Role of balloon enteroscopy for obscure gastrointestinal bleeding in those with surgically altered anatomy: A systematic review

BACKGROUND Obscure gastrointestinal(GI)bleeding is defined as persistent bleeding despite negative evaluation with both esophagogastroduodenoscopy and colonoscopy and can be secondary to small intestinal pathology.Standard endoscopy as well as push endoscopy can be a challenge in those with altered anatomy given inaccessible areas as well as perforation risk.Single and double balloon enteroscopy can be warranted in this patient population in instances of obscure GI bleed.AIM To assess the safety and diagnostic efficacy of balloon enteroscopy for obscure GI bleeding in patients with surgically altered anatomy.METHODS A search was conducted through PubMed,MEDLINE,Google Scholar,Scopus,and Embase with the key words“enteroscopy,”“obscure bleeding,”and“altered anatomy,”to identify relevant articles in English with no restricted time frame.A search within the Reference Citation Analysis database was conducted to ensure inclusion of the latest high impact articles.Study types included in the review were prospective and retrospective reviews,case series,and case reports.The reference lists of these papers were also reviewed to find further papers that were applicable.The authors extracted the data from the studies that fit inclusion criteria.Data of interest included type of study,type of procedure,and type of altered anatomy,as well as the number of patients with any diagnostic or therapeutic intervention.Data was also recorded on procedure tolerance and complications.The data was analyzed with descriptive statistics.RESULTS Our literature search yielded 14 studies that were included.There were 68 procedures performed with 61 unique patients subjected to these procedures.Forty-four(65%)of the procedures were double balloon,21(31%)were single balloon,and 3(4%)were classified as through the scope balloon assisted.The most common altered anatomy types included Gastric Bypass Roux-en-Y,Pylorus Sparing Whipple,Orthotopic Liver Transplantation with Roux-en-Y,and Gastrojejunostomy Roux-en-Y.The procedures were successfully performed in each patient.There were 5(7%)procedures that were complicated by perforation.Amongst the available data,the diagnostic yield was 48/59(81%)and a therapeutic yield of 39/59(66%).One patient was recommended surgical revision of their altered anatomy following enteroscopy.CONCLUSION Balloon enteroscopy is a useful diagnostic modality in investigating obscure GI bleeding within those with surgically altered anatomy;however,precautions must be taken as this population may have increased perforation risk.

Double balloon enteroscopy in children:Diagnosis,treatment,and safety

AIM:To assess the feasibility and utility of double balloon enteroscopy(DBE)in the management of small bowel diseases in children. METHODS:Fourteen patients(10 males)with a median age of 12.9 years(range 8.1-16.7)underwent DBE; 5 for Peutz-Jeghers syndrome(PJ syndrome),2 for chronic abdominal pain,4 for obscure gastrointestinal (GI)bleeding,2 with angiomatous malformations(1 blue rubber bleb nevus syndrome)having persistent GI bleeding,and 1 with Cowden's syndrome with multiple polyps and previous intussusception.Eleven procedures were performed under general anesthesia and 3 with deep sedation. RESULTS:The entire small bowel was examined in 6 patients,and a length between 200 cm and 320 cm distal to pylorus in the remaining 8.Seven patients had both antegrade(trans-oral)and retrograde(transanal and via ileostomy)examinations.One patient underwent DBE with planned laparoscopic assistance.The remaining 6 had trans-oral examination only.The median examination time was 118 min(range 95-195). No complications were encountered.Polyps were detected and successfully removed in all 5 patients with PJ syndrome,in a patient with tubulo-villous adenoma of the duodenum,in a patient with significant anemia and occult bleeding,and in a patient with Cowden's syndrome.A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy,and in 1 with a discrete angioma which was treated with argon plasma coagulation.The source of bleeding was identified in a further patient with varices.DBE was normal or revealed minor mucosal friability in the remaining 3 patients.Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved. CONCLUSION:Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children,allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.

Double balloon enteroscopy examinations in general anesthesia

AIM:To demonstrate that the double balloon enteroscopy(DBE) can be safely performed in general anesthesia with intubation.METHODS:We performed a retrospective examination between August 2005 and November 2008 amongpatients receiving intubation narcosis due to DBE examination.The patients were grouped based on sex,age and physical status.Anesthesia records includedduration of anesthesia,quantity of medication usedand anesthesia-related complications.We determinedthe frequency of complications in the different groupsand their relation with the quantity of medication usedand the duration of anesthesia.RESULTS:We compiled data for 108 cases of general anesthesia with intubation.We did not observeany permanent anesthesia-related complications;themost frequent side effects of anesthesia were hypo-tension(30.55%),desaturation(21.29%),and apnea(17.59%).These complications were significantly more frequent among patients with multiple additional diseases [hypotension(23.1% vs 76.9%,P = 0.005),desaturation(12.3% vs 69.2%,P < 0.001) and apnea(7.7% vs 53.8%,P = 0.001)],however,their incidence was not proportional to the quantity of medication used or the duration of anesthesia.CONCLUSION:General anesthesia with intubation is definitely a viable option among DBE methods.It is highly recommended in patients with multiple additional diseases.

Evaluation of the diagnostic and therapeutic utility of retrograde through-the-scope balloon enteroscopy and single-balloon enteroscopy

BACKGROUND Retrograde single balloon enteroscopy(SBE)is a minimally invasive procedure which is less frequently performed compared with antegrade SBE.There are few studies on the retrograde through-the-scope enteroscopy(TTSE),a novel technique for evaluation of the small bowel.AIM To compare the clinical utility and safety of retrograde TTSE with retrograde SBE.METHODS Clinical data and complications of retrograde TTSE(2014-2018)and retrograde SBE(2011-2018)performed in a community hospital were reviewed and presented as mean±SD or frequency(%)and compared using proper statistical tests.Technical success was defined as insertion of the enteroscope>20 cm beyond ileocecal valve.RESULTS Data obtained from 54 retrograde SBE in 49 patients and 27 retrograde TTSE in 26 patients were studied.The most common indication for retrograde enteroscopy was iron deficiency anemia(41 patients)followed by gastrointestinal bleeding(37 patients),and chronic diarrhea(7 patients).The duration of retrograde SBE procedure(91.9±34.2 min)was significantly longer compared with retrograde TTSE(70.5±30.7 min)(P=0.04).Technical success was comparable in TTSE[23/27(85.2%)]and SBE[41/54(75.9%)(P=0.33)].The mean depth of insertion beyond the ileocecal valve in retrograde SBE(92.5±70.0 cm)tended to be longer compared with retrograde TTSE(64.6±49.0 cm)(P=0.08).No complication was observed in this study.CONCLUSION Both retrograde TTSE and retrograde SBE are feasible and safe.Retrograde TTSE takes a shorter time and has a comparable technical success with SBE.TTSE has a lower capacity of small bowel insertion.

Clinical profile,diagnostic yield,and procedural outcomes of single balloon enteroscopy:A tertiary care hospital experience

BACKGROUND Single balloon enteroscopy(SBE)allows ease of access for small bowel visualization and has multiple diagnostic and therapeutic indications.It provides the advantage of performing various therapeutic interventions alongside the diagnostic procedure.SBE has also been considered a relatively safe procedure with no major complications.AIM To investigate the indications,safety,and clinical yield of SBE,and determine its effect on disease outcome.METHODS A retrospective,descriptive study was conducted at a tertiary care hospital in Karachi,Pakistan.Medical records of 56 adult patients(≥18 years)who underwent SBE between July 2013 and December 2021 were reviewed and data were collected using a structured proforma.A descriptive analysis of the variables was performed using Statistical Package of Social Sciences Version 19.Results are reported as the mean±SD for quantitative variables and numbers and percentages for qualitative variables.Missing data are reported as unknown.RESULTS A total of 56 patients who underwent 61 SBE procedures were included.The mean age was 50.93±16.16 years,with 53.6%of them being males.Hypertension(39.3%)and diabetes mellitus(25.0%)were the most common pre-existing comorbidities.Obscure gastrointestinal bleed(39.3%)was the most common indication for enteroscopy,followed by chronic diarrhea(19.7%)and unexplained anemia(16.4%).The majority of procedures were performed in the endoscopy suite(90.2%)under monitored anaesthesia care(93.4%).Most procedures were diagnostic(91.8%)and completed without complications(95.1%).The depth of examination ranged from 95 cm to 500 cm with a mean of 282.05±90.04 cm.The most common findings were inflammation and ulcerations(29.5%),followed by masses(19.7%)and vascular malformations(14.8%).As a result of the findings,a new diagnosis was made in 47.5%of the cases and a previous one was ruled out in 24.6%of them;65.6%of the cases had a change in management.CONCLUSION SBE is a suitable modality for investigating diseases in the small bowel.It is shown to be technically efficient and reasonably safe and is associated with high diagnostic and therapeutic yield.

Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy

The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy(EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass(RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status postRYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.

Strategies to manage the difficult colonoscopy

During endoscopy,an endoscopist is inevitably faced with the occasional“difficult colonoscopy,”in which the endoscopist finds it challenging to advance the endoscope to the cecum.Beyond optimization of technique,with minimized looping,minimal insufflation,sufficient sedation,and abdominal splinting when needed,sometimes additional tools may be needed.In this review,we cover available techniques and technologies to help navigate the difficult colonoscopy,including the ultrathin colonoscope,rigidizing overtube,balloon-assisted colonoscopy and the abdominal compression device.

Endoscopic management of difficult common bile duct stones:Where are we now?A comprehensive review

Endoscopic management for difficult common bile duct(CBD)stones still presents a challenge for several reasons,including anatomic anomalies,patients’individual conditions and stone features.In recent years,variable methods have emerged that have attributed to higher stone removal success rates,reduced cost and lower adverse events.In this review,we outline a stepwise approach in CBD stone management.As first line therapy,endoscopic sphincterotomy and large balloon dilation are recommended,due to a 30%-50%reduction of the use of mechanical lithotripsy.On the other hand,cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence.As discussed,findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions.Furthermore,we evaluate the management of CBD stones in various surgical altered anatomy(Billroth II,Roux-en-Y and Roux-en-Y gastric bypass).Moreover,we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use,rather than following a failed management option.In addition,we discuss the importance of dissecting other techniques,such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed.In conclusion,we recognize that endoscopic sphincterotomy and large balloon dilation,mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones,but emerging techniques are in rapid evolution with encouraging results.

Treatment of gastrointestinal bleeding in left ventricular assist devices:A comprehensive review

Left ventricular assist devices(LVAD)are increasingly become common as life prolonging therapy in patients with advanced heart failure.Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps.Unfortunately,continuous flow LVADs are fraught with complications such as gastrointestinal(GI)bleeding that are primarily attributed to the formation of arteriovenous malformations.With frequent GI bleeding,antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events.Small bowel bleeds account for 15%as the source and patients often undergo multiple endoscopic procedures.Treatment strategies include resuscitative measures and endoscopic therapies.Medical treatment is with octreotide.Novel treatment options include thalidomide,angiotensin converting enzyme inhibitors/angiotensinⅡreceptor blockers,estrogen-based hormonal therapies,doxycycline,desmopressin and bevacizumab.Current research has explored the mechanism of frequent GI bleeds in this population,including destruction of von Willebrand factor,upregulation of tissue factor,vascular endothelial growth factor,tumor necrosis factor-α,tumor growth factor-β,and angiopoetin-2,and downregulation of angiopoetin-1.In addition,healthcare resource utilization is only increasing in this patient population with higher admissions,readmissions,blood product utilization,and endoscopy.While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages,these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.