Small-bowel perforation after endoscopic resection of a Peutz-Jeghers polyp in an infant using double-balloon enteroscopy

Small bowel endoscopy for children: Collaboration of capsule endoscopy and device-assisted enteroscopy

Capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) have become indispensable techniques for the diagnosis and management of small bowel disease in both adult and pediatric cases. However, relevant differences exist in the indications between these cohorts, with body weight and age having particular relevance in decisions for the latter. Both CE and BAE are designed for adult physique and they were not widely used among children. In addition, the types of small intestinal diseases differ between adults and children, and consequently, the indications also differ between them. This review focuses on the issues relevant to pediatric cases and describes the practical application of endoscopy in clinical practice. In conclusion, although there are age and weight restrictions, both CE and BAE are safe and useful devices for use in children, and their indications for use in children are likely to expand in the future.

Safety of double-balloon enteroscopy in postoperative pediatric patients

BACKGROUND

The aim of the present study was to investigate the efficacy and safety of double-balloon enteroscopy (DBE) in postoperative pediatric patients.

METHODS

This was a retrospective analysis of pediatric patients 18 years and younger referred to Mie University Hospital. Twenty procedures in 11 children occurred postoperatively; 29 children (42 procedures) had not undergone surgery.

RESULTS

Among postoperative patients, five DBE procedures were performed via the oral route, 12 via the anal route, and three via a stomal route. Among nonoperative patients, 14 DBE procedures were performed via the oral route and 28 via the anal route. Four postoperative patients and two nonoperative patients had difficult pleating via the transanal route because of adhesions or thickening of the intestinal wall resulting from inflammation (P = 0.02). Excluding patients with stenosis, the mean length of endoscopic insertion for transanal procedures was significantly shorter among postoperative patients than among nonoperative patients (73.6 cm vs 160.5 cm, P < 0.01). There were no major complications in either group.

CONCLUSIONS

Insertion difficulty was encountered in postoperative pediatric patients. However, our findings indicate that DBE is a safe procedure in postoperative pediatric patients.

Primary experience of small bowel polypectomy with balloon-assisted enteroscopy in young pediatric Peutz-Jeghers syndrome patients

For Peutz-Jeghers syndrome (PJS) patients, small bowel polyps develop and result in symptoms at an early age. Balloon-assisted enteroscopy (BAE) is verified as a safe and efficient choice to evaluate and remove small intestinal polyps in adult PJS. But the safety of BAE, especially BAE-facilitated polypectomy for young pediatrics, is little known. This prospective study focused on the effectiveness and safety of BAE-facilitated polypectomy in small bowel for young pediatric PJS. PJS patients (aged 0-14 years old) with BAE (including both single-balloon and double-balloon enteroscopies) were included from 1 September 2012 to 30 April 2018. The demographic data, medical history, and details of BAE were recorded. BAE-related complications and symptom relief after BAE were evaluated and compared between the PJS patients aged 5-10 years old (the younger pediatric group) and those aged 11-14 years old (the older pediatric group). A total of 41 pediatric PJS patients (5-14 years old) subjected to 82 BAEs were included. BAE-facilitated polypectomy was performed for 33 children (80.5%), and 242 polyps in small bowel were removed. For 10 (24.4%) patients, one or more giant polyps (maximum diameter larger than 5 cm) were removed. For eight patients, no polypectomy was done as no polyps were observed (six subjects) or not suitable for BAE-facilitated polypectomy (two subjects) because of high risk of perforation. The complication rates of BAE and BAE-facilitated polypectomy were 1.2% (1/82) and 1.8% (1/55), and the symptom relief rate was 70.8% (17/24). Compared with the older pediatric group, the younger pediatric group showed no increased BAE complication rate (0.0% vs. 5.0%, p = 0.488) and a comparable rate of symptom relief after BAE therapy (80.8% vs. 55.6%, p = 0.356).Conclusion: BAE-facilitated polypectomy in young pediatric PJS is safe and effective.What is known:• Small bowel evaluation and prophetic polypectomy are important for pediatric PJS patients to avoid polyp-related intussusception, obstruction, and bleeding.• BAE polypectomy was a recommended intervention for removing small bowel polyps in adult PJS patients.What is new:• BAE-facilitated small bowel polypectomy is safe and effective for young pediatric PJS, even for those aged less than 10 years old.

Extremely young case of small bowel intussusception due to Peutz-Jeghers syndrome with nonsense mutation of STK11

Intussusception is a frequent and severe complication of Peutz-Jeghers syndrome (PJS). We herein present the case of a 3-year-old girl who experienced jejuno-jejunal intussusception due to PJS polyps. Despite no apparent family history of PJS, she had exhibited mucocutaneous pigmentation since infancy and recurrent abdominal pain and vomiting from 2 years of age. Segmental resection of the jejunum during emergency laparotomy for the intussusception revealed multiple hamartomatous polyps. Genetic analysis uncovered a germline nonsense mutation of c.247A>T in exon 1 of serine/threonine kinase 11 (STK11). Biannual follow-up surveillance for polyps by esophagogastroduodenoscopy, colonoscopy, and small bowel capsule endoscopy is ongoing. Reports describing the clinical and genetic features of extremely young PJS with intussusceptions are rare, although a literature review of STK11 germline mutations revealed several other pediatric cases of complicating intussusception at ≤ 8 years old. Considering the recent advances in surveillance and treatment options for the small bowel, earlier management of symptomatic children with PJS may be warranted to avoid surgical emergency.

Angiotensin-Converting Enzyme Inhibitor-Induced Gastrointestinal Angioedema: The First Danish Case Report

Angiotensin-converting enzyme inhibitors (ACEI) are widely used to treat hypertension and congestive heart failure. A rare side effect of ACEI therapy is angioedema, which in very rare cases may present as gastrointestinal angioedema (GA). A 45-year-old female presented with suddenly occurring diffuse abdominal pain. Imaging studies revealed small bowel wall edema. The patient had been on ACEI therapy for the last 6 months. The therapy was withdrawn, and the patient recovered quickly. There is no specific diagnostic test to confirm ACEI-induced GA, but symptoms usually regress completely after therapy discontinuation. An early diagnosis of ACEI-induced GA is important to avoid invasive diagnostic investigations and even laparotomy.

Advances in Pediatric Small Bowel Imaging

Technological advances for visualizing the small bowel have significantly grown over the past few decades. Balloon-assisted enteroscopy has come to the forefront of these innovations, and has been found to be safe and effective in children with small bowel ailments. The expanding body of research into balloon-assisted enteroscopy will continue to refine the current knowledge base of this technique, along with a growing assessment of the long-term benefits of such interventions.

Endoscopic Mucosal Resection of Jejunal Polyps using Double-Balloon Enteroscopy

Background

There are only two single case reports describing double-balloon enteroscopy (DBE)-assisted endoscopic mucosal resection (EMR) of the jejunum. The aim of this case series was to evaluate the feasibility and utility of DBE-assisted EMR in patients with familial and non-familial jejunal polyps.

Patients and methods

Observational, open-label, retrospective, single-arm case series in two hospitals.

Results

Eight patients underwent DBE assisted jejunal EMR. Median age of patients was 42 years (range 24–62 years), male: female ratio 1.5:1. DBE was done through the antegrade (i.e. oral) route in all patients. Four patients had FAP; two had Peutz-Jeghers syndrome, one had a sporadic adenoma and one had a bleeding jejunal polyp, which on histological examination turned out to be lipoma. 3/8 underwent piece-meal EMR. No immediate adverse events occurred.

Conclusions

This is the first case series presenting the technical details, feasibility and outcomes of EMR of the small bowel. EMR of the jejunum is feasible and safe during DBE.

Double balloon enteroscopy in children: a case series highlighting risks, and a review of the literature

AIM

Double balloon enteroscopy (DBE) is a relatively new endoscopic technique that allows endoscopic access into the small intestine. It has been studied in adults, but the literature remains scarce in the paediatric age group.

METHODS

We retrospectively assessed our experience with DBE in children.

RESULTS

We describe four procedures performed on three patients. The diagnostic yield was high (100%) with one major complication (perforation) encountered. A review of the benefits and risks in this cohort, and the available literature is included.

CONCLUSIONS

DBE is a promising endoscopic modality in children, but some aspects remain unanswered. There is a great need for a prospective study to better assess benefit and risk in this population.

Double balloon enteroscopy for pediatric inflammatory bowel disease

BACKGROUND

The aim of the present study was to evaluate the efficacy and safety of double balloon enteroscopy (DBE) in children with inflammatory bowel disease (IBD).

METHODS

A total of 106 DBE procedures in 67 patients were performed at Mie University Hospital from January 2008 to June 2011. Of these, 17 procedures in 12 children and adolescents with established or suspected Crohn's disease (CD) were included in the present study. The procedure, sedation, efficacy, and safety of DBE were evaluated.

RESULTS

Mean patient age was 12.9 years (range, 3-19 years). Patients ≤ 15 years old had general anesthesia. The procedures included the oral approach (n= 9), the anal approach (n= 4), and the ileostomal approach (n= 4). The mean procedure duration was 60 min. Accurate diagnosis was obtained in 7/8 cases (88%) of suspected CD. Only one case was diagnosed as indeterminate colitis, although the total small and large bowel was examined on DBE and pathology. Procedure tolerance was acceptable and recovery was uneventful in all cases. No serious complications were encountered.

CONCLUSIONS

With regard to the present limited IBD pediatric case series, DBE is a safe and effective procedure.

Double balloon enteroscopy in the old: experience from China

AIM

To evaluate the safety, efficacy and management of double balloon enteroscopy (DBE) carried out in those aged individuals with suspicious small intestine diseases.

METHODS

DBE is a wonderful invention of the past decade and is widely used as an examination tool for the gastrointestinal tract. From January 2003 to July 2011, data from patients who were ≥ 65 years old and underwent DBE examination in the Nanfang Hospital were included in a retrospective analysis.

RESULTS

Fifty-nine individuals were found and subsequently analyzed. The mean age was 69.63 ± 3.89 years (range 65-84), 34 were males. Indications for DBE were melena/hematochezia (36 cases), abdominal pain (15 cases), diarrhea (3 cases), stool change (1 case), weight loss (1 case), vomiting (2 cases), and debilitation (1 case). The average duration of symptoms was 33.34 ± 64.24 mo. Twenty-seven patients suffered from age-related diseases. Severe complications were not found during and after DBE. Comparison between systolic and diastolic blood pressure before and after DBE was statistically significant (mean ± SD, P < 0.01, P < 0.05, respectively). Small bowel pathologies were found by DBE in 35 patients, definite diagnoses were made in 31 cases, and detection rate and diagnostic yield for DBE were 68.6% and 60.8%, respectively.

CONCLUSION

DBE is a safe and effective method for gastrointestinal examination in the aged population. Aging alone is not a risk factor for elderly patients with suspicious gastrointestinal diseases and thorough preparation prior to the DBE procedure should be made for individuals with multiple diseases especially cardiopulmonary disorders.

Small bowel endoscopy in children

Endoscopic investigation of small bowel pathology in children has historically been difficult due to location, length and tortuosity of the small bowel. Recently, video capsule endoscopy and balloon-assisted enteroscopy techniques have evolved as new diagnostic tools and are increasingly used in the paediatric population. In this review the current literature is appraised to define the clinical indications and practical aspects of capsule endoscopy and balloon-assisted enteroscopy in children.

Enteroscopy in children

PURPOSE OF REVIEW

Endoscopic investigation of small bowel disorders in children has historically been difficult due to the length and tortuosity of the organ itself. New technology introduced over the past decade allows minimally invasive, detailed endoscopic evaluation of the small bowel mucosa from the duodenum to the cecum. While understudied in the pediatric population, literature is emerging supporting the use of these techniques and devices in children.

RECENT FINDINGS

Well tolerated and clinically useful capsule endoscopy has been reported a number of times in children, and the indications and potential complications of this procedure are discussed. The limitations of capsule endoscopy, namely inability to biopsy and treat small bowel lesions, have been addressed to some extent by the introduction of balloon enteroscopy, which allows deep intubation of the small bowel, and at times viewing of the entire mucosal surface. Balloon enteroscopy has been safely reported in children as small as 13.1  kg, and has been successfully performed in children with Roux-en-Y anastomoses in the evaluation and therapy of biliary strictures.

SUMMARY

New enteroscopic techniques now allow detailed investigation and therapy of small bowel lesions in a minimally invasive fashion in the pediatric population.

Single-balloon enteroscopy in children: initial experience at a pediatric center

Single-balloon enteroscopy (SBE) allows deep endoscopic access to the jejunum and ileum in adults; however, there are no published series describing the safety of, and indications for, SBE in a pediatric population.Seven pediatric patients (5-17 years) underwent SBE in a 9-month period. Five of 7 procedures achieved the goal. There were no serious complications, and SBE positively affected patient management in 5 of 7 cases.We conclude that SBE is feasible in a pediatric population and can positively affect patient care.

Double-balloon enteroscopy: pediatric experience

OBJECTIVES

Double-balloon enteroscopy (DBE) is a newly developed endoscopic modality for diagnosis and treatment of small bowel disorders. Most publications on DBE are from adult medical centers. Publication related to the use and application of DBE in children and adolescents is limited. We present our experience with the use of DBE in the pediatric age group.

PATIENTS AND METHODS

We reviewed patient information on all of the DBE procedures performed in 2006 through 2008 at a single tertiary pediatric referral center in Columbus, Ohio. Compiled information included patient demographics, procedure indications, diagnostic and therapeutic results, and procedure-associated complications or adverse events.

RESULTS

Thirteen DBE procedures were performed on eleven 8- to 20-year-old patients. Procedure indications were based on suspicion for organic small bowel pathology after an exhaustive diagnostic evaluation including upper and lower endoscopy failed to uncover an etiology. Clinically significant lesions were identified in 46% (6/13) of the procedures performed. No serious procedure-related complications occurred. Self-limited postprocedure abdominal pain and discomfort from gaseous distension was observed in several patients.

CONCLUSIONS

DBE appears to be a safe endoscopic modality for the diagnosis and treatment of children and adolescents with suspected small bowel disease. However, performance should be selectively reserved for patients with a high suspicion for small bowel pathology, in which other less invasive techniques have failed to adequately diagnose and treat a patient's disease.

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

BACKGROUND

Balloon enteroscopy is an emerging technique to allow access to the small intestine for both diagnostic and therapeutic purposes. To date, there have been few published data documenting the safety and efficacy of balloon enteroscopy in small children.

OBJECTIVE

To describe our experience with single-balloon enteroscopy (SBE) in a 37-month-old toddler with occult GI bleeding.

DESIGN

A single case report.

SETTING

A free-standing, academic children's hospital in Denver, Colorado.

PATIENT

The patient was a 37-month-old, 13.5-kg toddler with persistent heme-positive stools, severe microcytic anemia, and hypoalbuminemia. Previous workup was significant for eosinophilic inflammation in the antrum and a video capsule study showing erythematous lesions in the small bowel.

INTERVENTION

An antegrade SBE was performed with the child under general endotracheal anesthesia, with biopsy specimens obtained from identified lesions in the jejunum and ileum.

MAIN OUTCOME MEASUREMENTS

Complications and successful treatment of symptoms were the primary endpoints.

RESULTS

The procedure was performed successfully in 85 minutes, passing an estimated 200 cm beyond the pylorus, without complications. Identification of the lesions as consistent with eosinophilic enteropathy led to successful treatment with an elimination diet and corticosteroids.

LIMITATIONS

The primary limitation of this study is that it is a single case report. Therefore, it is difficult to make a generalized statement regarding the safety and efficacy of balloon enteroscopy in toddlers of this size.

CONCLUSIONS

Antegrade SBE can be a well-tolerated and effective procedure to evaluate occult GI bleeding in children as young as 3 years of age. Further study is needed to better establish safety parameters for balloon enteroscopy in small pediatric patients.

Small bowel polyps and tumours: endoscopic detection and treatment by double-balloon enteroscopy

BACKGROUND

Double-balloon enteroscopy has allowed us not only to inspect deeply the small bowel but also to carry out interventions for diseases of the small bowel.

AIM

To evaluate the utility of double-balloon enteroscopy for the diagnosis and therapy of these lesions.

METHODS

All patients undergoing double-balloon enteroscopy for evaluation of small bowel polyps and tumours during a 3.75-year period at a university referral hospital were studied. The types of polyps and tumours as well as endoscopic technique of removal, surgery and complications were documented.

RESULTS

The incidence of small bowel polyps and tumours in-patients undergoing DBE was 9.6%. A total of 40 double-balloon enteroscopy procedures were performed in 29 patients [13 female (44.8%), mean age 51 years, range 22-74]. The following lesions were found most frequently: adenomas in familial adenomatous polyposis syndrome, n = 8; hamartomas, n = 4 (Peutz-Jeghers and Cronkhite Canada syndromes), jejunal adenocarcinoma n = 5, neuroendocrine tumour n = 4 and others n = 6.

CONCLUSIONS

The incidence of small bowel tumours in those in-patients who were undergoing double-balloon enteroscopy was 10%. Double-balloon enteroscopy is useful for the diagnosis and treatment of small bowel polyps and tumours.

Enteroscopy

Until the end of the 20th century, push enteroscopy (PE) was the most commonly used method for the endoscopic investigation of the small bowel. However, PE has been almost completely replaced by double balloon enteroscopy (DBE). Undoubtedly the major endoscopic breakthrough of the last decade, DBE has contributed to the better diagnosis and understanding of diseases of the small bowel, opening-up this obscure part of the gastrointestinal tract to visualisation. Modern diagnostic and therapeutic DBE allows for a deeper and more thorough evaluation of the small bowel than PE, enabling the detection of more pathological lesions. In addition, DBE has for the first time enabled endoscopists to observe the entire small intestine, and has provided endoscopic interventions such as cauterisation of bleeding lesions, polypectomy, placement of small bowel stents, and foreign-body extraction.