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JANUARY 2012
VOL. 12, ISSUE 1
A D VA N C E D praxis
A JOURNAL OF CURRENT TRENDS IN MEDICINE FROM IU HEALTH PHYSICIANS, A PARTNERSHIP OF IU SCHOOL OF MEDICINE AND INDIANA UNIVERSITY HEALTH
CASE MANAGEMENT
Deep Enteroscopy to Evaluate Small
Bowel Bleeding
A 50-year old female loses consciousness at home and is brought by ambulance
to a local emergency department (ED) with massive lower gastrointestinal
(GI) bleeding. Four years earlier, she underwent a Puestow procedure (partial
pancreatectomy with lateral Roux-en-Y pancreaticojejunostomy) for chronic
pancreatitis and had an uncomplicated recovery. Upon presentation at the ED,
her hemoglobin is 5.9 g/dL, and she is resuscitated with 8 units of packed
red blood cells (PRBCs). She undergoes several diagnostic studies, including
esophagogastroduodenoscopy (EGD), colonoscopy, push enteroscopy,* a tagged
RBC scan (bleeding scan), and angiography, none of which reveals the source of
hemorrhage. Bleeding stops spontaneously, and she is discharged to home on an
acid suppressor. Her hemoglobin normalizes.
* A procedure that uses a dedicated small bowel enteroscope or a pediatric or adult colonoscope to reach further into the small bowel than standard EGD.
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Deep Enteroscopy
Three months later, the patient presents at the ED with another lower GI bleed. Her
hemoglobin is 7.6 g/dL, and she is given 4 units of PRBCs. The previous diagnostic
studies are repeated, and capsule endoscopy** is also performed. The endoscopic
images show coffee ground content in the small bowel, but once again, the bleeding
site cannot be identified. The patient is transferred to IU Health for evaluation of
recurrent GI bleeding of unknown source.
Obscure GI Bleeding and
the Small Bowel
Obscure GI bleeding is defined as bleeding of
unknown origin that persists or recurs after
an initial negative EGD and colonoscopy.
Although mid acute GI bleeding resolves
spontaneously in approximately 40 percent of
patients,1, 2 persistent iron deficiency anemia
and frank bleeding require further investigation.
“The most common source of obscure GI
bleeding is the small bowel, with bleeding
typically caused by vascular lesions
scattered throughout the upper intestine,”
explains Michael Chiorean, MD, associate
professor of clinical medicine at the Indiana
University School of Medicine. “These
angioectasias are most often seen in people
over age 50 who have a history of smoking
and/or heart, lung, or renal disease, and
they may result from chronic blood oxygen
depletion. Some individuals with obscure
small bowel bleeding require transfusions as
often as every other week, perhaps as much
as 100 units of PRBCs annually.”
When obscure bleeding develops in patients
with cardiovascular disease, it can be
particularly dangerous because treatment
for bleeding requires discontinuation of
antiplatelet and/or anticoagulant therapy,
thereby increasing the risk for stent occlusion
(in those who have undergone angioplasty)
or stroke (in those with atrial fibrillation).
The solution to this dilemma is self-evident:
identify and treat the source of the bleeding
to allow patients to resume taking these
life-saving medications. Historically, however,
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the source of small bowel bleeding has been
notoriously difficult to pinpoint.
“Throughout most of the 20th century, the
small bowel was considered the ultimate
black hole of gastroenterology,” Dr. Chiorean
says. “This 18-foot (550 centimeter)
tortuous segment of the GI tract is not
easily accessible by standard endoscopy
instruments, and radiographic studies—even
virtual endoscopy—miss 95 percent of small
bowel angioectasias because they tend to
be very subtle, with a density comparable to
adjacent bowel and a surface that is flush
with the bowel lining.
“The small bowel can be effectively evaluated
with intraoperative enteroscopy,” Dr. Chiorean
acknowledges. “But this is the diagnostic
modality of last resort owing to the high
potential for complications, such as ileus,
Gastroenterologists at IU Health have a high
index of suspicion that the patient is bleeding
from the area of the pancreaticojejunostomy. The
length and angulation of the small bowel at the
anastomosis creates a major challenge for access
with standard endoscopes, making her a good
candidate for deep enteroscopy.
infection, and pneumonia; mortality rates
that range from two to 10 percent; and the
need for a minimum one-week hospital stay
following the procedure.”
Capsule endoscopy, which became available
in the late 1990s, was a major breakthrough
in small bowel visualization and has largely
replaced radiologic imaging. Nonetheless, this
passive, uncontrolled endoscopic technique
has significant limitations. Abnormalities
in some areas of GI tract may be missed
because of rapid capsule transit times,
resulting in blurred, uninterpretable images.
Conversely, slow transit times in other areas
may lead to battery failure before the entire
small intestine can be examined. Strictures
or tumors can impede capsule movement,
causing obstruction. Finally, capsule
endoscopy is a diagnostic procedure only—no
intervention is possible.
“This 18-foot (550 centimeter) tortuous segment
of the GI tract is not easily accessible by standard
endoscopy instruments, and radiographic studies—
even virtual endoscopy—miss 95 percent of small
bowel angioectasias because they tend to be very
subtle, with a density comparable to adjacent bowel
and a surface that is flush with the bowel lining.”
Deep enteroscopy is an endoscopic
technique that provides complete small
bowel visualization together with the
opportunity for therapeutic intervention,
including cautery, biopsy, polypectomy,
tattoo, hemostasis, dilation, and foreignbody retrieval. The major indication for the
procedure is obscure overt bleeding, fecal
occult blood, or iron deficiency anemia with
no source detected on conventional EGD or
colonoscopy, but the technique is also used
for a variety of other indications (Table 1).
TABLE 1. INDICATIONS FOR DEEP ENTEROSCOPY
Indications:
Evaluate and manage abnormal findings on capsule endoscopy
(e.g., vascular malformations, ulcerations, neoplasms)
Evaluate and manage obscure overt bleeding, fecal occult blood, or iron
deficiency anemia when no bleeding source is detected on EGD, colonoscopy,
or capsule endoscopy
Evaluate small bowel abnormalities detected radiographically
•Polyps
•Strictures
•Neoplasm
•Changes consistent with inflammatory bowel disease
Evaluate patients with refractory sprue or unexplained diarrhea and malabsorption
Manage patients with hereditary polyposis syndromes
(e.g., familial adenomatous polyposis, Peutz-Jeghers syndrome)
Facilitate endoscopic retrograde cholangiopancreatography (ERCP) in patients
with altered surgical anatomy
** A video camera the size of a large vitamin pill is swallowed and wirelessly transmits
images to an external receiver as it passes through the intestinal tract.
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Instrumentation
Approximately 75 percent of deep
enteroscopy procedures performed at IU
Health use a double-balloon enteroscope
(DBE), an instrument developed by a
Japanese physician and introduced in
the United States in 2004. The two-part
instrument consists of an endoscope
and an overtube, each having a balloon
(Figure 1). The scope is advanced through
the overtube by a push and pull motion
that pleats the small bowel (Figure 2) in
a manner similar to putting on a sock. A
recent multicenter trial found the DBE has
a higher diagnostic yield and a three-fold
higher rate of complete enteroscopy than
single-balloon enteroscopy (SBE).3
Spiral enteroscopy, the newest modality
for small bowel diagnosis and treatment,
is performed with a small enteroscope
and an overtube that has helical spirals
on its surface that advance the tube by
rotation rather than push and pull (Figure
3). Preliminary data suggest that spiral
enteroscopy compares favorably to both
DBE and SBE for small bowel evaluation,4
and it is used in about 25 percent of deep
enteroscopies done at IU Health.
surger y and obesity, both of which can
make it difficult or impossible to advance
the endoscope.5
Procedure, Effectiveness, and
Complications
“Once the scope is properly positioned
within the small bowel (Figure 4), and
the bleeding source(s) is identified,
the gastroenterologist can intervene to
achieve hemostasis (or perform other
interventions),” Dr. Chiorean says. “Most
patients experience a 60 to 80 percent
reduction in small bowel bleeding following
deep enteroscopy, and in some individuals,
bleeding stops completely.”
Deep enteroscopy is an outpatient
procedure per formed under deep
sedation or general anesthesia.
Depending on whether the small bowel
is accessed antegrade or retrograde, the
procedure takes approximately 75 to 90
minutes. Challenges include previous GI
Potential complications associated with
deep enteroscopy include those common
to all endoscopic procedures: aspiration
pneumonia, infection, and sedation-related
issues.6 The most common problem
reported after the procedure is abdominal
cramping, which occurs in two to 20
percent of examinations and is linked to
the use of air for insufflation.
Image courtesy of Fujinon Medical, Inc., Saitama, Japan.
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Figure 4. Antegrade
fluoroscopy showing
the scope fully
advanced and
positioned within
the small bowel
“Complications that appear to be
increased after deep enteroscopy
compared with standard endoscopic
procedures include pancreatitis, GI
hemorrhage, and per foration,”6 Dr.
Chiorean points out. “Among patients
undergoing standard upper endoscopy,
the risk of per foration is one in 10,000
examinations (0.01 percent). In contrast,
the risk of per foration with antegrade
deep enteroscopy is 0.2 percent, and it is
somewhat higher in patients with surgically
altered anatomy.
Figure 1. Double-balloon enteroscope and overtube system
The scope is advanced through
the overtube by a push and
pull motion that pleats the
small bowel in a manner
similar to putting on a sock.
Figure 3. Spiral Enteroscope
Figure 2. Schematic showing double-balloon
enteroscope advanced to into the small bowel
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“In patients with obscure bleeding,
capsule endoscopy is usually the preferred
third-line test after negative endoscopy
and colonoscopy because of its ability
to visualize the small bowel, ease of
administration, and low potential for
complications,” continues Dr. Chiorean.
“When capsule endoscopy is inconclusive,
or when it identifies small bowel lesions
requiring endoscopic therapy or biopsy,
deep enteroscopy is per formed.”
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Image courtesy of Fujinon
Medical, Inc., Saitama, Japan.
Spiral enteroscopy, the newest modality
for small bowel diagnosis and treatment,
is performed with a small enteroscope
and an overtube that has helical spirals
on its surface that advance the tube by
rotation rather than push and pull.
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Approximately 75 percent of deep
enteroscopy procedures performed
at IU Health use a double-balloon
enteroscope (DBE), an instrument
developed by a Japanese physician
and introduced in the United
States in 2004.
Post-procedure angiography two
days after DBE shows a possible
small aneurism that does not
require intervention. The patient is
discharged to home. Following an
uneventful recovery and three years
of follow-up, she has no evidence
of recurrent bleeding.
DBE is used to reach the area of previous surgery. A visible vessel, likely an artery
at the level of the blind end of the Roux limb, bleeds briskly after air insufflation
and gentle probing with the scope (Figures 5-7). The area is first injected with
epinephrine to slow the bleeding, after which two hemostatic clips are placed over
the vessel, leading to complete cessation of bleeding (Figure 8).
Michael Chiorean, MD
Associate Professor of Clinical Medicine
Indiana University School of Medicine
[email protected]
Figure 5. Enteroscopic view of the pancreaticojejunal
anastomosis
The pancreatic duct remnant, including one of the
branches, is seen on the right side.
Figure 6. Enteroscopic view of the blind pouch
of the Roux limb
The view from the enteroscope is a few centimeters
proximal to the pancreatic anastomosis.
Dr. Chiorean received his medical degree from the University
of Medicine and Pharmacy in Cluj-Napoca, Romania and
completed a residency in internal medicine and a fellowship
in gastroenterology at the Mayo Clinic in Rochester, MN.
His research interests include inflammator y bowel disease
(IBD), colorectal neoplasia in IBD, small bowel imaging and
therapeutics, gastrointestinal injur y induced by nonsteroidal
anti-inflammator y drugs or Helicobacter pylori, and natural
orifice translumenal endoscopic surger y (NOTES).
Dr. Chiorean is cer tified by the American Boards of Internal
Medicine and Gastroenterology, is a fellow of the American
Gastroenterological Association, and is a member of American
Society of Gastrointestinal Endoscopy, the American College
of Gastroenterology, and the Crohn’s and Colitis Foundation of
America. He is the principal investigator or site co-investigator
for more than 15 ongoing clinical trials, the author of
numerous journal ar ticles, and has lectured in the United
States and abroad.
Dr. Chiorean has received honoraria as an advisor for Spirus Discovery and Given Imaging.
References
Figure 7. Enteroscopic view of the blind pouch of the
Roux limb following gentle probing with the scope
Brisk bleeding is seen at the end of the pouch.
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Figure 8. Cessation of bleeding after epinephrine
injection and placement of hemostatic clips
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1.
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6.
Raju GS, Gerson L, Das A, Lewis B. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007;133:1697-717.
Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000;118:201-21.
May A, Farber M, Aschmoneit I, et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010;105:575-81.
Morgan D, Upchurch B, Draganov P, et al. Spiral enteroscopy: prospective U.S. multicenter study in patients with small-bowel disorders. Gastrointest Endosc 2010;72:992-8.
Khashab M, Helper DJ, Johnson CS, Chiorean MV. Predictors of depth of maximal insertion at double-balloon enteroscopy. Dig Dis Sci. 2010;55(5):1391-1395.
Gerson LB, Tokar J, Chiorean M, et al. Complications associated with double balloon enteroscopy at nine US centers. Clin Gastroenterol Hepatol 2009;7:1177-82, 82 e1-3. 2007;94:198-203.
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