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Damjanovska S, Isenberg G. Endoscopic Treatment of Small Bowel Bleeding. Gastrointest Endosc Clin N Am 2024; 34:331-343. [PMID: 38395487 DOI: 10.1016/j.giec.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Approximately 5% of all gastrointestinal (GI) bleeding originates from the small bowel. Endoscopic therapy of small bowel bleeding should only be undertaken after consideration of the different options, and the risks, benefits, and alternatives of each option. Endoscopic therapy options for small bowel bleeding are like those treatments used for other forms of bleeding in the upper and lower GI tract. Available endoscopic treatment options include thermal therapy (eg, argon plasma coagulation and bipolar cautery), mechanical therapy (eg, hemoclips), and medical therapy (eg, diluted epinephrine injection). Patients with complicated comorbidities would benefit from evaluation and planning of available treatment options, including conservative and/or medical treatments, beyond endoscopic therapy.
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Affiliation(s)
- Sofi Damjanovska
- Department of Medicine, University Hospitals Cleveland Medical Center/Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Gerard Isenberg
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center/Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Massironi S, Fanetti I, Viganò C, Pirola L, Fichera M, Cristoferi L, Capurso G, Invernizzi P, Danese S. Systematic review-pancreatic involvement in inflammatory bowel disease. Aliment Pharmacol Ther 2022; 55:1478-1491. [PMID: 35505465 PMCID: PMC9322673 DOI: 10.1111/apt.16949] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/28/2022] [Accepted: 04/18/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic inflammatory immune-mediated disorder of the gut with frequent extra-intestinal complications. Pancreatic involvement in IBD is not uncommon and comprises a heterogeneous group of conditions, including acute pancreatitis (AP), chronic pancreatitis (CP), autoimmune pancreatitis (AIP) and pancreatic exocrine insufficiency (PEI); however, data on such an association remain sparse and heterogeneous. METHOD PubMed/MEDLINE and EMBASE databases were searched for studies investigating pancreatic involvement in patients with IBD. RESULTS Four thousand one hundred and twenty-one records were identified and 547 screened; finally, 124 studies were included in the review. AP is the most frequent pancreatic manifestation in IBD; the majority of AP cases in IBD are due to gallstones and drugs but cases of idiopathic AP are increasingly reported. AIP is a rare disease, but a strong association with IBD has been demonstrated, especially for type 2 and ulcerative colitis. The pathogenetic link between IBD and AIP remains unclear, but an immune-mediated pathway seems plausible. An association between CP and PEI with IBD has also been suggested, but data are to date scarce and conflicting. CONCLUSION This is the first systematic review of the association between IBD and pancreatic diseases. Gallstones and drugs should be considered the most probable causes of AP in IBD, with type 2 AIP also being possible.
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Affiliation(s)
- Sara Massironi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Ilaria Fanetti
- Gastroenterology and Endoscopy Unit, ASST Ovest MilaneseLegnano HospitalLegnanoItaly
| | - Chiara Viganò
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Lorena Pirola
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Maria Fichera
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Laura Cristoferi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Gabriele Capurso
- Pancreas Translational & Clinical Research Center, Pancreato‐Biliary Endoscopy & Endosonography DivisionSan Raffaele Scientific Institute IRCCSMilanItaly
| | - Pietro Invernizzi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Silvio Danese
- Gastroenterology and EndoscopyIRCCS Ospedale San Raffaele and Vita‐Salute San Raffaele UniversityMilanItaly
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The Etiology of Pancreatic Manifestations in Patients with Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8070916. [PMID: 31247968 PMCID: PMC6679036 DOI: 10.3390/jcm8070916] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is an idiopathic chronic and recurrent condition that comprises Crohn's disease and ulcerative colitis. A pancreatic lesion is one of the extraintestinal lesions in patients with IBD. Acute pancreatitis is the representative manifestation, and various causes of pancreatitis have been reported, including those involving adverse effects of drug therapies such as 5-aminosalicylic acid and thiopurines, gall stones, gastrointestinal lesions on the duodenum, iatrogenic harm accompanying endoscopic procedures such as balloon endoscopy, and autoimmunity. Of these potential causes, autoimmune pancreatitis (AIP) is a relatively newly recognized disease and is being increasingly diagnosed in IBD. AIP cases can be divided into type 1 cases involving lymphocytes and IgG4-positive plasma cells, and type 2 cases primarily involving neutrophils; the majority of AIP cases complicating IBD are type 2. The association between IBD and chronic pancreatitis, exocrine pancreatic insufficiency, pancreatic cancer, etc. has also been suggested; however, studies with high-quality level evidence are limited, and much remains unknown. In this review, we provide an overview of the etiology of pancreatic manifestation in patients with IBD.
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Blanco-Velasco G, Hernández-Mondragón O, Blancas-Valencia J, Paz-Flores V, Fuentes-Hernández D, Rodríguez-González P, González-Ortíz B. Safety and efficacy of small bowel polypectomy using a balloon-assisted enteroscope in pediatric patients with Peutz-Jeghers syndrome. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Blanco-Velasco G, Hernández-Mondragón OV, Blancas-Valencia JM, Paz-Flores V, Fuentes-Hernández D, Rodríguez-González P, González-Ortíz B. Safety and efficacy of small bowel polypectomy using a balloon-assisted enteroscope in pediatric patients with Peutz-Jeghers syndrome. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:234-237. [PMID: 29449094 DOI: 10.1016/j.rgmx.2017.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/01/2017] [Accepted: 07/13/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND AIMS Peutz-Jeghers syndrome is an autosomal dominant inherited pathology characterized by gastrointestinal hamartomatous polyps, predominantly in the small bowel, and pigmented mucocutaneous lesions. Guidelines suggest polypectomy with a balloon-assisted enteroscope when polyps are larger than 10mm. Complications in adults can be as high as 6.8%, but there is little information on pediatric populations. Our aim was to describe the safety and efficacy of polypectomy in a group of pediatric patients with Peutz-Jeghers syndrome using balloon-assisted enteroscopy. MATERIALS AND METHODS A retrospective study was conducted at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI on pediatric patients with Peutz-Jeghers syndrome that required balloon-assisted enteroscopy and polypectomy within the time frame of January 2010 and December 2015. Patients that underwent polypectomy with a push enteroscope were excluded from the study. RESULTS A total of 35 polypectomies were performed on 4 patients (female/male: 3/1). The mean age of the patients was 13.7 years (range:11-16). Twelve enteroscopies were carried out, 8 of which were anterograde. A single-balloon enteroscope was used in 7 procedures and a double-balloon enteroscope in 5. The mean size of the polyps was 1.6cm (range: 1-4cm). A major complication (acute pancreatitis) presented in only one case (8.3%). No other major complications associated with the procedures were observed. CONCLUSION Balloon-assisted enteroscopy with polypectomy in children is a safe and effective procedure, with complications similar to those reported in adults.
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Affiliation(s)
- G Blanco-Velasco
- Servicio de Endoscopia, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.
| | - O V Hernández-Mondragón
- Servicio de Endoscopia, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - J M Blancas-Valencia
- Servicio de Endoscopia, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - V Paz-Flores
- Servicio de Endoscopia, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - D Fuentes-Hernández
- Servicio de Endoscopia, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - P Rodríguez-González
- Servicio de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - B González-Ortíz
- Servicio de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
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Latorre R, López-Albors O, Soria F, Morcillo E, Esteban P, Pérez-Cuadrado-Robles E, Pérez-Cuadrado-Martínez E. Evidences supporting the vascular etiology of post-double balloon enteroscopy pancreatitis: Study in porcine model. World J Gastroenterol 2017; 23:6201-6211. [PMID: 28974886 PMCID: PMC5603486 DOI: 10.3748/wjg.v23.i34.6201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/28/2017] [Accepted: 08/25/2017] [Indexed: 02/07/2023] Open
Abstract
Double balloon enteroscopy (DBE) is an endoscopic technique broadly used to diagnose and treat small bowel diseases. Among the associated complications of the oral DBE, post-procedure pancreatitis has taken the most attention due to its gravity and the thought that it might be associated to the technique itself and anatomical features of the pancreas. However, as the etiology has not been clarified yet, this paper aims to review the published literature and adds new results from a porcine animal model. Biochemical markers, histological sections and the vascular perfusion of the pancreas were monitored in the pig during DBE practice. A reduced perfusion of the pancreas and bowel, the presence of defined hypoxic areas and disseminated necrotic zones were found in the pancreatic tissue of pigs. All these evidences contribute to support a vascular distress as the most likely etiology of the post-DBE pancreatitis.
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Affiliation(s)
- Rafael Latorre
- Department of Anatomy and Comparative Pathology, University of Murcia, Campus Espinardo, 30100 Murcia, Spain
| | - Octavio López-Albors
- Department of Anatomy and Comparative Pathology, University of Murcia, Campus Espinardo, 30100 Murcia, Spain
| | - Federico Soria
- Minimally Invasive Surgery Centre Jesús Usón, 10071 Cáceres, Spain
| | - Esther Morcillo
- Minimally Invasive Surgery Centre Jesús Usón, 10071 Cáceres, Spain
| | - Pilar Esteban
- Department of Gastroenterology, Small Bowel Unit, Morales Meseguer Hospital, 30008 Murcia, Spain
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Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy. Best Pract Res Clin Gastroenterol 2016; 30:705-718. [PMID: 27931631 DOI: 10.1016/j.bpg.2016.09.005] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/27/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
Endoscopy is an inherent and an invaluable tool in every gastroenterologist's armamentarium. The prerequisite for quality and safety remains foremost. Adverse events should be minimized and proactive steps should taken before, during and after the endoscopic procedure. Upper endoscopy and colonoscopy are part of basic endoscopy and their major complications will be reviewed here, together with those of enteroscopy. The most common of all endoscopy related complications are cardiopulmonary and thus they will be addressed in detail first. Colonoscopy's major complications are bleeding and perforation. Their epidemiology, mechanisms/risk factors, diagnosis, treatment and prevention will be addressed. The incidence of both of these complications increases significantly with polypectomy. Thus clinical judgment and experience in both polypectomy techniques and the ways to treat these complications, especially with the advanced endoscopic options advanced in the last decade, are of paramount importance. Post-polypectomy syndrome, infection and gas explosion are less frequent and will be reviewed briefly. Bleeding and perforation are upper endoscopy's major complications as well. Advances in endoscopic techniques in recent years offer endoscopic treatment instead of directly resorting to surgery, as was used to be the case and still is if the first fails. Enteroscopy is generally a more advanced procedure and overall complication rate is often quoted as 1%, most of them have been attributed to the passage of the overtube. Perforation and bleeding are the major complications, and a unique upper enteroscopy-associated complication is pancreatitis.
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Kopáčová M, Bureš J, Rejchrt S, Vávrová J, Bártová J, Soukup T, Tomš J, Tachecí I. Risk Factors of Acute Pancreatitis in Oral Double Balloon Enteroscopy. ACTA MEDICA (HRADEC KRÁLOVÉ) 2016; 59:84-90. [PMID: 27638962 DOI: 10.14712/18059694.2016.95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Double balloon enteroscopy (DBE) was introduced 15 years ago. The complications of diagnostic DBE are rare, acute pancreatitis is most redoubtable one (incidence about 0.3%). Hyperamylasemia after DBE seems to be a rather common condition respectively. The most probable cause seems to be a mechanical straining of the pancreas. We tried to identify patients in a higher risk of acute pancreatitis after DBE. We investigated several laboratory markers before and after DBE (serum cathepsin B, lactoferrin, E-selectin, SPINK 1, procalcitonin, S100 proteins, alfa-1-antitrypsin, hs-CRP, malondialdehyde, serum and urine amylase and serum lipase). Serum amylase and lipase rose significantly with the maximum 4 hours after DBE. Serum cathepsin and procalcitonin decreased significantly 4 hours after DBE compared to healthy controls and patients values before DBE. Either serum amylase or lipase 4 hours after DBE did not correlate with any markers before DBE. There was a trend for an association between the number of push-and-pull cycles and procalcitonin and urine amylase 4 hours after DBE; between procalcitonin and alfa-1-antitrypsin, cathepsin and hs-CRP; and between E-selectin and malondialdehyde 4 hours after DBE. We found no laboratory markers determinative in advance those patients in a higher risk of acute pancreatitis after DBE.
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Affiliation(s)
- Marcela Kopáčová
- 2nd Department of Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic.
| | - Jan Bureš
- 2nd Department of Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic
| | - Stanislav Rejchrt
- 2nd Department of Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic
| | - Jaroslava Vávrová
- Institute of Clinical Biochemistry and Diagnostics, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic
| | - Jolana Bártová
- 2nd Department of Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic
| | - Tomáš Soukup
- 2nd Department of Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic
| | - Jan Tomš
- 2nd Department of Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic
| | - Ilja Tachecí
- 2nd Department of Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Teaching Hospital, Hradec Králové, Czech Republic
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Latorre R, López-Albors O, Soria F, Candanosa E, Pérez-Cuadrado E. Effect of the manipulation of the duodenal papilla during double balloon enteroscopy. World J Gastroenterol 2016; 22:4330-4337. [PMID: 27158201 PMCID: PMC4853690 DOI: 10.3748/wjg.v22.i17.4330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/11/2016] [Accepted: 03/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the hypothesis that inflating the balloons in the duodenal papilla determines changes in the biochemical markers of pancreatitis.
METHODS: Four groups of pigs were used: Group papilla (GP), the overtube’s balloon was inflated in the area of the papilla; GP + double balloon enteroscopy (GP + DBE), the overtube’s balloon was kept inflated in the area of the papilla for 20 min before a DBE; Group DBE (GDBE), DBE was carried out after insuring the balloon’s inflation far from the pancreatic papilla; and Group control (GC). Serum concentrations of amylase, lipase and C-reactive protein (CRP) were evaluated. Pancreases were processed for histopathology examination.
RESULTS: Main changes occurred 24 h after the procedure compared with baseline levels. Amylase levels increased significantly in GP (59.2% higher) and were moderately higher in groups GP + DBE and GDBE (22.7% and 20%, respectively). Lipase increased in GP and GP + DBE, whereas it hardly changed in GDBE and in GC. CRP increased significantly in GP, GP + DBE and GDBE, while no changes were reported for GC. No statistically significant difference between groups GP and GP + DBE was found for the histopathological findings, except for vacuolization and necrosis of the pancreatic parenchyma that was higher in GP than in GP + DBE.
CONCLUSION: The manipulation of the duodenal papilla by the inflated overtube’s balloon during DBE causes pancreatic structural damage and increased biochemical markers associated with pancreatitis.
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Yamauchi H, Kida M, Okuwaki K, Miyazawa S, Iwai T, Tokunaga S, Takezawa M, Imaizumi H, Koizumi W. Passive-bending, short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients. World J Gastroenterol 2015; 21:1546-1553. [PMID: 25663773 PMCID: PMC4316096 DOI: 10.3748/wjg.v21.i5.1546] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/29/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate short-type-single-balloon enteroscope (SBE) with passive-bending, high-force transmission functions for endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis.
METHODS: Short-type SBE with this technology (SIF-Y0004-V01; working length, 1520 mm; channel diameter, 3.2 mm) was used to perform 50 ERCP procedures in 37 patients with Roux-en-Y anastomosis. The rate of reaching the blind end, time required to reach the blind end, diagnostic and therapeutic success rates, and procedure time and complications were studied retrospectively and compared with the results of 34 sessions of ERCP performed using a short-type SBE without this technology (SIF-Y0004; working length, 1520 mm; channel diameter, 3.2 mm) in 25 patients.
RESULTS: The rate of reaching the blind end was 90% with SIF-Y0004-V01 and 91% with SIF-Y0004 (P = 0.59). The median time required to reach the papilla was significantly shorter with SIF-Y0004-V01 than with SIF-Y0004 (16 min vs 24 min, P = 0.04). The diagnostic success rate was 93% with SIF-Y0004-V01 and 84% with SIF-Y0004 (P = 0.17). The therapeutic success rate was 95% with SIF-Y0004-V01 and 96% with SIF-Y0004 (P = 0.68). The median procedure time was 40 min with SIF-Y0004-V01 and 36 min with SIF-Y0004 (P = 0.50). The incidence of hyperamylasemia was 6.0% in the SIF-Y0004-V01 group and 14.7% in the SIF-Y0004 group (P = 0.723). The incidence of pancreatitis was 0% in the SIF-Y0004-V01 group and 5.9% in the SIF-Y0004 group (P > 0.999). The incidence of gastrointestinal perforation was 2.0% (1/50) in the SIF-Y0004-V01 group and 2.9% (1/34) in the SIF-Y0004 group (P > 0.999).
CONCLUSION: SIF-Y0004-V01 is useful for ERCP in patients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.
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Moeschler O, Mueller MK. Deep enteroscopy - indications, diagnostic yield and complications. World J Gastroenterol 2015; 21:1385-1393. [PMID: 25663758 PMCID: PMC4316081 DOI: 10.3748/wjg.v21.i5.1385] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 10/14/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023] Open
Abstract
Since its introduction in 2001 capsule endoscopy opened up the small bowel for diagnostic approaches followed by double balloon enteroscopy which enabled the endoscopic community to perform therapeutic interventions in the whole small intestine. In this review the scientific developments related to indications, diagnostic yield and complications of the last years between the competing devices double ballon enteroscopy, single balloon enteroscopy and spiral enteroscopy are illustrated.
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Chavalitdhamrong D, Adler DG, Draganov PV. Complications of enteroscopy: how to avoid them and manage them when they arise. Gastrointest Endosc Clin N Am 2015; 25:83-95. [PMID: 25442960 DOI: 10.1016/j.giec.2014.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Deep small bowel enteroscopy is a safe procedure that has revolutionized the strategy for diagnosis and treatment of small bowel diseases. However, enteroscopy-associated adverse events are more common compared with standard endoscopy. Prevention, early detection, and effective intervention are crucial in reducing the adverse event severity and improving outcomes. In this article, how to safely perform enteroscopy, avoid adverse events, detect adverse events early, and accomplish effective treatments are discussed. This knowledge can serve as a continuing quality improvement process to reduce the risk of future adverse events and improve the overall quality of endoscopy.
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Affiliation(s)
- Disaya Chavalitdhamrong
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Utah School of Medicine, 30 North 1900 East 4R 118, Salt Lake City, UT 84132, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Florida, Gainesville, FL, USA.
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Feng N, Dai J, Lu H, Li XB, Gao YJ, Ge ZZ. Hyperamylasemia is associated with increased intestinal permeability in patients undergoing diagnostic oral double-balloon enteroscopy. World J Gastroenterol 2014; 20:539-545. [PMID: 24574723 PMCID: PMC3923029 DOI: 10.3748/wjg.v20.i2.539] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 09/29/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the correlations between serum amylase levels, intestinal permeability (IP), and pancreatic injury and to explore the mechanisms responsible for hyperamylasemia in double-balloon enteroscopy (DBE).
METHODS: A prospective study was conducted in 20 patients who underwent DBE from August 1, 2008 to February 28, 2009. Serum amylase was examined 0, 2, 6 and 24 h post-DBE, C-reactive protein and lipase were examined at 24 h, and urine lactulose, mannitol, and trypsinogen-II (TRY-II) levels were measured at 6 h. Lactulose/mannitol ratio indicated IP, and TRY-IIindicated pancreatic injuries. Procedure duration and enteroscope insertion length were recorded.
RESULTS: Twelve patients underwent oral DBE (M:F, 5:7; mean age 50.42 ± 11.11 years) and 8 underwent anal DBE (M:F, 5:3; mean age 44.75 ± 12.66 years). They all showed significantly increased post-DBE serum amylase. Amylase and lipase levels were higher in the oral DBE group (P < 0.05). Hyperamylasemia was diagnosed in 9 (75.0%) patients undergoing oral DBE. Only patients receiving oral DBE showed increased post-procedure IP, which correlated with increased serum amylase (r = 0.611, P = 0.035) and procedure duration (r = 0.668, P = 0.018). Adverse events included one oral case with pancreatic injury (elevated TRY-II) and two cases of abdominal discomfort in each group. Pancreatitis was not reported.
CONCLUSION: Hyperamylasemia correlates with increased IP and clinically undetectable pancreatic injuries. DBE could cause intestinal mucosa damage, which may result in IP elevation and increased amylase absorption, necessitating improvements and standardization of DBE methods.
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Zhang Y, You SH, Peng ZY, Huang GM. Clinical value of double balloon endoscopy in small intestinal diseases. Shijie Huaren Xiaohua Zazhi 2013; 21:3894-3898. [DOI: 10.11569/wcjd.v21.i34.3894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the diagnostic and therapeutic value and safety of double balloon endoscopy (DBE) in small intestinal diseases.
METHODS: A retrospective analysis of 123 patients who underwent DBE under conscious sedation anesthesia with suspected small intestinal diseases from January 2009 to February 2013 was performed. Oral and anal DBE was performed in 52 and 55 patients, respectively, while 16 patients underwent a combination of both approaches. Endoscopic tissue biopsy of suspicious lesions was performed routinely.
RESULTS: The overall diagnostic yield of DBE was 75.6% (93/123), with nonspecific intestinal inflammations in 37 patients and Crohn's diseases in 17 patients. There were benign or malignant tumors in 13 patients, including small intestine adenocarcinoma in 5 patients, stromal tumors and lymphomas in 3, lipomas in 2, and polyps in 11 (including inflammatory polyps in 8 and Peutz-Jeghers syndrome in 3), vascular diseases in 6 (including vascular malformations in 4 and angiotelectasia in 2), ulcers in 4 and other lesions in 5 (including lymphangiectasia, small intestinal diverticulum, Behcet's disease, entericintussusception and portal hypertensive enteropathy). In addition, there were three cases of external compressive lesions. The overall therapeutic yield of DBE was 9.8% (12/123), including endoscopic snare and electric coagulation or cutting in all polyps and clipping (with a titanium clip) in one case of vascular malformation with active bleeding. There were no severe complications such as bleeding, perforation, and pancreatitis.
CONCLUSION: DBE is a method with high diagnostic value, safety and reliability for small intestinal diseases, and can be used for endoscopic treatment.
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Itaba S, Nakamura K, Aso A, Tokunaga S, Akiho H, Ihara E, Iboshi Y, Iwasa T, Akahoshi K, Ito T, Takayanagi R. Prospective, randomized, double-blind, placebo-controlled trial of ulinastatin for prevention of hyperenzymemia after double balloon endoscopy via the antegrade approach. Dig Endosc 2013; 25:421-7. [PMID: 23368820 DOI: 10.1111/den.12014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 10/30/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Double balloon endoscopy (DBE) allows the entire small intestine to be viewed using a combination of antegrade and retrograde approaches. Acute pancreatitis is a serious complication of antegrade DBE with no effective prophylactic treatment currently available. Ulinastatin has been shown to be effective for the prevention of pancreatitis following endoscopic retrograde cholangiopancreatography. We therefore assessed the efficacy of ulinastatin for hyperenzymemia after antegrade DBE. PATIENTS AND METHODS Forty-four patients were enrolled in this prospective, randomized, double-blind, placebo-controlled trial. Patients in the ulinastatin group received 150 000 U ulinastatin by i.v. drip infusion for 2 h from the start of the procedure. Serum concentrations of pancreatic amylase and lipase were measured before and 3 and 18 h after antegrade DBE. RESULTS The study was terminated after interim analysis. Of the 44 patients, 23 were randomized to ulinastatin and 21 to placebo.The groups were similar with regard to sex ratio, age, type of endoscope, insertion time, total procedure time, number of endoscope pull-back procedures, and baseline pancreaticamylase and lipase concentrations. Post-DBE hyperenzymemia was observed in 35.0% and 47.8% of patients in the placebo and ulinastatin groups, respectively. The higher frequency of hyperenzymemia in the ulinastatin group was unexpected, but the difference was not statistically significant. One patient in the placebo group (5.0%) and none in the ulinastatin group experienced acute pancreatitis, but the difference was not statistically significant. CONCLUSION The results of this trial suggest that ulinastatin does not prevent hyperenzymemia following antegrade DBE.
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Affiliation(s)
- Soichi Itaba
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, Fukuoka, Japan
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Latorre R, Soria F, López-Albors O, Sarriá R, Sánchez-Margallo F, Esteban P, Carballo F, Pérez-Cuadrado E. Effect of double-balloon enteroscopy on pancreas: an experimental porcine model. World J Gastroenterol 2012; 18:5181-7. [PMID: 23066311 PMCID: PMC3468849 DOI: 10.3748/wjg.v18.i37.5181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/18/2012] [Accepted: 05/26/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effect of double-balloon enteroscopy (DBE) on pancreas histology and levels of pancreatic enzymes. METHODS Conventional upper gastrointestinal endoscopy was performed on five control pigs. Oral DBE was performed with an EN-450T5 enteroscope on 20 pigs. Two experimental groups (10 pigs each) were defined according to DBE duration: 90 min for Group 1 and 140 min for group 2. During oral insertion, the balloons were not inflated in the descending part of the duodenum to avoid the minor duodenal papilla. Serum amylase, lipase and C-reactive protein (CRP) levels were monitored before the procedure and repeated every 30 min until the exploration was finished, as well as 24 h and 7 d after. After the procedure and for a total of 7 d, the pigs were observed twice a day for signs of decreased activity, irritability, vomiting or anorexia. Gross and microscopic examination of the pancreas was performed on day 7. RESULTS All animals tolerated DBE without clinical manifestations of acute pancreatitis. Experimental groups had higher levels of enzymes than the control group at 24 h. Throughout the exploration, the amylase levels increased significantly above the baseline 24 h after DBE, although the increase was not statistically significant and did not reach 20% of the baseline. An increase in lipase and CRP was observed at 24 h after the procedure, although by day 7, all enzymatic levels had returned to baseline. No differences between groups 1 and 2 were found for any enzyme and sampling site during and after the procedure. Similarly, no correlation between insertion depth and enzyme levels was observed. Direct in situ and post-removal inspection of the pancreas did not show any evidence of fluid collection, abscesses or hemorrhage. Histological examination of the pancreas from groups 1 and 2 revealed the existence of focal areas (0.14-0.26 mm2) of ischemic necrosis in 47.4% of the animals. In the pigs with damaged pancreas, the left lobe (tail) was always affected. However, this only happened in 83.3% of the samples from the right lobe (head) and in 33.3% of the samples from the body of the pancreas. Significant differences were found between the left lobe (tail) and the body for the percentage of affected pancreas. Both the size of the lesions and the percentage of affected pancreas were higher in the left pancreatic lobe (tail). The presence of the lesions was not related to the exploration length. CONCLUSION The increase in pancreatic enzymes after DBE could be related to focal points of pancreatic ischemic necrosis due to mechanical stress.
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Rondonotti E, Sunada K, Yano T, Paggi S, Yamamoto H. Double-balloon endoscopy in clinical practice: where are we now? Dig Endosc 2012; 24:209-19. [PMID: 22725104 DOI: 10.1111/j.1443-1661.2012.01240.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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%.
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Small bowel diagnostics: current place of small bowel endoscopy. Best Pract Res Clin Gastroenterol 2012; 26:209-20. [PMID: 22704565 DOI: 10.1016/j.bpg.2012.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 03/08/2012] [Indexed: 01/31/2023]
Abstract
The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Until the end of the last century, the small bowel follow through was the primary diagnostic tool for suspected small bowel disease. In recent years capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computerized tomography and magnetic resonance enteroclysis or enterography have facilitated the diagnosis, monitoring, and management of patients with small bowel diseases. These technologies are complementary, each with its advantages and limitations. In the present article, we will discuss the different options and indications for modern diagnostic methods for visualization of the small bowel. We also try to provide a clinical rationale for the use of these different diagnostic options in less established, newly emerging, indications for small bowel evaluation.
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Kaffes AJ. Advances in modern enteroscopy therapeutics. Best Pract Res Clin Gastroenterol 2012; 26:235-46. [PMID: 22704567 DOI: 10.1016/j.bpg.2012.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Revised: 02/24/2012] [Accepted: 03/08/2012] [Indexed: 02/07/2023]
Abstract
Advances in modern enteroscopy have been largely due to endoscope development but also through the improved availability of endoscopic accessories along with improved understanding in their application. Device assisted enteroscopy began with the double balloon system in 2001 and was quickly followed by single balloon enteroscopy and spiral enteroscopy. These tools revolutionised deep small bowel endoscopy and allowed for the delivery of virtually all known therapeutic endoscopy intervention to almost all segments of the small bowel. This review covers the types of interventions in regards to indications, methods and their safety profiles as well as reviewing the various device assisted endoscopes available and their attributes.
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Affiliation(s)
- Arthur John Kaffes
- Royal Prince Alfred Hospital, AW Morrow Gastroenterology and Liver Centre, Gastroenterologist, Missenden Rd, Camperdown, NSW 2050, Australia.
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Abstract
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 complication 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.
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