Search

Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.

Background Double-balloon endoscopy (DBE) has been used in clinical practice for nearly 10 years. Objective To systematically collect and produce pooled data on indications, detection rate, total enteroscopy, complications, and the composition of positive findings in diagnostic DBE. Design A systematic review. Main Outcome Measurements We searched PubMed between January 1, 2001 and March 31, 2010 for original articles about DBE evaluation of small-bowel diseases. Data on total number of procedures, distribution of indications, pooled detection rate, pooled total enteroscopy rate, and composition of positive findings were extracted and/or calculated. In addition, the data involving DBE-associated complications were analyzed. Results A total of 66 English-language original articles involving 12,823 procedures were included. Suspected mid-GI bleeding (MGIB) was the most common indication (62.5%), followed by symptoms/signs only (7.9%), small-bowel obstruction (5.8%), and Crohn's disease (5.8%). The pooled detection rates were 68.1%, 68.0%, 53.6%, 63.4%, and 85.8% for overall, suspected MGIB, symptoms/signs only, Crohn's disease, and small-bowel obstruction, respectively. Inflammatory lesions (37.6%) and vascular lesions (65.9%) were the most common findings, respectively, in suspected MGIB patients of Eastern and Western countries. The pooled total enteroscopy rate was 44.0% by combined or antegrade-only approach. The pooled minor and major complication rates were 9.1% and 0.72%, respectively. Limitations Inclusion and exclusion criteria were loosely defined. Conclusion The detectability and complication risk of diagnostic DBE are acceptable. Suspected MGIB is the most common indication, with a relatively high detection rate, but there was a difference in its causes between Western and Eastern countries.

c f m r t a m p c o s a p F d Gallstone ileus is an infrequent cause of intestinal obstruction and is responsible for 1% to 4% of all mechanical intestinal obstructions.1 Gallstones usually enter the bowel via a holecystoenteric fistula resulting from recurrent attacks of holecystitis.2 However, gallstone ileus may arise in the absence of a gallbladder, especially in patients with previous surgeries, including biliary-enteric anastomosis.3 Surgical intervention has been the primary treatment of gallstone ileus.4 Here, we report a case of a gallstone ileus that was nonsurgically treated with endoscopic fragmentation by using double-balloon endoscopy (DBE).

Background Double balloon endoscopy (DBE) is an emerging modality for complete endoscopic visualization of the small intestine. Although the most common indication of DBE is currently for evaluation of obscure GI bleeding or suspected small-bowel pathology, the unique technical features of the double balloon endoscope have led to its newer uses. Objective To evaluate the utility of DBE by the retrograde approach to perform a complete evaluation of the colon. Patients Sixteen patients in whom examination of the entire colon could not be achieved with conventional colonoscopy. Results Using DBE by the retrograde approach, we achieved a high success rate of complete endoscopic examination of the entire colon, and we were also able to perform appropriate therapeutic interventions. The procedures were well tolerated by the patients and could be performed with the patient under conscious sedation and without the use of fluoroscopy. Limitations This study comprised a small number of patients and there was no control group. Conclusions Anecdotal data suggest that other areas in which DBE technology may be potentially helpful are ERCP in patients with surgically altered anatomy, and endoscopic evaluation of the bypassed segment of the upper GI tract in patients who have undergone bariatric surgery, but such applications will require the development of appropriate accessories and substantial technical modification to currently available instruments.

Background GI bleeding secondary to small-intestine vascular lesions (SIVLs) is associated with rebleeding despite initial hemostasis by endotherapy applied at double-balloon endoscopy (DBE). Objective To evaluate the long-term outcomes of DBE endotherapy of SIVL (as described by the Yano-Yamamoto classification). The impact of repeat DBE endotherapy for recurrent bleeding also was assessed. Design Retrospective cohort study. The mean (± standard deviation [SD]) follow-up period was 4.9 (± 1.7) years (range 2.4-9.1 years). Setting Tertiary-care referral center. Patients A total of 43 patients, who underwent 69 sessions of DBE endotherapy of SIVLs. Intervention DBE endotherapy. Main Outcome Measurements Frequency of overt rebleeding after the initial DBE endotherapy. Results Overt rebleeding occurred in 16 of 43 patients (37%). Patients with multiple SIVLs showed a significantly higher rate of overt rebleeding than did those with a solitary SIVL (12/23 [52%] vs 4/20 [20%]; P = .017). The trend toward frequency of rebleeding after the first DBE hemostasis appeared to be higher for patients with type 1a SIVLs than for those with type 1b or type 2 lesions: type 1a (8/16, 50%) versus type 1b (5/19, 26%) ( P = .12) and type 1a (8/16, 50%) versus type 2 (2/7, 29%) ( P = .31), respectively. In 12 of 16 patients (75%) who underwent repeat DBE endotherapy at each episode of overt rebleeding (median 3 times, range 2-6), the frequency of rebleeding decreased significantly after the first year of follow-up, as compared with the remaining 4 patients who did not undergo repeat DBE; mean (± SD) 0.12 (± 0.19) versus 0.52 (± 0.33) times per year per patient ( P = .006). Limitations Single-center, retrospective study. Conclusion Although the presence of multiple SIVLs was associated with rebleeding, repeat DBE endotherapy resulted in an improved long-term outcome in patients with refractory SIVL bleeding.

Background The source of small-bowel stricture is often difficult to diagnose due to the difficulty of placing an endoscope into the small bowel. It has recently become possible to examine the entire small bowel and perform balloon dilatation for stricture by means of double balloon endoscopy (DBE). Objective To identify clinical features of small-bowel stricture and determine the validity of balloon dilatation as a treatment option. Design Retrospective multicenter study. Setting Researchers at 7 institutions affiliated with the DBE Working Group. Patients One hundred seventy-nine patients with stricture among a total of 1035 patients who underwent DBE at the 7 institutions. Interventions Surgical treatment or balloon dilatation was performed as clinically indicated. Main Outcome Measurements Ability to detect stricture lesions by DBE, types of lesions, locations of small-bowel strictures, details of strictures, treatments for strictures, and outcomes of balloon dilatation for strictures associated with inflammatory disease. Results The total number of patients with strictures was 179. Lesions were detected within the small bowel in 156 patients. Inflammatory disease was the most common (n = 87) in patients with small-bowel stricture, and the ileum was the most common site of the inflammatory disease. Crohn's disease was the most common of the inflammatory diseases (n = 57). Balloon dilatations were performed in 31 patients with inflammatory disease, and long-term success was achieved in 22 patients. Limitations The number of patients treated by balloon dilatation was small. Conclusion DBE appears to be useful for the detection as well as treatment of small-bowel lesions.

Background The inability to pass endoscopes beyond strictures is a considerable problem in patients with a colonic stricture. Methods In patients with bowel obstruction, we have modified the insertion method for double-balloon endoscopy with a long, transnasal decompression tube. Observations We have succeeded in reaching the proximal side of the stricture from the oral approach across the entire small bowel in a patient. Conclusions This modified double-balloon enteroscopy is useful for patients with bowel obstruction in whom a long decompression tube is already placed.

The advent of capsule endoscopy has substantially advanced the diagnosis of small-intestinal disorders. Moreover, the development of a new technique, doubleballoon endoscopy, also allows visualization of the entire small bowel. This system includes an endoscope with a working length of 200 cm and an outer diameter of 8.5 mm. It has a built-in air-insufflation system, which is directly connected to the balloon at the tip of the endoscope. The system also includes a flexible overtube 145 cm in length and 12.2 mm in outer diameter. The endoscope and the overtube are both equipped with soft latex balloons that can be inflated or deflated by means of a balloon-pump controller while monitoring balloon pressure. This report describes a case of GI bleeding in which the diagnosis was made by capsule endoscopy, followed by treatment with the use of double-balloon endoscopy.

Su1396 Overtube Assisted Direct Per Oral Cholangioscopy: Initial Experience of Diagnostic and Therapeutic Applications Rajkumar P. Wadhwa* Gastroenterology, Vikram Hospital, Mysore, India Introduction: Cholangioscopy was first done in mid 1970s but has largely remained outside endoscopy practice due to instrumentation and technical difficulty. With the availability of newer ultrslim endoscopes interest in field is rekindled. However introduction of ultraslim scope directly into bile duct is difficult as it bends into stomach while pushing it into bile duct. Here we present our initial experience of modifieddouble balloon endoscopy overtube with transnasal endoscope for performing direct per oral cholangioscopy (DPOC). Methods&AIMS: Thin diameter (5.9mm) transnasal upper GI endoscope with working channel of 2mm was used for performing direct per oral cholangioscopy (DPOC). Overtube (14mm diameter) used for double balloon endoscopy was modified (30mm opening on one side was created at 70cms from tip of overtube image 1 and 2) and transnasal endoscope was passed through the side opening of overtube so that it comes out of tip of the overtube. By doing this balloon inflation method was kept intact. ERCP and wide sphincterotomy/sphincteroplasty was performed with standard side viewing duodenoscope. Duodenoscope removed and replaced with overtube and transnasal scope passed through the side opening till the tip of overtube. Overtube balloon was placed in first part of duodenum/antrum and scope from tip was passed upto papilla, after turning to left stiff guidewire with hydrophilic tip was passed up into bile duct and scope slipped into bile duct over the wire. Institutional ethics comittee’s permission was obtained prior to study. Results: Procedures done: 19. Technically successful: 13, Unsuccessful: 6 (Lower CBD stricture, ampulla within diverticulum, angle of insertion causes of unsuccessful procedures) Diagnostic: 11 and Therapeutic: 8 (Table 1). One patient developed mild pancreatitis which resolved with conservative management. Conclusions: Direct per oral cholangioscopy is simple safe and effective technique. Use of modified overtube prevents ultraslim scope from bending in stomach and enhances success of cholangioscopy. It has excellent images and 2mm working channel gives possibility of performing wide range of therapeutic procedures but it also has limitations of requirement of sphincterotomy prior to procedure and is difficult to perform in lower CBD strictures.