intestinal diseases

Advances in the diagnosis and management of small bowel diseases are the subject of this review. Topics covered include improving the specificity of breath tests for bacterial overgrowth; small bowel enteroscopy; early diagnosis of mesenteric ischemia; the use of polymerase chain reaction for diagnosing central nervous system involvement in Whipple's disease; progress in defining the cause and pathogenesis of chronic idiopathic intestinal pseudoobstruction and the Peutz-Jeghers syndrome; defining the role of gut barrier function in health and disease; the therapeutic role for bile acid-binding resins in diarrhea after refeeding in critically ill patients; use of genetic techniques and topical steroid therapy in treating graft-versus-host disease; and the beneficial effects of combination hormonal therapy in occult gastrointestinal blood loss resulting from angiodysplasia.