Milestone in gastrointestinal endoscopy: double-balloon enteroscopy of the small bowel

The performance and safety of motorized spiral enteroscopy, including in patients with surgically altered gastrointestinal anatomy: a multicenter prospective study

BACKGROUND

Data are scarce on the efficacy and safety of motorized spiral enteroscopy (MSE). No data are available on the utility of this technique in patients with surgically altered gastrointestinal (GI) anatomy. We aimed to evaluate the safety and efficacy of MSE in patients with suspected small-bowel disease, including those with surgically altered GI anatomy.

METHODS

A multicenter prospective observational, uncontrolled study evaluated MSE in consecutive patients with suspected small-bowel pathology and an indication for diagnostic and/or therapeutic intervention.

RESULTS

A total of 170 patients (102 men; median age 64 years, range 18-89) were included. The overall diagnostic yield was 64.1 %. Endotherapy was performed in 53.5 % of procedures. The median total procedure times for the antegrade and retrograde approaches were 45 minutes (interquartile range [IQR] 30-80) and 40 minutes (IQR 30-70), respectively. When total (pan)enteroscopy was intended, this was achieved at rate of 70.3 % (28.1 % by antegrade approach and 42.2 % by a bidirectional approach). Surgically altered GI anatomy was present in 34 /170 of all procedures (20.0 %) and in 11 /45 of the successful total enteroscopy procedures (24.4 %). Propofol sedation or general anesthesia were used in 92.9 % and 7.1 % of the procedures, respectively. Minor adverse events were observed in 15.9 % of patients, but there were no major adverse events.

CONCLUSION

MSE seems to be an effective and safe endoscopic procedure. Total (pan)enteroscopy can be achieved, in one or two sessions, even in the presence of surgically altered GI anatomy. The total procedure time is relatively short. For both antegrade and retrograde MSE procedures, propofol sedation seems sufficient and safe.

Role of endoscopy in inflammatory bowel disease

Crohn’s disease (CD) and ulcerative colitis (UC) constitute the two most common phenotypes of inflammatory bowel disease (IBD). Ileocolonoscopy with biopsy has been considered the gold standard for the diagnosis of IBD. Differential diagnosis of CD and UC is important, as their medical and surgical treatment modalities and prognoses can be different. However, approximately 15% of patients with IBD are misdiagnosed as IBD unclassified due to the lack of diagnostic certainty of CD or UC. Recently, there has been increased recognition of the role of the therapeutic endoscopist in the field of IBD. Newer imaging techniques have been developed to aid in the differentiation of UC vs CD. Furthermore, endoscopic balloon dilation and stenting have become an integral part of the therapeutic armamentarium of CD stricture management. Endoscopic ultrasound has been recognized as being more accurate than magnetic resonance imaging in detecting perianal fistulae in patients with CD. Additionally, chromoendoscopy may help to detect dysplasia earlier compared with white-light colonoscopy. Hence, interventional endoscopy has become a cornerstone in the diagnosis, treatment and management of IBD complications. The role of endoscopy in the field of IBD has significantly evolved in recent years from small-bowel imaging to endoscopic balloon dilation and use of chormoendoscopy in dysplasia surveillance. In this review article, we discuss the current evidence on interventional endoscopy in the diagnosis, treatment and management of IBD compications.

Refractory celiac disease

Refractory celiac disease (RCD) affects patients who have failed to heal after 6-12 months of a strict gluten-free diet (GFD) and when other causes of symptoms (including malignancy) have been ruled out. It may also occur in patients who previously had responded to a long-term GFD. RCD may be categorized as RCD1 (normal immunophenotype) and RCD2 (aberrant immunophenotype). RCD1 usually responds to a continued GFD, nutritional support, and therapeutic agents such as corticosteroids. In contrast, clinical response in RCD2 is incomplete and prognosis is often poor. RCD (particularly RCD2) is associated with serious complications, such as ulcerative jejunitis and enteropathy-associated T-cell lymphoma (EATL). Strict clinical and laboratory criteria should be used to diagnose RCD and specialized tests for aberrancy and clonality should be interpreted in the context of their sensitivity and specificity. Adequate nutritional support and anti-inflammatory treatment may even allow patients with RCD2 to attain a clinical remission.

[Peutz-Jeghers syndrome manifested as massive melæna at CHU-JRA Madagascar hospital: a case report]

Le syndrome de Peutz-Jeghers (SPJ) est caractérisé par l'association d'une polypose digestive hamartomateuse et d'une lentiginose cutanéo-muqueuse. Les malades sont exposés à des complications mécaniques et hémorragiques. Il s'agit d'un syndrome de prédisposition au cancer. Notre étude a pour objectif de rappeler les diagnostiques d'un syndrome de Peutz-Jeghers, de connaitre les complications ainsi que les progrès thérapeutiques dans la prise en charge. Nous avons rapporté le cas d'un homme de 32 ans présentant un melaena massif. Il a été hospitalisé en service de réanimation chirurgicale pour état de choc hypovolémique difficile à contrôler. Il a nécessité une intervention chirurgicale pour arrêter l'hémorragie. Nous avons trouvé un polype hamartomateux dans le grêle qui a causé le saignement. Le diagnostic d'un Syndrome de Peutz-Jeghers a été posé devant la notion de lentiginose labiale pendant l'enfance. Lors de l'exploration clinique et paraclinique, il ne présente pas encore de cancer. A Madagascar, cette pathologie est encore mal connue. Dans la littérature, le syndrome de Peutz-Jeghers peut être révélé cliniquement ou au stade de complication comme l'hémorragie, l'invagination ou l'occlusion intestinale. Dans notre cas, la maladie est compliquée d'une hémorragie digestive avec état de choc hypovolémique. La polypectomie endoscopique par entéroscopie à double ballonnet permet de diminuer le recours à la chirurgie grêlique d'urgence. Le syndrome de Peutz-Jeghers est une affection rare. Mais il est important aux cliniciens de le connaitre et de penser à sa possibilité en cas d'hémorragie digestive.

Advances in balloon endoscopes

In September 2003, a double-balloon endoscope (DBE) composed of balloons attached to a scope and an overtube was released in Japan prior to becoming available in other parts of the world. The DBE was developed by Dr. Yamamoto (1), and 5 different types of scopes with different uses have already been marketed. In April 2007, a single-balloon small intestinal endoscope was released with a balloon attached only to the overtube as a subsequent model. This article presents a detailed account of the development of these scopes up to the present time.

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%.

Enteropathy-associated T-cell lymphoma: a review on clinical presentation, diagnosis, therapeutic strategies and perspectives

INTRODUCTION

Enteropathy-associated T-cell lymphoma (EATL) is a rare complication of celiac disease (<1% of lymphomas) and has a poor prognosis.

METHODS

International literature review with PubMed search (up to January 2009) of pathophysiological, clinical and therapeutic data.

RESULTS

EATL is found in patients with a mean age of 59 years, often with a complication that signals its diagnosis. Refractory celiac disease (RCD), equivalent to low-grade intraepithelial T-cell lymphoma, could be an intermediary between celiac disease and high-grade invasive T-cell lymphoma. The median survival is 7 months, with no significant difference between stages; the cumulative 5-year survival is less than 20%. The poor prognosis is determined by disease that has often spread before it is diagnosed (50%), multifocal involvement of the small bowel (50%), poor general health status and undernutrition, and recurrence of complications (infections, perforations, gastrointestinal haemorrhages, occlusions), thus delaying the chemotherapy and contributing to frequent chemotherapy resistance. There is currently no effective and consensual treatment: preventive surgery for complications is controversial, and the results of chemotherapy are disappointing. The classic CHOP protocol (combination of doxorubicin-cyclophosphamide-vincristine-prednisone) does not have satisfactory results and survival remains poor, especially in patients with underlying RCD. High-dose chemotherapy with autotransplantion seems to only improve the prognosis in localised forms. Allogeneic bone marrow transplantation was not evaluated. In all, 1/3 of patients, being unfit for treatment, die before 3 months and half of treated patients stop chemotherapy prematurely due to inefficacy, intolerance and/or complications.

CONCLUSION

Improvement of the prognosis requires collaboration in order to compose a national cohort, to evaluate new diagnostic and therapeutic strategies and to define prognostic factors.

Primary balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding: findings and outcome of therapy

GOALS

The aim of this study was to evaluate the diagnostic and therapeutic outcome of a primary balloon-assisted enteroscopy (BAE) approach in obscure gastrointestinal bleeding (OGIB) patients.

BACKGROUND

In the diagnostic approach of OGIB, both wireless capsule endoscopy (WCE) and BAE are used. The advantage of the primary wireless capsule endoscopy approach is its noninvasiveness. The main advantage of the primary BAE approach is the excellent diagnostic accuracy and the possibility to perform treatment during the same procedure.

STUDY

A retrospective analysis of our BAE database with patients evaluated for OGIB was performed. BAE data, findings, and follow-up were obtained and evaluated.

RESULTS

One hundred and thirty-two patients (81 male, mean age 62 (11-88) years) were included. In 60 (45%) patients with follow-up, a likely cause for OGIB was found in the small bowel during BAE: angiodysplasia or vascular malformations in 42 (70%), ulcerative lesions in 7 (12%), tumors in 3 (5%), and other findings in 8 (13%) patients. Follow-up was available in 118 (89%) patients; mean time of follow-up was 18 (1-47) months. Thirty-eight (76%) patients with findings at BAE received endoscopic treatment, 27 (71%) of them improved, but anemia also improved spontaneously in 34 patients (63%) with normal findings during BAE. The total number of angiodysplasia per patient was not related to the outcome after treatment.

CONCLUSIONS

The primary BAE approach in OGIB patients has an acceptable diagnostic yield. Therapy seems successful at mid-term follow-up. A high frequency of spontaneous resolution of anemia in patients with normal findings during BAE was observed.

Antegrade double balloon enteroscopy for continued obscure gastrointestinal bleeding following push enteroscopy: is there a role?

BACKGROUND

The benefit of double balloon endoscopy (DBE) over push enteroscopy (PE) for the proximal small bowel in patients with obscure gastrointestinal bleeding remains unclear.

AIM

To quantify the benefit of DBE if PE fails to benefit patients with obscure gastrointestinal bleeding.

METHODS

This retrospective DBE database review between July 2004 and April 2008 was conducted at a tertiary university hospital in Australia. Thirty-three patients with obscure gastrointestinal bleeding who had undergone PE for proximal small bowel lesions were identified from a DBE database of 280 patients. Mean age was 68.6 (range 30-91) years, and 17 were men. In group A (n = 15) the target lesion was not reached by PE, and in group B (n = 18) an abnormality was found by PE (angioectasia in 17 and red spots in 1) but the patient had ongoing bleeding. Mean follow-up for the cohort was 19.2 (range 5-39) months. DBE interventions were performed as appropriate.

RESULTS

An abnormality was found at DBE in 28/33 (85%) patients. DBE found an abnormality in 12/15 (80%) in group A and 16/18 (89%) in group B. Endoscopic intervention was performed in 23/33 patients (70%). In 27/33 (82%) patients a clinical benefit was seen following DBE. Six patients (18%) had no clinical benefit from DBE.

CONCLUSIONS

In patients with obscure gastrointestinal bleeding and proximal small bowel lesions who fail to benefit from PE, DBE offers a very high benefit in finding and treating lesions with good long-term outcomes.

MR enteroclysis in the diagnosis of small-bowel neoplasms

PURPOSE

To evaluate the diagnostic accuracy and interobserver variance of magnetic resonance (MR) enteroclysis in the diagnosis of small-bowel neoplasms, with small-bowel endoscopy, surgery, histopathologic analysis, and follow-up serving as standards of reference, and to identify MR enteroclysis characteristics capable of enabling discrimination between benign and malignant small-bowel neoplasms.

MATERIALS AND METHODS

This study was performed in accordance with the guidelines of the institutional review board, and the requirement for informed consent was waived. MR enteroclysis studies of 91 patients (43 women, 48 men; age range, 18-83 years) were retrospectively evaluated by two radiologists blinded to clinical details. Only studies explicitly performed to investigate or exclude the presence of small-bowel neoplasms were included. Radiologic findings were compared with findings of double-balloon endoscopy (n = 45), surgery (n = 18), esophagogastroduodenoscopy (n = 3), ileocolonoscopy (n = 2), autopsy (n = 2), and clinical follow-up for more than 18 months (n = 21). Efficacy parameters were calculated with 95% confidence intervals. Tumor characteristics were compared with the Student t test and the Fisher exact test.

RESULTS

Readers 1 and 2 interpreted 31 and 33 studies, respectively, as depicting a small-bowel neoplasm and 19 and 17 studies, respectively, as depicting small-bowel malignancy. In 32 patients, the presence of small-bowel neoplasm was confirmed. In 19 of these patients, the neoplasm was malignant. Sensitivity and specificity in the diagnosis of small-bowel neoplasms was 0.91 and 0.95, respectively, for reader 1 and 0.94 and 0.97, respectively, for reader 2; the kappa value was 0.95. Factors associated with malignancy were the presence of longer solitary nonpedunculated lesions, mesenteric fat infiltration, and enlarged mesenteric lymph nodes.

CONCLUSION

Eighty-six of 91 studies were correctly interpreted, resulting in an overall diagnostic accuracy of 0.95 for MR enteroclysis in the detection of small-bowel neoplasms.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09090828/-/DC1.

Peutz-Jeghers syndrome: Diagnostic and therapeutic approach

Peutz-Jeghers syndrome (PJS) is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. Prevalence of PJS is estimated from 1 in 8300 to 1 in 280 000 individuals. PJS predisposes sufferers to various malignancies (gastrointestinal, pancreatic, lung, breast, uterine, ovarian and testicular tumors). Bleeding, obstruction and intussusception are common complications in patients with PJS. Double balloon enteroscopy (DBE) allows examination and treatment of the small bowel. Polypectomy using DBE may obviate the need for repeated urgent operations and small bowel resection that leads to short bowel syndrome. Prophylaxis and polypectomy of the entire small bowel is the gold standard in PJS patients. Intraoperative enteroscopy (IOE) was the only possibility for endoscopic treatment of patients with PJS before the DBE era. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful. An overall recommendation for PJS patients includes not only gastrointestinal multiple polyp resolution, but also regular lifelong cancer screening (colonoscopy, upper endoscopy, computed tomography, magnetic resonance imaging or ultrasound of the pancreas, chest X-ray, mammography and pelvic examination with ultrasound in women, and testicular examination in men). Although the incidence of PJS is low, it is important for clinicians to recognize these disorders to prevent morbidity and mortality in these patients, and to perform presymptomatic testing in the first-degree relatives of PJS patients.

Present status and problems in diagnosis and treatment of Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disease, which is caused by inactivating germline mutations in LKB1/STK11 and characterized by mucocutaneous pigmentation, multiple gastrointestinal hamartomatous polyps and family history. Life-threatening complications include intestinal obstruction, an increasing risk for developing gastrointestinal malignancies and extraintestinal cancers. PJS more frequently happens to teenagers. Besides susceptibility to malignant cancer, it was characterized by complications associated with polyps, repeated hospitalizations and operations, as well as a high cost of medical cost, which especially brings harm to one-child family in China. This paper focuses on the diagnoses and treatments in PJS, such as clinical use of double-balloon enteroscopy and open surgery combined with intraoperative endoscopy. Also, COX-2 inhibitors and rapamycin for chemoprevention are introduced.

Obscure gastrointestinal bleeding: role of videocapsule and double-balloon enteroscopy

Capsule endoscopy (CE), which allows the non-invasive visualisation of mucosa throughout the entire small bowel, has revolutionised the exploration of small-bowel diseases, and particularly the evaluation of obscure gastrointestinal bleeding (OGIB) after a negative initial evaluation, including gastroscopy and colonoscopy. CE has a high negative predictive value and a higher diagnostic yield than all other modalities, such as radiology (small-bowel X-rays or computed tomography scan) or push enteroscopy. CE may be the preferred initial diagnostic choice in OGIB because of its non-invasive quality and better tolerance. Double-balloon enteroscopy, also known as push-and-pull enteroscopy, has recently been developed. It has made it possible not only to explore the small bowel but also to carry out therapeutic interventions deep in the small bowel without the need for surgical laparotomy. This exploration should be considered as a second-line exploration for OGIB in patients with a positive finding on CE requiring endoscopic follow-up for histology or intervention, and in patients in whom suspicion of a small-bowel lesion is high despite a negative CE.

Double-balloon endoscopy: who needs it?

OBJECTIVE

Double-balloon endoscopy (DBE) made the small bowel accessible to inspection and therapy in its entirety. However, DBE is a time-consuming procedure that requires a highly skilled endoscopist, several nurses and--more often than not--anesthesiological support. This makes the selection of patients for DBE a pivotal point. The mainstay of this screening examination of the small bowel is capsule endoscopy (CE). The aim of this study was to describe the results of this screening procedure and the subsequent DBE in patients with suspected mid-gastrointestinal bleeding (MGIB).

MATERIAL AND METHODS

Patients referred for CE from March 2004 to September 2006 were evaluated retrospectively. If CE revealed pathology suitable for DBE, the procedure was then carried out. All referred patients were followed-up at the end of the period with regard to final diagnosis and symptom resolution.

RESULTS

A total of 83 patients were referred for suspected MGIB. Indications for DBE were found in 26 patients (31%). A total of 34 DBEs (27 oral, 7 anal) were performed. Insertion length for the oral and anal DBE was 200 cm (range 40-500 cm) beyond the ligament of Treitz and 137 cm (range 10-200 cm) beyond the ileocecal valve, respectively. In 2 out of 4 patients where insertion was attempted, a total inspection of the small bowel was possible (50%). The diagnostic yield was 77% (CI: 58-89%) with a therapeutic yield of 73% (CI: 54-86%). None of the 57 patients for whom there was no indication for DBE required DBE within the next 12 months.

CONCLUSIONS

CE can be applied as a screening procedure for DBE and allows for an approximately two-thirds reduction in the need for DBE as well as enabling a choice to be made between the oral and anal route.