Small Bowel Strictures Research Articles

Agile Patency System Eliminates Risk of Capsule Retention in Patients with Known Intestinal Strictures Who Undergo Capsule Endoscopy (CE)

Purpose: CE has become a standard tool for evaluating the small bowel but there have been concerns regarding the risk of capsule retention in certain high risk groups. Using radiographic modalities to predict which patients are at risk of having a retained capsule has been shown to be inaccurate. Consequently, a radiation-free tool was developed to assess whether patients may safely undergo CE. The agile™ patency system (Given Imaging), an ingestible and dissolvable capsule with an external scanner, was developed to allow physicians to perform CE with greater confidence that the capsule will be safely excreted in patients at risk of capsule retention. Initial studies of an earlier version of this patency capsule demonstrated several cases where this device may have led to a partial obstruction. A new design of the capsule employs two timer plugs, one at each end, that allows the capsule to begin to dissolve at 30 hours after ingestion, thereby reducing the risk of obstruction if there is a stricture. This international, multi-center study was designed to assess the safety of the patency capsule in patients with known strictures and its ability to help physicians identify which patients may safely undergo CE. Methods: After informed consent, patients with known intestinal strictures ingested the new patency capsule. They underwent periodic scanning with a handheld scanner as well as fluoroscopy until the capsule was excreted. The intestinal tract was considered to be sufficiently patent if the capsule was excreted intact, or if the capsule was not detected by the scanner at 30 hours after ingestion. If patency was established, then the patient underwent CE with the PillCam™ SB capsule. Results: 106 patients ingested the patency capsule. 59 (56%) excreted it intact and subsequently underwent CE. There were no cases of retention of the video capsule. No patency capsules were found to have dissolved before 30 hours after ingestion. Significant findings on CE were found in 24 (41%). There were three adverse events labeled as severe. Two patients had abdominal pain which was also present before entering the study. One patient had nausea. Conclusion: These results suggest that the agile patency system is a useful tool for physicians to use prior to CE in patients with small bowel strictures to avoid retention of the capsule. In those patients believed to be at high risk for obstruction, the patency capsule functioned safely. This group of patients may have a high yield of clinically significant findings at CE. This capsule may determine if patients who have a contraindication to CE may safely undergo CE and obtain useful diagnostic information.

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

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.

CARD15 variants predict small-bowel stenosis in Crohn's disease

CARD15 variants predict small-bowel stenosis in Crohn's disease

Small bowel capsule endoscopy in 2007: indications, risks and limitations.

Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn's disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool (which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions). The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions (i.e. obscure GI bleeding), the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way (with capsule endoscopy) and to define and treat the lesions identified (with double balloon enteroscopy).

Computed tomographic enterography adds information to clinical management in small bowel Crohnʼs disease

CT enterography yields striking findings in the bowel wall in Crohn's disease. These images may help to evaluate whether small bowel narrowing results from active disease requiring anti-inflammatory therapy. However, the clinical relevance of these images is unknown. It is also not known if these radiologic findings correlate with objective biomarkers of inflammation. In a blinded and independent evaluation, IBD subspecialty gastroenterologists reviewed clinical data, and CT radiologists reviewed CT enterography scans of 67 consecutive patients with Crohn's disease and suspicion of either small bowel inflammation or stricture. Comparisons were made between (1) clinical and radiologic assessments of inflammation and stricture, (2) clinical assessments before and after computed tomographic enterography (CTE) reports were revealed, and (3) radiologic findings and objective biomarkers of inflammation. (1) Individual CTE findings correlated poorly (Spearman's rho < 0.30) with clinical assessment; (2) clinicians did not suspect 16% of radiologic strictures, and more than half the cases of clinically suspected strictures did not have them on CTE; (3) CTE data changed clinicians' perceptions of the likelihood of steroid benefit in 41 of 67 cases; (4) specific CTE findings correlated with CRP, and a distinct set of CTE findings correlated with ESR in the subset of patients who had these biomarkers measured. CTE seems to add unique information to clinical assessment, both in detecting additional strictures and in changing clinicians' perceptions of the likelihood of steroids benefiting patients. The biomarker correlations suggest that CTE is measuring real biologic phenomena that correlate with inflammation, providing information distinct from that in a standard clinical assessment.

Predictive value of the CARD15 variant 1007fs for the diagnosis of intestinal stenoses and the need for surgery in Crohnʼs disease in clinical practice: Results of a Prospective Study

The diagnostic and therapeutic relevance of CARD15 genotyping in Crohn's disease (CD) for daily clinical practice has not been investigated so far. We therefore analyzed whether CARD15 variants are independent predictive factors for small bowel stenosis in CD evaluated by magnetic resonance enteroclysis (MRE). On the basis of these findings, the potential implications for patient management were investigated. Eighty CD patients with clinical symptoms suggestive of small bowel stenosis were included. All patients were genotyped for the CARD15 variants c.2104C > T (p.R702W), c.2722G > C (p.G908R), and c.3019_3020insC (p.Leu1007fsX1008) and examined by MRE of the small bowel. CARD15 variants were found in 40 (50%) patients. MRE identified 31 (38%) patients with small bowel stenoses. Twenty-five of the 40 (62%) patients with at least one CARD15 variant were diagnosed of intestinal stenosis by MRE (odds ratio [OR] = 9.44; confidence interval [CI] 3.21-27.77; P = 0.00028, Bonferroni corrected). Particularly, the presence of the 1007fs variant was associated with an increased risk of an intestinal stenosis (OR = 12.00, CI 3.47-41.54, P = 0.00042, Bonferroni corrected). Twenty-one of 31 (68%) patients with stenoses required surgical intervention, with 13 of these 21 (62%) patients carrying the 1007fs variant. In the largest prospective study analyzing the diagnostic value of CARD15 variants in CD patients performed so far, we identified the 1007fs variant as strong predictor for intestinal stenoses with need for surgery in CD patients. Genotyping could therefore be an important diagnostic tool in clinical practice for identifying high-risk patients with specific diagnostic and therapeutic needs. Moreover, MRE is an excellent technique for diagnosing small bowel stenoses.

Crohn's Disease and an Olive

This 45-year-old man presented with 3 days of colicky abdominal pain, nausea, and vomiting. He had been admitted 36 months earlier because of a similar episode. Computed tomography demonstrated a small-bowel stricture with an intraluminal radiopaque mass.

Wireless Capsule Endoscopy in Inflammatory Bowel Disease: State of the Art and Image of the Future

Wireless Capsule Endoscopy in Inflammatory Bowel Disease: State of the Art and Image of the Future

Possible Small-Bowel Neoplasms: Contrast-enhanced and Water-enhanced Multidetector CT Enteroclysis

To prospectively evaluate the sensitivity and specificity of contrast material-enhanced and water-enhanced multidetector computed tomographic (CT) enteroclysis in depicting small-bowel neoplasms in symptomatic patients, with endoscopic, tissue, and follow-up findings as reference standards. The study protocol was approved by the Human Research Committee of the institution, and all patients gave written informed consent. Two hundred nineteen patients (108 male, 111 female; age range, 17-98 years; mean, 53.1 years) with clinical suspicion of small-bowel neoplasm underwent contrast- and water-enhanced multidetector CT enteroclysis after normal findings of upper and lower gastrointestinal endoscopy. The prospective interpretations of CT enteroclysis results include evaluation of focal bowel wall thickening, small-bowel masses, small-bowel stenosis, mesenteric stranding, enlarged mesenteric lymph nodes, and visceral metastasis. Positive enteroclysis findings were compared with results of pathologic examination after surgical (n = 35) or endoscopic (n = 20) procedures. Negative results were compared with results of surgery (n = 8), enteroscopy (n = 15), capsule endoscopy (n = 14), and clinical follow-up (n = 127). Sensitivity, specificity, accuracy, and positive and negative predictive values were calculated on a per-patient basis with 95% confidence intervals. Findings of CT enteroclysis were positive in 55 cases and negative in 164. The overall sensitivity and specificity in identifying patients with small-bowel lesions were 84.7% and 96.9%, respectively. The negative and positive predictive values were 94.5% and 90.9%, respectively. Findings of pathologic examination confirmed small-bowel tumor in 50 patients with carcinoid tumor (n = 19), adenocarcinoma (n = 7), lymphoma (n = 5), jejunal adenoma (n = 9), stromal tumor (n = 5), ectopic pancreas (n = 2), angiomatous mass (n = 2), or metastasis (n = 1). Five examinations resulted in false-positive findings. Contrast- and water-enhanced multidetector CT enteroclysis had an overall accuracy of 84.7% for depiction of small-bowel neoplasms.

Capsule endoscopy in the pediatric patient

Wireless capsule endoscopy represents an extraordinary technical innovation in diagnostic gastrointestinal endoscopy. As in adult patients, it opens new horizons that permit an accurate and noninvasive approach to identifying occult lesions in the small bowel in children and adolescents. A limitation in the pediatric age group is the size of the capsule, precluding its use in infants and small toddlers. In children unable to swallow the capsule, "front loading" the gastroscope to introduce it into the duodenum is a suitable alternative approach. Capsule endoscopy is highly useful to evaluate for inflammatory changes in patients suspected to have small bowel Crohn's disease in whom conventional imaging failed to confirm the diagnosis. It is now the method of first choice to assess for small bowel polyps or tumors, to find a source of blood loss in obscure intestinal bleeding, and for undiagnosed malabsorptive conditions such as intestinal lymphangiectasia. Capsule retention is the one major potential adverse effect of capsule endoscopy. In patients suspected to have a small bowel stenosis, consideration should be given to using the patency capsule prior to using the real videocapsule so as to decrease the risk of capsule retention.

Performing Capsule Endoscopy in Pediatric Patients

Capsule endoscopy constitutes a truly remarkable technical innovation in diagnostic gastrointestinal endoscopy. It permits for the first time an accurate and noninvasive approach to identifying mucosal lesions anywhere along the small bowel in children and adolescents, as in adults. A limitation in the pediatric age group is the size of the capsule, precluding its use in infants. In children unable to swallow the capsule, “front loading” the gastroscope permits its introduction into the duodenum as an alternative approach. Capsule endoscopy is highly useful to evaluate for inflammatory changes such as in patients suspected to have small bowel Crohn’s disease in whom conventional imaging did not confirm the diagnosis. It is now the method of first choice to screen pediatric patients for small bowel polyps or tumors, to find a source of blood loss in obscure intestinal bleeding, and for the investigation of undiagnosed malabsorptive conditions such as intestinal lymphangiectasia. Capsule retention is the one major potential adverse effect of capsule endoscopy at any age. In patients suspected to have a small bowel stenosis, use of a “patency capsule” before employing the true videocapsule can decrease the risk of capsule retention.

Long-term results of intraoperative presacral electron boost radiotherapy (IOERT) in combination with total mesorectal excision (TME) and chemoradiation in patients with locally advanced rectal cancer

We analyzed the long-term results of patients with locally advanced rectal cancer using a multimodal approach consisting of total mesorectal excision (TME), intraoperative electron-beam radiation therapy (IOERT), and pre- or postoperative chemoradiation (CRT). Between 1991 and 2003, 210 patients with locally advanced rectal cancer (65 International Union Against Cancer [UICC] Stage II, 116 UICC Stage III, and 29 UICC Stage IV cancers) were treated with TME, IOERT, and preoperative or postoperative CHT. A total of 122 patients were treated postoperatively; 88 patients preoperatively. Preoperative or postoperative fluoropyrimidine-based CRT was applied in 93% of these patients. Median age was 61 years (range, 26-81). Median follow-up was 61 months. The 5-year actuarial overall survival (OS), disease-free survival (DFS), local control rate (LC), and distant relapse free survival (DRS) of all patients was 69%, 66%, 93%, and 67%, respectively. Multivariate analysis revealed that UICC stage and resection status were the most important independent prognostic factors for OS, DFS, and DRS. The resection status was the only significant factor for local control. T-stage, tumor localization, type of resection, and type of chemotherapy had no significant impact on OS, DFS, DRS, and LC. Acute and late complications > or =Grade 3 were seen in 17% and 13% of patients, respectively. Multimodality treatment with TME and IOERT boost in combination with moderate dose pre- or postoperative CRT is feasible and results in excellent long-term local control rates in patients with intermediate to high-risk locally advanced rectal cancer.

Capsule Endoscopy Retention: Is it a Complication?

Capsule endoscopy has been found superior to barium x-rays and push enteroscopy in the investigation of obscure gastrointestinal bleeding and in the evaluation of suspected Crohn's disease. Currently, small bowel obstruction and strictures are considered by many physicians to be a contraindication to capsule endoscopy for fear of capsule retention or impaction. The goal of this study was to reassess this conventional wisdom that capsule endoscopy is contraindicated in small bowel obstruction and to determine the safety and efficacy of capsule endoscopy in the evaluation of patients with suspected stricture or small bowel obstruction. A retrospective chart review was performed using a database of 568 capsule endoscopy cases performed between August 2001 and November 2003. Cases of suspected small bowel obstruction were selected and reviewed. Nineteen cases were identified in which capsule endoscopy was used in the setting of suspected small bowel obstruction. The diagnosis of suspected small bowel obstruction was based on symptoms alone in 8 cases and on symptoms plus abnormal radiographs in the remaining 11 cases. Capsule endoscopy made a definitive diagnosis in 5 of the 19 cases (26%): 2 Crohn's strictures, 1 radiation induced stricture, 1 nonsteroidal anti-inflammatory drug induced stricture, and 1 MALT lymphoma. The capsule was retained proximal to a stricture in 4 cases, in which the obstructing lesions were electively resected without complications. There was no case in which administration of the capsule led to an acute small bowel obstruction. Capsule endoscopy can be safely used to help identify the etiology and site of a small bowel obstruction. Retention of the capsule may indicate the presence of a lesion requiring surgery, but small bowel obstruction or strictures are not in themselves contraindications to the procedure. It is understood, however, that retention may lead to surgery in a patient who otherwise may have been treated medically without surgery for the same illness (eg, Crohn's disease and nonsteroidal anti-inflammatory drug enteropathy).

Double-balloon endoscopy: Extending the arm of the gastroenterologist

Double-balloon endoscopy: Extending the arm of the gastroenterologist

Retention of the Capsule Endoscope

Purpose: Capsule endoscopy (CE) permits direct and painless visualization of small bowel mucosa. It has become a powerful imaging modality in evaluating diseases of the small bowel. Retention of the capsule is one of the most significant potential complications. We aimed to determine the incidence and causes of capsule retention and to investigate the clinical outcomes after capsule retention. Methods: A retrospective review of all patients undergoing CE from June 2002- March 2006 was carried out. Demographics, indication for the CE study, causes of retention found on surgery, and post-operative clinical outcomes were extracted. Results: One thousand patients underwent CE for suspected small bowel disease. Eleven patients (1.1%; 1 male, 10 female; average age 60) were found to have radiologically confirmed capsule retentions. The indication for CE was obscure gastrointestinal bleeding in 8 patients and suspected Crohn's disease in 2 patients. One patient underwent CE for evaluation of possible radiation enteritis associated abdominal pain. Eight patients failed to pass the capsule because of small bowel strictures due to NSAID enteropathy (diaphragm disease). Two patients had capsule retention due to obstructing small bowel carcinoid tumors. Metastatic ovarian cancer with invasion of the ileum was the cause of retention in another patient. All patients remained “asymptomatic,” despite retention of the capsules. Ten patients underwent elective partial small bowel resection and capsule removal. No mortality was associated with these surgeries. Two patients developed mild post-op ileus. Conclusions: Capsule retention in clinical practice appears to be low. In most cases, capsule retention is asymptomatic and is unlikely to cause acute obstruction. Capsule retention always occurs at the site of pathology, therefore surgical removal usually leads to identification and treatment of the underlying small bowel disease. Most common cause of retention in our center appears to be diaphragm disease due to NSAIDs followed by small bowel tumors.

Colonic Varices Secondary to Superior Mesenteric Vein Stenosis in a Patient with Crohnʼs Disease

Albeit rare, colonic varices are usually seen in the anorectum in the setting of portal hypertension, although idiopathic and familial cases of colonic varices have also been described. Cases have also been reported resulting from mesenteric hypertension secondary to portal or mesenteric vein (MV) thrombosis. The association of inflammatory bowel disease and MV thrombosis is well recognized. We are aware of only one case series describing Crohn's disease resulting in MV stenosis and subsequent portal hypertensive lower gastrointestinal varices. The series described 3 patients with small bowel (SB) varices. We report a case of superior MV stenosis resulting in colonic varices in a patient with Crohn's disease. The patient is a 43 year old male with Crohn's ileitis and proctitis, who had been in remission on oral mesalamine since the diagnosis 2 years prior. The patient presented with several weeks of intractable nausea and vomiting, intermittent melenic stools, and a reported 25 pound weight loss over 2 months. Physical examination was unrevealing and bloodwork was only remarkable for mild anemia. A CT-scan showed thickened distal SB, with possible narrowing of the superior MV with colonic collaterals. A SB follow-through was normal. The patient was started on antibiotics and immunosuppressive medications, with mild improvement. Upper endoscopy was unremarkable. Colonoscopy revealed erythematous mucosa and pseudopolyps in the distal ileum with an intrinsic stricture. Varices were seen in the ascending and transverse colon. An opening was seen at the rectosigmoid junction with passage of air and stool, which was consistent with an entero-colonic fistula when injected with contrast dye. The patient underwent angiogram with balloon angioplasty of the stenosed superior MV and ileocolic veins, which resulted in decomperssion of the varices. Surgical resection of the ileo-sigmoid fistula and multiple SB strictures was then performed. Pathology review revealed SB adenocarcinoma arising from the ileal aspect of the fistula, with positive lymph nodes. Severe intestinal inflammation from Crohn's Disease can result in stenosis in the adjacent vasculature. This is the first reported case of a patient with Crohn's disease and superior MV stenosis resulting in colonic varices.

CARD15 in inflammatory bowel disease and Crohn's disease phenotypes: An association study and pooled analysis

Background Three major polymorphisms of the Caspase-Activation Recruitment Domain containing protein 15 gene have been described to be associated with Crohn's disease. Genotype–phenotype studies reported in literature provide conflicting data on disease localisation and behaviour. We investigated the relation of Caspase-Activation Recruitment Domain containing protein 15 with inflammatory bowel disease and Crohn's disease phenotypic characteristics in a large Dutch cohort and performed a pooled analysis on inflammatory bowel disease patients and Crohn's disease phenotypic characteristics reported in association studies. Methods We genotyped 781 cases and 315 controls for the R702W, G908R and 1007fsinsC variants and for six microsatellite markers in and close to Caspase-Activation Recruitment Domain containing protein 15. In the pooled analysis data of 7201 inflammatory bowel disease patients and 3720 controls from 20 studies were included. Results Association was found for Crohn's disease with R702W and 1007fsinsC, including several disease characteristics, and not for ulcerative colitis. In the pooled analysis all three common Caspase-Activation Recruitment Domain containing protein 15 variants showed strong association with Crohn's disease ( p < 0.00001; odds ratio varying from 3.0 for single heterozygotes to 14.7 for compound heterozygotes) and not with ulcerative colitis. Phenotype analysis showed association with small bowel involvement, stricturing and penetrating disease. Conclusion Caspase-Activation Recruitment Domain containing protein 15 is associated with Crohn's disease and not with ulcerative colitis. All three common Crohn's disease-associated variants are associated with small bowel involvement, the G908R and 1007fsinsC alleles also being associated with a complicated disease course.

The Risk of Retention of the Capsule Endoscope in Patients with Known or Suspected Crohn's Disease

Capsule endoscopy (CE) allows visualization of the mucosa of the entire small bowel and is therefore a potentially important tool in the evaluation of patients with known or suspected Crohn's disease (CD). However, small bowel strictures, which are not uncommon in Crohn's, are considered to be a contraindication to CE for fear of capsule retention. Our goal was to determine the risk of capsule retention in patients with suspected or known CD. We retrospectively reviewed the records of 983 CE cases performed at three private gastroenterology practices between December 2000 and December 2003, and selected those with suspected or proven Crohn's. A total of 102 cases were identified in which CE was used in patients with suspected (N = 64) or known (N = 38) CD. Only one of 64 patients (1.6%) with suspected CD had a retained capsule. However, in five of 38 (13%) patients with known Crohn's, the capsule was retained proximal to a stricture. Of the five cases of retained capsules, three strictures were previously unknown. In four cases, the obstructing lesions were resected without complications, leading to complete resolution of the patient's underlying symptoms. One patient chose not to undergo surgery and has remained without an episode of small bowel obstruction for over 38 months. Capsule retention occurred in 13% (95% CI 5.6%-28%) of patients with known CD, but only in 1.6% (95% CI 0.2%-10%) with suspected Crohn's. A retained capsule may indicate unsuspected strictures in Crohn's that may require an unexpected, but therapeutic, surgical intervention. Patients and physicians should be aware of these potential risks when using CE in CD.

Evaluation of Deep Small Bowel Involvement by Double-Balloon Enteroscopy in Crohn's Disease

Double-balloon enteroscopy (DBE) enables inspection of deep small bowel, and total small bowel examination can be performed by either antegrade or retrograde DBE. The aim of this study was to evaluate ileal involvement, which cannot be achieved using conventional colonoscopy, by DBE in patients with Crohn's disease. From December 2003 to September 2005, a total of 44 patients with Crohn's disease underwent 53 examinations using DBE. Forty patients with Crohn's disease, seven women and 33 men, underwent DBE, and the ileum was investigated in 38 patients. There were 25 cases of ileitis, 2 of colitis, and 13 of ileocolitis. Jejunal lesions were found in two and ileal lesions proximal to the terminal ileum were found in 24 patients with Crohn's disease. DBE was superior to radiological study to detect aphthae, erosions, and small ulcers in the ileum. Small bowel stricture was demonstrated in six and nine patients with DBE and small bowel barium study (SBBS), respectively. An additional mucosal finding was demonstrated in one of the eight patients who underwent wireless capsule endoscopy, and one patient had a capsule removed by DBE that had become lodged because of an ileal stricture. One ileal perforation because of overtube balloon pressure occurred in 53 examinations of patients with Crohn's disease (1.9%). DBE is useful to evaluate small bowel lesions in patients with Crohn's disease; however, special attention should be paid to mesenteric longitudinal ulcers during insertion and the overtube balloon should not be inflated if a clear intestinal view is not possible.

A Novel Treatment of Congenital Duodenal Stenosis: Image-Guided Treatment of Congenital and Acquired Bowel Strictures in Children

Image-guided balloon dilatation has been used in adults as an alternative to standard surgical treatment of intestinal stricture. The experience in children is limited. We report our results with this procedure in the management of both congenital and acquired intestinal stenosis in children. A retrospective analysis was done of children younger than 2 years of age who underwent balloon dilatation of small and large intestinal stenosis between 1994 and 2003. Eleven children underwent dilatation during the study period. Two of these children had congenital duodenal stenosis, and this represents the first report of nonoperative management of this condition. Three children underwent dilatation of small bowel strictures and 6 had dilatation of colonic and rectal strictures. Necrotizing enterocolitis was the most common (6/9) etiology of stricture. Ten of 11 patients did not require subsequent operative management although 3 children required further dilatations. The mean follow-up was 36.5 months (range, 13 days-103 months). One patient underwent a subsequent dilatation that was unsuccessful, and required operative resection of a 5-cm stricture. There was one complication, a small leak that was managed nonoperatively. Image-guided balloon dilatation holds promise as an alternative to surgical treatment in children with congenital or acquired stenosis of the small or large bowel, and should be considered in select patients with short strictures.