Double Balloon Endoscopy for Stenosis of the Small Intestine

Before enteroscopy, evaluation of clinical symptoms, plain abdominal radiography, CT, MRI, or a contrast-enhanced study should be performed to estimate whether the jejunum or the ileum is involved. The location where the internal diameter of the intestine dramatically changes should be explored; however, examination of the entire small intestine is often required because of uncertainty about the stenotic site. In those cases, the endoscope should be inserted through the anus and the remaining region examined through the mouth.

First, the endoscope is advanced to the stenotic site to observe the lesions. When epithelial changes protruding into the lumen due to a tumor or inflammation are found, the differential diagnosis of lesions can be made by routine observation. In most cases, histological examination leads to definite diagnosis. When no gross change in the luminal epithelium is found in the stenosis of the small intestine, adhesion, intestinal ischemia, nonepithelial tumor, and extrinsic compression by tumor outside the intestine should be considered. When a severe stenosis makes it difficult to direct endoscopic observation of the stenotic lumen, a selective contrast-enhanced study with the balloons of the endoscope and the overtube inflated before the stenotic site allows evaluation of the degree and length of the stenosis and provides useful information for the diagnosis. After contrast enhancement, a biopsy forceps may be carefully inserted under fluoroscopic guidance to collect tissues. In cases of inflammatory stenosis associated with ulcerative lesions, such as tuberculosis and Crohn's disease, particularly with new ulcers, careful judgment is required when the endoscope or the overtube is inserted beyond the stenotic site even if the stenosis allows passage of the endoscope because the passage of the endoscope or the overtube and balloon inflation may cause perforation by applying pressure to the affected area. In the presence of these ulcera-tive lesions, tissue sampling from the ulcer base should be avoided to prevent perforation.

Stenosis of the small intestine often occurs as a single lesion but may occur as multiple lesions, as in Crohn's disease. When the endoscope reveals a stenotic lesion in the small intestine and fails to pass through the lesion, a selective contrast-enhanced study with balloon inflation, as described above, is useful for obtaining information on the distal end of the stenotic site. Tattooing in the vicinity of the stenotic site requiring treatment is useful for identifying the lesion from the serosal side during surgery when laparoscopic treatment is required later.

Table 10.3.1. Diseases that may cause stenosis of the small intestine

Benign inflammatory stenosis Crohn's disease NSAID-induced ulcer Behcet's disease Intestinal tuberculosis

Nonspecific multiple ulcers of the small intestine Traumatic ischemic stenosis of the small intestine Anticoagulant bowel obstruction Small-intestinal tumor Postoperative intestinal adhesion Stenosis of the small intestine after pancreatitis Compression by lesions outside of the intestine

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