Double balloon enteroscopy and acute pancreatitis

Double balloon enteroscopy(DBE)is a new technique, first published and introduced into clinical practice in 2001 by Yamamoto,the inventor of this outstanding method.DBE allows complete visualization,biopsy and treatment of the small bowel.Nowadays,we have some experience of this method for evaluation of the complica- tion rate.Severe complications are described in 1%-1.7% of patients.Acute pancreatitis is a rare complication of the investigation.The incidence of acute pancreatitis after diagnostic DBE is 0.3%in most studies.More than 50 cases of acute pancreatitis have been described in the literature so far.On the contrary,hyperamylasemia after DBE seems to be a rather common condition.Association with acute pancreatitis is supposed to be possible,but not obligatory.The causal mechanism of post-DBE acute pancreatitis is uncertain,and there are several theories in the literature.The most probable cause seems to be a mechanical straining of the endoscope with over-tube on the pancreas or in the papillary area.

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.

DOUBLE BALLOON ANGIOPLASTY FOR TREATING RESTENOTIC VEIN GRAFT

A 53-year-old man with a restenotic large right coronary vein graft was successfully treated by double balloon angioplasty. The technique and clinical application of double balloon angioplasty were discussed.

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.

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.

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.

Impact of enteroscopy on diagnosis and management of small bowel tumors

Small bowel tumors(SBTs)have been increasingly diagnosed in recent decades.The pathogenesis of this increment is largely unknown,but advances in radiological and endoscopic methods facilitate the improvement of the diagnosis.Capsule endoscopy(CE)and device-assisted enteroscopy(DAE)allow the clinician to assess the entire small bowel in the search for suspicious lesions,or a cause of symptoms.In this review,we discuss the role of enteroscopy,techniques and strategies in the diagnosis and management of SBTs,and a brief description of the most common tumors.

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.