Small Small Bo Bowel: el: The he Dar Dark k Con Contine - - PowerPoint PPT Presentation

• Dr. Jimma Hossain

Assistant Professor Gastroenterology Rangpur Medical College, Rangpur

Small Small Bo Bowel: el: The he Dar Dark k Con Contine tinent nt in in Gast Gastroe

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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 20th 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

Capsule Endoscopy Picture

Angio dysplasia

Portal Hypertensive jejunopathy

varices TB TB Crohn’s

Capsule Endoscopy Picture

Enterolith Tomour Tomour Tomour Hook worm Bleeding

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
• ver 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

• f

FB, pre-operative tattooing

• f

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.