Endoscopic Observation

Points to consider for observation with the double-balloon endoscope are described in this chapter. There is no significant difference between an observation with the double-balloon endoscope and a conventional endoscopic observation; however, air insufflation must be kept to a minimum because the double-balloon endoscope is inserted while the intestine is shortened. Thus, observation is inevitably limited during insertion, with a detailed examination being performed during removal. The examination during removal takes place while the shortened intestine is being returned to its original condition. Balloons are used to anchor the intestine during observation to prevent instant stretching of the shortened intestine and to allow observation with minimal blind spots.

More specifically, observation is started from the deepest reachable point with the overtube balloon inflated and the endoscope balloon deflated. The observation is performed while a modest amount of air is insufflated. The observation is made while the endoscope is being withdrawn up to the point at which the 155-cm marking on the endoscope reaches the rear end of the overtube (where the endoscope balloon reaches the tip of the overtube). The endoscope cannot be withdrawn further, and the endoscope balloon is then inflated to secure the endoscope temporarily at that location. Under these conditions, the overtube balloon is deflated, and the overtube alone is withdrawn approximately 10 cm (up to the 165-cm marking on the endoscope). During this manipulation, it is important not to withdraw the overtube to the proximal end of the endoscope at once. That is because the intestine is substantially shortened over the overtube during observation and because a 10-cm length of shortened intestine during withdrawal may be equivalent to a 30- to 40-cm portion of the small intestine at the time of insertion. After the overtube is withdrawn approximately 10 cm, the overtube balloon is inflated again to secure the overtube in the intestine. The endoscope balloon is deflated, and observation is made again until the 155-cm marking on the endoscope reaches the rear end of the overtube. Similar observations are repeated whenever the overtube is withdrawn approximately 10 cm. Thus, holding the intestine with the overtube balloon during withdrawal allows back-and-forth observation at any point in the distal small intestine and detailed endoscopic observation.

During this examination of the small intestine, attention should be given to villous changes. Inflammation-related erythematous or edematous villi are often found around ulcers and erosions, and the presence or absence of these findings is useful for differentiation from mucosal damage due to insertion of the endoscope (Fig. 10.1.1). Villous atrophy is often found in the mucosa of a submucosal tumor, and localized villous atrophy may be an indication of a submucosal tumor (Fig. 10.1.2). Although rare in Japan, extensive villous atrophy is observed in patients with celiac disease and other malabsorption syndromes. Because of the presence of villi in the small intestine, it is often difficult to clearly identify small areas of angiodysplasia compared with that in the large intestine, and careful observation is needed not to overlook the lesion.

Also in the small intestine, dye spraying is useful for detailed observation of lesions such as ulcers and tumors (Figs. 10.1.1, 10.1.3). Underwater observations and magnified observations are useful for detailed examination of villi (Figs. 10.1.1, 10.1.2, 10.1.4).

Electronic magnified image after indigo carmine Fig. 10.1.2. Villous atrophy on a submucosal spraying tumor (underwater examination)

Normal villi are seen in the center of the screen, and villous atrophy on the submucosal tumor is noted on the left of the screen

Fig. 10^.3. Endoscopic view of mucosa-associ- Fig. 10.1.4. Normal villi of the ileum (underwater ated lymphoid tissue (MALT) lymphoma of the examination)

ileum

Indigo carmine spraying allows detailed observation of the surface

Fig. 10^.3. Endoscopic view of mucosa-associ- Fig. 10.1.4. Normal villi of the ileum (underwater ated lymphoid tissue (MALT) lymphoma of the examination)

ileum

Indigo carmine spraying allows detailed observation of the surface

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