Dra. Ana Echarri Piudo
Complejo Hospitalario Universitario de Ferrol
Dr. Vicente Pons Beltrán
Hospital Universitari i Politècnic La Fe. Valencia
The role of enteroscopy in Crohn’s disease is fundamentally therapeutic, with its primary indication being balloon dilation of the stenoses in the small intestine. Other less common indications in a patient with inflammatory bowel disease are the removal of foreign bodies (endoscopic capsule) retained in case of the presence of stenosis, gastrointestinal haemorrhage therapy or stent placement.
Stenosis balloon dilation of the small intestine follows guidelines similar to balloon dilation in stenoses accessible via conventional endoscopy. The use of balloon enteroscopy allows for the access and treatment of localized lesions in the small intestine that are not accessible via endoscopic systems, by using the oral or rectal route according the location of the stenosis previously assessed with the proper radiologic test (MR enterography or CT enterography)1-3.
Once the stenosis is reached with the enteroscope, the balloon at the tip of the enteroscope is inflated (the proper tube in the double balloon system, and the overtube that will have previously been moved to the tip in the single-balloon system). Contrast can be inserted (Fig.1) (Gastrografin®) to assess the length of the stenosis, its angulation and the presence of fistulae or abscesses, although radiologic pre-assessment is recommended for stenosis, if possible with a radiologic technique that enables one to also analyse the presence of inflammation/fibrosis in stenosis4.
The balloon is introduced through the endoscope channel (TTS) and it is preferred that the pre-mounted guide be removed from the balloon and that a less stiff guide be used (Jagwire 0.35). The balloons are the same used in the conventional dilation process, which ensures a minimum length of 230 cm. Insertion through the working channel can be more difficult if the enteroscope is bent in the bowel; in such cases, straightening the tube and using oil (2–3 ml) through the working channel facilitates insertion.
It is better to center the balloon in the stenosis and inflate it slowly; if necessary, its position can be confirmed by fluoroscopy. Progressive or multi-diameter balloons allow three diameters of varying calibres to be reached in relation to the pressure reached, with varying inflation times between different work groups, generally between 30 seconds and a minute (Fig. 2)5.
It is advised that three consecutive dilations per session (rule of three)6 be performed, which can be repeated in a series of sessions until the objective is achieved. In general, we can begin with a 12-mm balloon (or 10-mm in the case of a very pronounced stenosis) and increase to 13.5 mm and 15 mm in consecutive dilations (Video 2), which is generally a sufficient diameter to achieve passage of the enteroscope and to consider the dilation effective5,7. During dilation, the balloon is in contact with the tip of the endoscope, and we can observe the mucosa of the stenosis during the procedure. Afterwards, the dilated area must be observed carefully, with confirmation of the presence or absence of complications such as significant bleeding or tears.
If the enteroscope passes through the stenosis, the dilation is considered effective, although symptomatic improvement can occur in cases in which passage of the tube is not achieved.
It is important to take into consideration, if proceeding with the progression of the enteroscope (consecutive dilations), that although the endoscope adequately passes through the dilated stenosis, the overtube has a larger diameter and cannot pass through it, since the diameter of the enteroscope is 8.5 mm and the overtube is 12.5.
Another endoscopic therapeutic indication in CD is the removal of foreign bodies from the intestinal lumen, basically a retained endoscopic capsule, in relation to the presence of stenosis, which may occur in up to 13% of known CD patients8,9.
It is important to advance the enteroscope up to the area where the capsule is kept and catch it with a Roth basket, a Dormia basket or a snare (Fig. 3), and try to situate it on the same axis as the enteroscope to enable removal through the Killian mouth.
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2. May A, Nachbar L, Pohl J, Ell C. Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations. Am J Gastroenterol. 2007; 102(3): 527-35.
3. Pohl J, Delvaux M, Ell C, Gay G, May A, Mulder CJ, et al; ESGE Clinical Guidelines Committee. European Society of Gastrointestinal Endoscopy (ESGE) Guidelines: flexible enteroscopy for diagnosis and treatment of small-bowel diseases. Endoscopy. 2008; 40(7): 609-18.
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6. Langdon DF. The rule of three in esophageal dilation. Gastrointest Endosc. 1997; 45: 11.
7. Ferlitsch A, Reinisch W, Püspök A, Dejaco C, Schillinger M, Schöfl R, et al. Safety and efficacy of endoscopic balloon dilation for treatment of Crohn’s disease strictures. Endoscopy. 2006; 38(5): 483-7.
8. Cheifetz AS, Kornbluth AA, Legnani P, Schmelkin I, Brown A, Lichtiger S, et al. The risk of retention of the capsule endoscope in patients with known or suspected Crohn’s disease. Am J Gastroenterol. 2006; 101(10): 2218-22.
9. Herrerías JM, Caunedo A, Rodríguez-Téllez M, Pellicer F, Herrerías JM Jr. Capsule endoscopy in patients with suspected Crohn’s disease and negative endoscopy. Endoscopy. 2003; 3