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Capsule endoscopy is a noninvasive test that allows diagnostic evaluation of the entire small bowel.
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Deep enteroscopy techniques (balloon-assisted and spiral enteroscopy) allow endoscopic management of small bowel disorders, including biopsies, polypectomy, dilation of strictures, tattooing, and retrieval of retained capsules.
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The deep enteroscopy techniques have a comparable diagnostic and therapeutic yield in the management of small bowel disorders.
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Capsule endoscopy and deep enteroscopy are
Endoscopic Techniques for Small Bowel Imaging
Section snippets
Key points
Anatomy of the small bowel
The small bowel is a tubular organ that is 600 to 800 cm in length, and extends between the pylorus and the ileocecal (IC) valve. It is divided into 3 segments: duodenum, jejunum, and ileum. The duodenum is the most proximal and shortest segment of the small bowel, with a mean length of 25 cm. It is shaped like a C loop. This segment is the only one located in the retroperitoneal space, and is therefore relatively fixed. It includes the bulb, second, third, and fourth portions, and extends up
Video capsule endoscopy
Capsule endoscopy (CE) was introduced in the year 2000, and was the first endoscopic test that enabled visualization of the entire small bowel. There are 4 CE systems currently available. The CE systems used in the United States are Pillcam SB2 (Given Imaging, Yoqneam, Israel) and Endo Capsule (Olympus America Inc, Center Valley, PA). The systems include a capsule endoscope, 8-point sensory array, and a portable data recorder. Both the Pillcam SB2 and Endo Capsule measure 11 × 26 mm, and
Double-balloon enteroscopy
The double-balloon enteroscope (Fujinon Inc, Tokyo, Japan) was the first therapeutic deep enteroscopy tool that was introduced in 2004. The double-balloon enteroscopy (DBE) system comprises an enteroscope, an overtube, and a balloon-pump system. Two double-balloon enteroscopes are currently available, diagnostic (EN-450P5) and therapeutic EN-450T5. The enteroscope has a working length of 200 cm and an overtube made of polyurethane, which is 140 cm in length. Both the enteroscope and overtube
Single-balloon enteroscopy
The single-balloon enteroscope (Olympus Optical, Tokyo, Japan) was introduced in 2007. In contrast to the double-balloon enteroscope, this device has only one balloon at the distal end of the overtube. The enteroscope (SIF-Q180) has a length of 200 cm, and the overtube is 140 cm. The outer diameter of the enteroscope is 9.2 mm and the accessory channel is 2.8 mm. The overtube and balloon are made from silicon.
Single-balloon enteroscopy (SBE) is also performed by the push-and-pull technique, but
Spiral enteroscopy
The Endo-Ease Discovery SB (Spirus Medical, Stoughtom, MA) is a spiral overtube made of polyvinyl chloride. It measures 118 cm and has a 21-cm raised helix at the distal end. In the technique of spiral enteroscopy, the overtube is placed over a pediatric colonoscope or push enteroscope and locked into place. It is then advanced into the small bowel until the ligament of Treitz is reached. The device is rotated using clockwise movements until the furthest extent possible is reached. The
Obscure gastrointestinal bleeding
OGIB is defined as bleeding from the gastrointestinal tract that persists or recurs after a negative initial evaluation with bidirectional endoscopy and small bowel radiography.2, 37 The majority of patients with OGIB have midgut bleeding, and the small bowel enteroscopy techniques have led to a trend toward endoscopic evaluation and management of these patients.
Capsule Endoscopy
CE is superior to other tests in the evaluation of patients with Crohn's disease. A meta-analysis showed that CE had an incremental yield of 42% over PE, 37% over small bowel radiography, 39% over computed tomography (CT) enterography, and 15% over ileoscopy for the diagnosis of nonstricturing Crohn's disease. CE was superior to these tests for the diagnosis of patients with suspected as well as established Crohn's disease.70 The overall yield of CE has been reported to range from 43% to 71%.71
Small bowel tumors
Although small bowel tumors are rare, they are important to recognize because they are often malignant and carry a poor prognosis resulting from a delay in their diagnosis. Deep enteroscopy techniques may allow earlier diagnosis (Fig. 3) and, therefore, improved outcomes in these patients. Most small bowel polyps can now be removed endoscopically at deep enteroscopy, but surgery continues to remain the definitive management for tumors.
Summary
There have been significant advances in small bowel enteroscopy over the last decade. The development of CE as well as other deep enteroscopy techniques has enabled both diagnostic evaluation and therapeutic management of almost all small bowel disorders. The enteroscopic tools have a complementary role in the evaluation of the small bowel, and their selection should be based on clinical presentation and suspected location of the lesion, as well as the necessity for therapeutics.
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The authors have no conflict of interest or financial involvement with this article.