Small Small Bo Bowel: el: The he Dar Dark k Con Contine tinent nt in in Gast Gastroe oent nter erolog ology Dr. Jimma Hossain Assistant Professor Gastroenterology Rangpur Medical College, Rangpur
Introduction • Key organ as per GI function concern • Plays important role in health and in disease • Difficult to image or visualize • Posing constant challenge in making diagnosis and management of small bowel diseases
Barriers • Long length • Loops • Mobility • Distant location from mouth and anus
Evolution of small bowel imazing and endoscopy • Scientists are trying to conquer the barriers • As a result small bowel imazing and endoscopy has progressed with serial inventions over centuries, like- • Barium follow through • Enteroclysis • CT/MR Enterography • Push enteroscopy • Sonde enteroscopy • Capsule endoscopy • Single balloon enteroscopy • Double balloon enteroscopy.
Small bowel follow through • Primary modality for small bowel diseases. • Radiological studies showing small intestine were first performed at the beginning of 20 th century. • Cole & colleagues in 1927 described anatomy of small gut as shown on barium follow through. Since then it has become established. • Barium follow through under fluoroscopy gives better yields.
Small bowel follow through • Advantages: • Available • Low cost • Non invasive • Disadvantages: • Low sensitivity and specificity • Can’t reliably detect vascular lesions and early mucosal lesions • Some times difficult to interpret
Sumittra Rani 27y
Hamida 55y
Sharmin 25y
Golzar 22y
Zobaidul 18y
Nazma 35y
Belal 40y
Sagor 30y
Niloy 12y
Enteroclysis • Optimal method • Special balloon-tipped enteroclysis catheter containing a guide-wire passed through nose guided fluoroscopically into proximal jejunum • Barium followed by methylcellulose infused at high rates via a pump
Enteroclysis • Demonstrates excellent mucosal detail,fold pattern • Shows bowel distention & areas of subtle narrowing • High sensitivity, specificity & accuracy • Best examination demonstrating features of early Crohn’s disease.
Approach to small bowel diseases • History and physical findings: • Abdominal pain, vomiting • Loose stools , steatorrhoea • Moving lump • Weight loss • GI bleeding • Anaemia • Features of nutrient deficiency • Lump • Clubbing, etc.
Approach to small bowel diseases • Following investigations are done serially to detect structural lesions: • Barium study of small gut • Colonoscopy with terminal ileoscopy • Upper GIT endoscopy with D2 biopsy • Enteroscopy
Small bowel diseases • Intestinal TB • Crohn’s disease • Lymphoma • Tumours like GIST, carcinoids, polyps, cacinoma • GI bleeding from Meckel’s diverticulum, vascular ectasiae, ulcers, tumours • Tropical Sprue • Coeliac disease • Others-ulcerative Jejuno-ileitis,intestinal lymphangiectasiae etc.
Capsule Endoscopy
Capsule endoscopy • Technologically sophisticated, painless method of GI endoscopy accomplished with a swallowing a capsule • Capsule endoscope (CE)- 26X11 mm capsule containing a battery-powered camera, a transmitter, antenna and 4 light emitting diodes • Takes two images per second • The capsule is swallowed and propelled through the intestine by peristalsis • Pillcam SB- Israel, Endocapsule- Olympus Japan
• Contains Lens • 4 emitting diodes • Color camera • 2 batteries • Radio Frequency Transmitter • Antenna
Technique • 8 to 12 hours fasting • Bowel preparation with polyethylene glycol, sodium phosphate, Prokionetics, Simethicone • 8 sensors placed to abdominal wall • Imazes transmitted via sensors to a data recorder worn on a belt • Data from recorder downloaded into a computer work station to be viewed as a video
Indications • Obscure gastrointestinal bleeding (overt and occult) • Chronic small bowel diarrhea including celiac disease • Abnormal small bowel imaging • Chronic abdominal pain with reasonable suspicion of organic cause in the small intestine • Evaluation of Crohn’s disease and its extent • Visualization of surgical anastomosis • Suspected small bowel tumor • Polyposis syndrome • Portal hypertensive enteropathy and small intestinal varices
Angio dysplasia Portal Hypertensive jejunopathy varices TB Crohn’s TB Capsule Endoscopy Picture
Enterolith Tomour Tomour Tomour Hook worm Bleeding Capsule Endoscopy Picture
Complications & Contraindications • Complications • Capsule retention • Contraindications • Known stricture • Swallowing disorder • Extensive small bowel Crohn’s • Pregnancy • Patient with ICD, permanent pace-maker
Double Balloon Enteroscopy
Double Balloon Enteroscopy • New engineering innovation in flexible endoscopy • With the introduction of double balloon endoscopy system, endoscopists are now able to shed light on the uncharted territory of small bowel
Double Balloon Enteroscopy DBE system consist of – • A high resolution video endoscope- working length 200cm, outer diameter 8.5mm • A flexible over tube- length 145cm, outer diameter 12mm • Latex balloons- attached to tip of endoscope & the over tube • Balloons are inflated & deflated with air from a pressure control pump system
Preparation • Minimum 10 hours fasting & no other preparation is required for anterograde approach. • For retrograde approach full colonoscopic is required. • Conscious sedation is sufficient • Deep monitored sedation with propofol is widely accepted.
DBE Technique • Inflated balloon on over tube use to maintain stable position while enteroscope advance. • Over tube balloon is deflated while enteroscope balloon is inflated & over tube is advanced towards the distal end of enteroscope. • This is described as “Push procedure” • “Push procedure” is followed by “pull procedure” where both the enteroscope & over tube are pulled back under endoscopic guidance when both balloons inflated. • This procedure repeated multiple times to visualize entire small bowel.
Schematic diagram of DBE technique
Indications • Suspected or known mid GI bleeding • Endoscopic diagnosis & histological confirmation of lesions detected by other imaging modalities • First diagnostic step in patients with suspected small bowel stenosis & tumors • Endoscopic interventions within the small bowel, e.g. haemostasis, polypectomy, balloon dilation of stenosis, removal of FB, pre-operative tattooing of lesions, percutaneous endoscopic jejunostomy tube placement
Complications • Less than 1% in diagnostic DBE & 3-4% in therapeutic DBE • Mucosal Stripping, Duodenal perforation, pancreatitis, mallery-weiss tear
Limitations • Time consuming procedure • Total enteroscopy via anterograde approach can be performed in about 5% of patients • Combination of anterograde & retrograde approach can be achieved 40-80% of cases
Conclusion Though the advent of capsule & balloon assisted enteroscopy has improved our access to the diseases of small bowel. But cost & availability of these new ultramodern modalities are still beyond our economy. On the other hand, there are situations even with all modalities diagnoses are still elusive. In those cases surgery, resection & full thickness biopsy will give the final diagnosis. So, in our perspective small bowel is still a dark continent but hopefully no longer it will remain the same.
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