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Yield of double-balloon enteroscopy in the diagnosis and treatment of small bowel strictures

Digestive and Liver Disease, Volume 48, Issue 4, April 2016, Pages 446 - 448

Abstract

Background

Small bowel strictures are common in gastroenterology practice. We report diagnostic and therapeutic yield of double-balloon enteroscopy for small bowel strictures.

Methods

Retrospective study of 71 consecutive patients who were found to have small bowel stricture at the time of double-balloon enteroscopy.

Results

During double-balloon enteroscopy, stricture identification and tissue sampling were possible in all 71 cases. Surgical pathology reported aetiology as non-steroidal anti-inflammatory drugs (32%), non-specific (21%), Crohn's disease (21%), radiation-induced (9%), tumour (10%), anastomotic (4%), celiac disease (1%), and surgical adhesions (1%). Sixteen patients (23%) underwent balloon dilation. Sensitivity of abdominal computed-tomography and video-capsule endoscopy for strictures based on double balloon enteroscopy findings was 61% and 43%, respectively.

Conclusion

Double-balloon enteroscopy was safe and effective to access small bowel stricture with direct visualization and tissue sampling or for therapeutic balloon dilation. Given low sensitivity with conventional computed-tomography and/or video-capsule endoscopy for small bowel stricture, double-balloon enteroscopy can be considered if clinical suspicion is high.

Keywords: Balloon-assisted enteroscopy, Double-balloon enteroscopy, Small bowel stricture.

1. Introduction

Small bowel strictures are common in gastroenterology practice [1] and [2]. They are identified most frequently in the ileocecal region, but can be found throughout the gastrointestinal tract. The causes of small bowel strictures (on imaging) are diverse, including Crohn's disease, non-steroidal anti-inflammatory drug (NSAID) induced, neoplasm, post-surgical, and idiopathic [1]. Establishing small bowel stricture aetiology is a challenge as routine endoscopy does not allow small bowel inspection and tissue sampling. Therefore, historically surgical resection was mostly required for establishing diagnosis of small bowel pathology [2]. Double balloon enteroscopy (DBE) overcomes these challenges and offers diagnostic and therapeutic interventions in the small bowel, which encompass direct visualization, tissue sampling, as well as minimally-invasive therapy with balloon-dilation of benign strictures [1], [3], [4], [5], [6], [7], [8], and [9]. We conducted a retrospective study to determine the aetiology of all consecutive identified small bowel strictures on DBE and their associated with imaging findings and presenting symptoms.

2. Materials and methods

2.1. Subjects

Between February 2009 and September 2013, 1296 patients underwent 1747 DBE in our tertiary centre. Retrospectively, 71 consecutive patients were found to have small bowel stricture during DBE. Small bowel stricture on DBE was defined as the presence of a fixed luminal narrowing in relation to the remaining small bowel. In all cases the enteroscopy passed the stricture, requiring previous balloon dilation in 23% of cases.

Patient information was extracted from the electronic medical record, which included demographics, self-reported usage of NSAIDs, self-reported tobacco use, medication list, outside work-up by referring physicians, indication for the DBE procedure, presenting symptoms, cross-sectional imaging reports, video capsule endoscopy reports, intervention details (i.e., total procedural time, upper vs. lower approach, additional procedures), findings, and immediate post-procedural data (Table 1). The retrospective study was exempt from Institutional Review Board approval.

Table 1 Indication for double balloon enteroscopy procedures.

Indication Number of patients
n = 71
Recurrent SBO 23 (32%)
Occult GI bleed 17 (24%)
Suspected CD 11 (16%)
Foreign body extraction 11 (16%)
Suspected tumour 6 (8%)
Overt GI bleeding 3 (4%)

CD, Crohn's disease; GI, gastrointestinal; SBO, small bowel obstruction.

2.2. Double balloon enteroscopy (DBE)

All DBEs were performed after appropriate written informed consent was obtained. Based on the patient's clinical setting, after evaluating available previous endoscopic and radiologic imaging, the expert endoscopist decided on an antegrade or retrograde (or both) DBE approach. DBE was performed by two trained, experienced gastroenterologists (MES and FJL). Patients were required to fast for at least 6 h prior to the procedure. Sedation with general anaesthesia was performed by a certified anaesthesiologist. The EN450-T5 enteroscope (Fujinon Inc., Wayne, NJ) was used for all DBEs. It included a 230 cm-long endoscope, an overtube, and double barostatic pump (PB-10 balloon pump controller) that allowed controlled inflation of the endoscope and overtube balloons. DBE was performed by using the insertion technique described by Yamamoto [16]. Bowel luminal inflation was achieved with carbon dioxide. Decision to dilate was made by the endoscopist based on benign appearance of the stricture. Each stricture was gradually dilated by 2 mm at a time then the site was assessed before attempting further dilation up to no more than 13 mm in total inner diameter, to allow passage of the enteroscope.

2.3. Video capsule endoscopy (VCE)

Of 71 patients who underwent DBE, 49 also underwent VCE evaluation (69%), interpreted by one physician (MES) at Mayo Clinic, Jacksonville, Florida, prior to undergoing DBE. Most of the VCE were performed by the referring physicians, when the presentation of the patient was not suspicious for small bowel obstruction, and their VCE findings were reinterpreted by our physician (MES); all remaining VCE were performed according to the standard protocol endorsed by the American Society for Gastrointestinal Endoscopy (ASGE) at our institution prior DBE utilizing the PillCam small bowel (Given Imaging, Duluth, GA) system and were interpreted by MES.

2.4. Cross-sectional imaging

Forty-four patients underwent one or combination of following type of cross-sectional imaging prior to DBE, which included computed tomography (CT) with or without intravenous (IV) contrast, CT with enterography protocol, and magnetic resonance imaging (MRI) with IV contrast, and MRI with enterography protocol. Data were abstracted from radiology reports for findings that were compatible with small bowel stricture or indicating stricture aetiology using keywords “transition point/proximal dilation/small bowel obstruction/small bowel thickening”.

2.5. Outcomes

The primary outcome was establishing stricture aetiology by visual confirmation and histopathology. Secondary outcomes were the sensitivity of VCE and conventional CT imaging for small bowel strictures.

2.6. Statistics

Descriptive statistics were calculated for the patients’ data and clinical parameters and are presented as means with standard deviation and range (minimum–maximum) for continuous data. All statistical analyses were performed with SPSS, version 17.0.

3. Results

Seventy-one patients (59% females, mean age 62.7 ± 15 years) underwent 31 antegrade and 53 retrograde DBEs and were diagnosed with small bowel strictures. The indications for DBE are listed in Table 1. The endoscopic impression in conjunction with the pathology reports identified the aetiologies of the strictures as NSAIDs, non-specific, Crohn's disease, radiation-induced, tumour-induced, anastomotic, celiac disease, and surgical adhesions (Table 2). Of these benign strictures, 33% were related to NSAIDs, 25% Crohn's disease, 25% anastomotic, and 17% non-specific.

Table 2 Stricture aetiology based on pathology reports from tissue samples obtained by double-balloon enteroscopy.

Aetiology Total
n = 71
Suspected SBO
n = 23
Occult GI bleed
n = 20
Suspected CD
n = 11a
Suspected SB tumour
n = 6b
NSAIDs 23 (32%) 7 (30%) 5 (25%) 3 (27%) 1 (17%)
Non-specific 15 (21%) 7 (30%) 5 (25%) 1 (17%)
Crohn's disease 15 (21%) 1 (4%) 3 (15%) 1 (17%)
Radiation 6 (9%) 4 (17%) 1 (5%) 1 (9%)
Tumour-induced 7 (10%) 1 Lymphoma (4%) 2 Villous adenoma (10%)
2 Lymphoma (10%)
1 Carcinoid (5%)
1 Lymphoma (9%)
Anastomotic 3 (4%) 2 (9%) 1 (5%) 2 (33%)
Celiac disease 1 (1%) 1 (9%)
Surgical adhesions 1 (1%) 1 (4%)

a Correlated in 5 out of 11 patients DBE confirmed SB Crohn's disease suspicion. The 6 remaining are listed in the table.

b Correlated in 1 out of 6 patients DBE confirmed SB tumour suspicion. The 5 remaining are listed in the table.

CD, Crohn's disease; DBE, double balloon enteroscopy; GI, gastrointestinal; NSAIDs, non-steroidal anti-inflammatory drugs; SB, small bowel; SBO, small bowel obstruction.

Forty-four patients (62%) and 49 patients (69%) underwent cross-sectional imaging and VCE prior to DBE, respectively. Of the 44 abdominal CT scans, only 27 were diagnostic for a small bowel stricture (sensitivity of 61%). Only 21/49 VCE detected a small bowel stricture, although a total of 41 VCE revealed abnormal small bowel findings, which included strictures and non-stricture-related pathology (sensitivity for small bowel stricture 43% and for all abnormalities 84%).

Of the patients with identified benign strictures, 16 patients (23%) underwent therapeutic balloon stricture dilation without any immediate complication. Of the 49 patients who underwent VCE, 11 had retention of the capsule; we do not have data if these patients underwent Agile (patency) capsule prior to VCE. All retained capsules were successfully retrieved through DBE, and 3 out of the 11 patients underwent dilation at the time of retrieval, which has been previously reported by our group [15].

4. Discussion

This case series demonstrates that, with DBE, small bowel strictures can be accessed and visualized, and tissue sampling can be safely performed in all cases, which is comparable to published data [10]. Our case series also suggests that the aetiology of almost 75% of the small bowel strictures were NSAID use, non-specific, and Crohn's disease. The non-specific category included patients who denied use of NSAIDS, and biopsies were non-specific, which might be explained by findings described by Matsumoto et al. [11] and Perlemuter et al. [12]. Interestingly, it has been described that despite patients’ denial of NSAIDs use, there has been evidence of its surreptitious use, which means that the majority of these non-specific strictures might be from NSAID use [13].

Based on the fact that pathological diagnosis was achieved in all of the cases, therapy could be oriented to treat not only the stricture itself, but the underlying cause. Forty-three (61%) stricture were identified incidentally, of which 37 (86%) were benign and 6 (14%) were malignant. Endoscopic balloon dilation is shown to be safe and effective for the short primary or anastomotic strictures; however, often repeated dilations are needed and long-term outcomes of endoscopic balloon dilation remain to be investigated [14].

In our study, VCE and conventional CT scan missed 57% and 39% of small bowel strictures, respectively, including malignant strictures. However, VCE use could have been limited when strictures were suspected due to fear of impaction; most of these patients did not get CT/MR enterography. Also, there is a referral bias in this study, which can lead to false low sensitivity of CT and VCE for small bowel strictures. As the patients returned to their referring physician, we did not have any long-term follow-up data beyond 30 days. This study was limited due to its single-centre, retrospective design, relatively small sample size in a heterogeneous patient population, and limited follow-up.

In conclusion, DBE was safe and had a high-yield to diagnose the aetiology of small bowel strictures in our series. NSAID-related, non-specific, and Crohn's disease-related strictures accounted for the vast majority of small bowel strictures. Although a standardized role of small bowel dilation is lacking, in our limited experience, cautious dilation of benign small bowel strictures was not associated with any immediate post-procedural complications, and can be considered a bridge to definitive treatment if local expertise is available.

Conflict of interest

None declared.

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Footnotes

Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA

Corresponding author at: Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA. Tel.: +1 904 953 2814; fax: +1 904 953 7366.

1 Co-first authors.