Device-assisted enteroscopy: A review of available techniques and upcoming new technologies

The advent of video capsule endoscopy into clinical routine more than 15 years ago led to a substantial change in the diagnostic approach to patients with suspected small bowel diseases, often indicating a deep enteroscopy procedure for diagnostical confirmation or endoscopic treatment. Device assisted enteroscopy was developed in 2001 and for the first time established a practicable, safe and effective method for evaluation of the small bowel.Currently with double-balloon enteroscopy, single-balloon enteroscopy and spiral enteroscopy three different platforms are available in clinical routine.Summarizing, double-balloon enteroscopy seems to offer the deepest insertion depth to the small bowel going hand in hand with the disadvantage of a longer procedural duration. Manual spiral enteroscopy seems to be a faster procedure but without reaching the depth of the DBE in currently available data. Finally,single-balloon enteroscopy seems to be the least complicated procedure to perform. Despite substantial improvements in the field of direct enteroscopy,even nowadays deep endoscopic access to the small bowel with all available methods is still a complex procedure, cumbersome and time-consuming and requires high endoscopic skills. This review will give an overview of the currently available techniques and will further discuss the role of the upcoming new technology of the motorized spiral enteroscopy(PowerSpiral).

Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis

AIM:To develop an algorithm to improve the diagnosis and treatment of patients with biliary candidiasis.METHODS:We performed a prospective study of 127patients who underwent endoscopic retrograde cholangiopancreatography,for various biliary disorders,at 3 tertiary referral centers in Germany from July 2011through July 2012(ClinicalTrials.gov:NCT01109550).Bile,buccal,and stool samples were collected.When indicated,endoscopic transpapillary bile duct biopsies were performed to clarify the etiology of bile duct strictures and to prove invasive fungal infections.RESULTS:Candida species were detected in 38 of the 127 bile samples(29.9%).By multivariate analysis patients’age and previous endoscopic sphincterotomy were independent risk factors for biliary candidiasis(P<0.05).Patients with immunosuppression(P=0.058)and recent long-term antibiotic therapy(>7 d)(P=0.089)tend to be at risk for biliary candidiasis.One patient was negative in mycological culture of bile fluid but invasive biliary candidiasis was diagnosed histologically.Of Candida subspecies detected,36.7%were azole-resistant,such as C glabrata.Eight patients received anti-mycotic therapy,based on our algorithm.Of these,3 had cancer with biliary tract involvement,2had secondary sclerosing cholangitis,1 had retroperitoneal fibrosis,and 5 had septicemia.In all patients contamination was ruled out by smears of the endoscope channel.CONCLUSION:Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders.Our suggested algorithm facilitates the further clinical management.

A typical presentation of a rare cause of obscure gastrointestinal bleeding

A 52-year-old white woman had suffered from intermittent gastrointestinal (GI) bleeding for one year. Upper GI endoscopy, colonoscopy and peroral doubleballoon enteroscopy (DBE) did not detect any bleeding sour ce, suggesting obscure GI bleeding. However, in video capsule endoscopy a jejunal ulceration without blee ding signs was suspected and this was endoscopically conf irmed by another peroral DBE. After transfusion of packed red blood cells, the patient was discharged from our hospital in good general condition.Two weeks later she was readmitted because of another episode of acute bleeding. Multi-detector row computed tomography with 3D reconstruction was performed revealing a jejunal tumor causing lower gastrointestinal bleeding. The patient underwent exploratory laparotomy with partial jejunal resection and end-to-end jejunostomy for reconstruction. Histological examination of the specimen confirmed the diagnosis of a low risk gastrointestinal stromal tumor (GIST). Nine days after surgery the patient was discharged in good health. No signs of gastrointestinal rebleeding occurred in a followup of eight months. We herein describe the comp lex presentation and course of this patient with GIST and also review the current approach to treatm ent.