Deep Enteroscopy Methods to Diagnose Small Bowel IBD

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1 Deep Enteroscopy Methods to Diagnose Small Bowel IBD Name: Institution: Peter Draganov University of Florida, Gainesville, FL

2 Overview Types of enteroscopy Enteroscopy equipment Enetoscopy do and don'ts The role of enteroscopy in IBD

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4 Enteroscopy Rout of insertion Antegrade Retrograde go in TI at standard colonoscopy Type of equipment Pediatric Colonoscope Push Enteroscope Overtube assisted enteroscopy Depth of insertion Push Deep

5 Deep Enteroscopy Double-Balloon Enteroscopy Single-Balloon Enteroscopy Spiral Enteroscopy

6 Deep Enteroscopy Do s and Don'ts Have a good indication Imaging first (capsule, CTE, MRE) vs enteroscopy first? Can you accomplish the goal with standard endoscopy? Know the post surgical anatomy Roux-en-Y, Billroth, Small bowel resections Allow plenty of time Use general anesthesia Use CO 2 Carefully consider anticoagulation/antiplatelet options Be aware of potential complications and be ready to mange them

7 Perforation Less than 1% Higher with therapeutic procedures (polypectomy, stricture dilation) May be higher in post surgical anatomy or Crohn s Immediate consider endoscopic management Delayed typically requires surgery Not recognized From thermal injury

8 Bleeding Other Complications From mucosal tear Partially treated bleeding lesion (e.g. AVM) Post-polypectomy or stricture dilation From esophageal varices (Spiral) Latex allergy (DBE only) Pancreatitis 1% Minor Sore throat Mucosal injury (more common with Spiral) Abdominal distention use CO 2

9 Inspection During Enteroscopy Double and Single balloon Look for pathology on the way IN Look for trauma/perforation on the way OUT Spiral Minimize insufflation on the way IN Look on the way OUT

10 Role of Enteroscopy in IBD Establishing the diagnosis Provide therapy stricture dilation

11 64 yr old with abdominal pain and partial SBO No prior surgeries Negative EGD Negative colonoscopy including terminal ileum

12 64 yr old with abdominal pain and partial SBO CT abdomen: Dilated loops of small bowel Some small bowel thickened No visible transition point Crohn s vs lymphoma Concerns about capsule retention

13 Enteroscopy Abnormal distal jejunum and ileum Ulcers, stricture and polyps Biopsies c/w Crohn s Medical therapy

14 57 yr old man with intermittent partial SBO 3 years of episodic sharp RLQ pain Every 1 to 4 months No other symptoms Negative EGD, colonoscopy, SBFT

15 CTC CT: focal thickened and dilated segment of small bowel

16 Intermittent SBO and Thick Segment Small Intestine Treat for Chron s disease? Surgical exploration? Deep enteroscopy?

17 Intermittent SBO and Thick Segment Retrograde Enteroscopy Terminal ileum normal Mid-ileum (100cm from IC valve) with nodular mucosa Small Intestine

18 Intermittent SBO and Thick Segment Retrograde Enteroscopy Terminal ileum normal Mid-ileum (100cm from IC valve) with nodular mucosa Biopsies Follicular lymphoma, smallcelled cleaved type (low grade NHL) Small Intestine

19 Strictures and Ulcers Capsule Endoscopy Appearance NSAID Lymphoma XRT Crohn s Amyloidosis Adhesions XRT NSAID

20 Take-Home Lesson Deep enteroscopy is an option to evaluate suspected small bowel narrowing when there is concern for capsule retention. Crohn s disease, small bowel lymphoma, amyloidosis, adhesions and intestinal TB can have similar clinical presentation, XR and capsule endoscopy appearance. Deep enteroscopy can provide definitive diagnosis

21 70 yr old man with recurrent hematochezia 15 + transfusions in last 2 years EGD, SBFT negative Colonoscopy: incomplete to transverse due to looping (4 different experienced gastroenterologists) Capsule endoscopy negative

22 Colon xray

23 Overtube Assisted Colonoscopy Complete colonoscopy with enteroscope Two cecal AVM, brisk bleed with probe Successful hemostasis with APC

24 Take-Home Lesson Overtube-assisted enteroscopy may allow complete colon examination when standard colonoscopy not possible

25 Enteroscopy is not always the answer

26 Conclusions Deep enteroscopy is one of many modalities for SB evaluation Carefully consider your options Use general anesthesia Use CO 2 Know the post surgical anatomy Tailor anticoagulation/antiplatelet management Be aware of potential complications and be ready to mange them

27 Conclusions Role of enteroscopy in suspected IBD Concerns for capsule retention Many small bowel lesions have similar appearance on capsule Deep enteroscopy can provide definitive tissue diagnosis Deep enteroscopy can assist stricture dilation in Crohn s disease Overtube assisted device can facilitate difficult colonoscopy

28 Deep small bowel enteroscopy The final frontier of luminal GI To boldly go where no man has gone before

29 Power Spiral