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doi:10.1111/j.1440-1746.2009.05936.

GASTROENTEROLOGY

jgh_5936

1631..1638

Diagnostic yield and therapeutic impact of single-balloon


enteroscopy: Series of 106 cases
Mohan Ramchandani, D Nageshwar Reddy, Rajesh Gupta, Sandeep Lakhtakia, Manu Tandan,
Guduru V Rao and Santosh Darisetty
Asian Institute of Gastroenterology, Hyderabad, India

Key words
balloon assisted enteroscopy, insertion depth,
single-balloon enteroscopy.
Accepted for publication 8 May 2009.
Correspondence
Dr D Nageshwar Reddy, Asian Institute of
Gastroenterology, 6-3-661, Somajiguda,
Hyderabad 500 082, India. Email:
aigindia@yahoo.co.in

Abstract
Background and Aim: Single-balloon enteroscopy (SBE) is a novel method of balloon
assisted enteroscopy which allows deep intubation of intestine and has therapeutic potential. This prospective study was done in a tertiary care center to evaluate the feasibility,
complications, diagnostic and therapeutic yield of SBE in patients with suspected small
bowel disorders.
Methods: One hundred and six patients (mean age 40.1 years, range 1276 years, 65 men)
with suspected small bowel diseases underwent 131 SBE procedures between February
2007 and July 2008.
Results: Indications for SBE included obscure gastrointestinal bleeding (OGIB) (40),
chronic abdominal pain with abnormal imaging studies (34), chronic diarrhea (20), polyposis syndromes (11) and foreign body (1).The mean insertion depth was 255.8 84.5 cm
beyond the duodenojejunal flexure by the oral route and 163 59.3 cm proximal to the
ileocecal valve by the per anal approach. The mean duration of the procedure for antegrade
and retrograde enteroscopy was 65.9 19.5 min and 72.3 18.3 min, respectively.
Pan-enteroscopy was possible in 25% of cases (five of 20 cases in which total enteroscopy
was attempted). Diagnostic yields in cases of OGIB, chronic abdominal pain and chronic
diarrhea were 60%, 65% and 55%, respectively. Overall new diagnosis was established in
46% and the extent of known disease was assessed in 15% of cases. In 21% of patients,
therapeutic interventions were carried out while surgical treatment was directed to 8.4% of
the patients. No major complications were observed.
Conclusion: SBE is well tolerated and has good diagnostic yield, having a similar yield to
previous double-balloon enteroscopy reports.

Introduction
Because of inherent difficulties, the small bowel has long been
considered the final frontier for the gastrointestinal (GI) endoscopist. Of late, several new technologies to evaluate small bowel
diseases have emerged which have made visualization of the entire
small bowel easier. The first breakthrough was wireless capsule
enteroscopy (CE), which was introduced in 2001 (M2A; Given
Imaging Ltd, Yoqneam, Israel) and allows evaluation of the small
bowel mucosa,1 but has no therapeutic interventional capacity.
Double-balloon enteroscopy (DBE) has also revolutionized small
bowel endoscopy.25 DBE (Fujinon, Saitama, Japan) is a method
that has overcome the limitation of capsule endoscopy and not
only allows full-length inspection of the small bowel but has
therapeutic capabilities also. However, it requires considerable
expertise and is significantly more invasive than CE.
A novel method of push and pull enteroscopy using the singleballoon scope (XSIF-Q260Y; Olympus Corporation, Tokyo,

Japan) has recently been developed. This new technique simplifies


the double-balloon concept by removing the endoscope balloon;
however, there is very little literature available regarding its
application.6,7 We present our experience with this new enteroscopy method.

Methods
Patients
Between February 2007 and July 2008, 106 patients underwent
131 enteroscopies in a single tertiary care center. Demographic
details including age, gender, indication for enteroscopy, findings
of prior upper- and lower-GI endoscopies, prior capsule endoscopy
findings, and any prior abdominal surgery were collected. Radiological studies including barium studies, computed tomography
(CT) scan/CT enteroclysis where available were noted. In all
patients with abdominal pain who underwent enteroscopic

Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


Journal compilation 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

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Impact of single-balloon enteroscopy

M Ramchandani et al.

examination, radiological findings revealed either suspected narrowing, non-specific thickening of small bowel folds, suspicion of
ulcers or bowel wall thickness. The details of SBE, including the
length of advancement in centimeters with the oral and the anal
approaches, investigation time and complications, were carefully
noted.

Single-balloon enteroscopy system


We used a prototype Olympus video enteroscope (XSIF-Q260Y),
a splinting tube with balloon (XST-SB1) and a balloon controller
(MAJ 1440). The high-definition enteroscope is 2 m long with an
outer diameter of 9.2 mm. The working channel of the enteroscope
has a diameter of 2.8 mm. The tip of the endoscope has a broad
bending capability due to its extreme flexibility which allows
anchoring of the enteroscope. The flexible overtube is made of
silicon, and has a total length of 140 cm with an outer diameter of
13.2 mm. A silicon balloon attached at the tip of the overtube is
inflated and deflated with air from a balloon control pump. The
balloon acts as a mucosal anchor that allows the scope and
overtube combination to be extended forward. The splinting tube
is lubricated with 1020 mL of saline before insertion of the
enteroscope.

Technique
Once the instrument is in the small intestine, the splinting tube
balloon is inflated to fix the tube to the intestines, and the tip of the
enteroscope is advanced into the deep part of the intestine. Then,
the tip of the enteroscope is bent to fix to the intestine, and the tube
with the deflated balloon is slowly pushed forward over the enteroscope. Once the splinting tube reaches the endoscope tip, the
balloon is inflated and the splinting tube and endoscope are withdrawn together. This maneuver leads to shortening of the gut,
which is folded over the splinting tube in a concertina like fashion,
reducing intestinal looping, which further facilitates advancement
of the endoscope. By repeating this process, the enteroscope is
inserted into the deeper part of the intestine.
No specific preparation is required for the oral approach,
patients were instructed to be nil orally for 8 h before the procedure. For enteroscopy through the anal approach, bowel cleansing
is required, as in colonoscopy. The examination is carried out with
the patients under conscious sedation with a sedato-analgesic
cocktail (midazolam + pentazocine + ketamine) and propofol was
given to all the subjects who underwent SBE.8 Blood pressure,
pulse rate, SPO2 (saturation of oxygen in arterial blood) and
electrocardiogram (ECG) were monitored during and after the
procedure under the care of an experienced anesthetist. Depth of
insertion of the enteroscope was assessed by the method previously described for DBE.9 The length of the visualized small
bowel was estimated by calculating the sum of each sequential
progressive extension of the scope through the overtube, starting
the calculation from the duodenojejunal flexure onwards. The
length of small bowel threaded during each maneuver was
recorded, with the individual lengths advanced being added up at
the end of the examination. This technique has been evaluated in
an animal model using DBE, and the estimated insertion depths,
on average, showed only a deviation of less than 10% from the
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actual insertion depths.9 The intention of the enteroscopy was to


find out the lesion/s responsible for the presenting symptoms. The
route of insertion was guided by capsule endoscopy (wherever
available) in cases with obscure GI bleed, otherwise the oral route
was attempted first. In cases of abdominal pain, the route was
decided by findings in preliminary radiological imaging (barium
studies, CT scan/CT enteroclysis etc.), whereas in cases of polyposis syndromes and chronic diarrhea, enteroscopy was done
through the oral route. If no lesion was found with the per-oral
route, the per-anal route was subsequently attempted. If total enteroscopy could not be achieved with the initial approach, an India
ink tattoo was left as a landmark for a subsequent examination.
Fluoroscopy was used intermittently, especially when the insertion
of the endoscope was difficult due to loop formation, intestinal
adhesions etc.
The patients position during enteroscopy was basically prone
for the oral route and supine for the anal route.
All procedures were carried out by one experienced endoscopist. One nurse assisted the endoscopist in operating the overtube.
An additional nurse was called to assist during therapeutic interventions such as polypectomies and balloon dilations.

Ethical considerations
All patients provided written consent prior to undergoing SBE. All
patients undergoing therapeutic enteroscopy, including argon
plasma coagulation (APC), polypectomy or dilation therapy were
informed that surgical laparotomy with intraoperative enteroscopy
or small bowel resection was the standard approach. The study was
approved by the institutional review board.

Statistics
Descriptive statistics were calculated for the patients data in clinical parameters presenting the mean, standard deviation (SD) and
range (minimummaximum).

Results
One hundred and six patients (65M / 41F, mean age
40.1 14.6 years, range 1276 years) with suspected small bowel
diseases underwent 131 enteroscopic procedures. Indications
included obscure gastrointestinal bleeding (OGIB) (40), chronic
abdominal pain with abnormal imaging studies (34), chronic diarrhea (20), polyposis syndromes (11) and foreign body (1). Ninety
five patients underwent examination by the per oral route and in 25
of these patients, the per anal route was also attempted, whereas 11
patients underwent enteroscopy by the per anal route only.

Technical details
The mean depth of insertion was 255.8 84.5 cm (range 40380)
beyond the duodenojejunal flexure by the oral route and
163.0 59.3 cm (range 50270) proximal to the ileocecal valve
by the per anal approach. The mean duration of the procedure was
65.9 19.5 min (range 25120 min) for antegrade examination
and 72.3 18.3 min (range 40120 min) for retrograde examination. The mean length of intestine examined in 25 patients who
underwent both antegrade and retrograde examinations was

Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


Journal compilation 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

M Ramchandani et al.

Figure 1

Impact of single-balloon enteroscopy

Enteroscopic findings, diagnosis and therapy in patients with obscure gastrointestinal bleeding.

424 133 cm (range 120650 cm). The average time taken for
the procedure was 151.6 27.2 min (range 100200 min). India
ink tattooing was carried out in 20 patients, those in whom panenteroscopy was attempted. Examination of the entire intestine was
possible in five patients (25%).
Retrograde enteroscopy failed in six of 36 (16%) patients. In
four patients, ileocecal intubation was not possible because of
altered anatomy due to previous surgeries and, in the other two, the
scope could not reach the ileocecal valve because of excessive
looping in the colon. Five of the six failed retrograde examinations
occurred during the first 20 retrograde enteroscopies. Only one
failure occurred during the last 16 examinations.
Detailed enteroscopic findings, diagnosis and therapy in
patients with OGIB, chronic abdominal pain, chronic diarrhea and
polyposis syndrome are given in Figures 14, respectively.

arteriovenous malformation (AVM) (n = 9) including two patients


with Osler-Weber-Rendu syndrome. Six patients with ulcers had a
history of non-steroidal anti-inflammatory drugs (NSAIDs) intake,
and two others had non-specific ulcers. Three patients had mass
lesions in the jejunum accounting for recurrent GI bleeding. The
histology was suggestive of adenocarcinoma in all. One patient with
OGIB had ulcerated polypoidal lesions in the jejunum with active
bleeding which was treated with APC and subsequently diagnosed
as amyloidosis (Fig. 5). Another patient who had recurrent episodes
of melena had a polyp in the distal jejunum which was removed with
a polypectomy snare. A patient diagnosed with blue rubber bleb
nevus syndrome had episodes of melena. SBE revealed extensive
involvement of the small intestine showing multiple venous malformations throughout the small bowel. One patient had actively
bleeding jejunal Dieulafoys lesion which was successfully treated
with an enteroscopic clipping device.

Diagnostic yield
Obscure gastrointestinal bleed (n = 40)

Abdominal pain with abnormal radiological imaging


(n = 34)

Overall, lesions that could potentially account for OGIB were found
in 24 of 40 patients (60%) on SBE. The more common lesions were

Overall diagnostic yield of SBE in this group was 22 of 34 (65%)


patients. Details are given in Figure 2. Four patients with Crohns

Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


Journal compilation 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

1633

Impact of single-balloon enteroscopy

Figure 2

M Ramchandani et al.

Enteroscopic findings, diagnosis and therapy in patients with chronic abdominal pain.

disease had ulcers with stricture in the jejunum, three were successfully dilated with a balloon and one patient required surgery.
Two patients had masses in the jejunum which were subsequently
confirmed to be adenocarcinoma and were operated on. One patent
had infiltrating adenocarcinoma at the duodenojejunal flexure
from the pancreas and two patients had lymphoma.

Chronic diarrhea (n = 20)


Diagnosis could be established in 11 of 20 cases (55%). Effacement of small intestinal mucosal folds and scalloping was seen in
seven patients, two of whom had serological and histological evidence of celiac disease, whereas one was diagnosed as having
tropical sprue. Four subjects with known celiac disease who had a
partial response to a gluten-free diet had ulcerative jejunitis
without evidence of lymphoma on histological examination.
Giardiasis was diagnosed in one patient with chronic diarrhea
after enteroscopic biopsy, although the enteroscopic picture was
normal. Two patients who were taking long-term steroids were
diagnosed with intestinal strongyloidiasis (Fig. 6) whereas the enteroscopic findings were of diffuse enteritis.
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Polyposis syndrome (n = 11)


All patients had established diagnosis at the time of the SBE. Eight
patients had Peutz-Jeghers syndrome, two patients had familial
adenomatous polyposis (FAP) and one had Cronkhite-Canada syndrome. The indication for SBE in the Peutz-Jeghers group was
treatment of obstructive polyps in two patients and evaluation of
the extent of the involvement of the small bowel in the remaining
patients. All eight patients with Peutz-Jeghers syndrome had
extensive small bowel polyps. In two patients, large polyps were
removed. In two patients with FAP, one had periampullary polyps
which were successfully removed and another had no polyps in the
small bowel. In the patient with Cronkhite-Canada syndrome, few
duodenal polyps were seen and the rest of the small bowel was
normal.

Therapeutic interventions
Twenty-three patients underwent therapeutic procedures, including APC (Fig. 7) in 14 patients (nine patients with AVM and five
with actively bleeding ulcers), polypectomy in four patients, dilation therapy in three patients for small bowel strictures due to

Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


Journal compilation 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

M Ramchandani et al.

Figure 3

Impact of single-balloon enteroscopy

Enteroscopic findings, diagnosis and therapy in patients with chronic diarrhea.

Crohns disease, foreign-body extraction (Fig. 8) in one patient


and one patient underwent a clipping procedure for jejunal
Dieulafoys lesion.
Surgical therapy was considered to be indicated after the SBE in
five patients with jejunal adenocarcinoma and in two patients with
small bowel lymphoma. One patient with pancreatic malignancy
with duodenojejunal flexure infiltration underwent palliative
gastrojejunostomy. A patient with Crohns disease had long
segment small bowel stricture and underwent resection and
anastomosis.

Complications
No enteroscopy-associated severe complications such as pancreatitis, perforation or bleeding were observed. Minor side-effects
were observed in eight of the 131 enteroscopies, consisting of
abdominal discomfort for 12 days, sore throat and mild fever.
Reddening of the mucosa or slight intramucosal hemorrhage was
seen in 14 patients.

Overall impact of SBE


Overall, in 49 (46.2%) patients, a specific diagnosis was established to explain their presenting symptoms. In another 16 (15%)
patients with a known disease, the extent of the small bowel
involvement could be further assessed. In 23 (21.6%) patients,
therapeutic intervention could be carried out during enteroscopy.
Surgical treatment was required in nine (8.4%) of the patients.

Discussion
Non-surgical management of small bowel disorders is difficult.
This is due to lack of availability of proper investigational modalities to venture into long redundant small bowel loops. Balloon
assisted enteroscopy (BAE) is an emerging technique to carry out
enteroscopies with therapeutic potential. Double-balloon enteroscopy was the first tool using the BAE technique for examining the
small bowel, but there are certain limitations of DBE: it is labor
intensive to set up, it is a complicated procedure, and it has a
limited availability.

Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


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Impact of single-balloon enteroscopy

Figure 4

M Ramchandani et al.

Enteroscopic findings and therapeutic intervention in patients with polyposis syndrome.

Figure 5 (a) Enteroscopic picture showing


multiple sessile polyps in the jejunum with
active bleeding from an ulcerated lesion. (b)
Histological appearance of the jejunal biopsy
specimen under polarized light showing characteristic apple-green birefringent amyloid
deposits within the thickened vessel wall and
intracellularly in the jejunal mucosa suggestive of amyloidosis. (Congo red, original magnification 100).

As there is limited availability and affordability of CE in India,


a suitable endoscopic method is required for diagnosis and treatment, as histology is an important element especially for tuberculosis (Fig. 9), parasitic infestations and tropical sprue etc. which
are more common in this part of the world.10,11
There were three major indications for SBE in this study. The
diagnostic yields in patients with OGIB, chronic abdominal pain
and chronic diarrhea were 60%, 65% and 55%, respectively. In
patients with OGIB, the common lesions were NSAID-induced
ulcers, angiodysplasias and mass lesions located mainly in the
jejunum. In 20 patients, the diagnosis was established through per
oral enteroscopy and the procedure was terminated early. In another
four patients, the lesions were identified on per anal enteroscopy. In
16 patients, no cause could be established even after attempted
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panenteroscopy. These patients were subjected to intraoperative


enteroscopy if they continued to bleed. Our diagnostic yield for
SBE of 60% in OGIB is comparable with other published studies
(6080%) evaluating the role of DBE in various small bowel
diseases.12,13,14 In patients with abdominal pain, the enteroscopies
were done to confirm the abnormalities seen in imaging. None of
the patients had confirmed diagnosis before enteroscopy. Earlier
studies to evaluate chronic abdominal pain had variable outcomes.
Capsule endoscopy had a low yield for evaluation of abdominal
pain (9% for abdominal pain alone and 13% when associated with
diarrhea).15 However, the yield of enteroscopy increases when there
is abnormal radiological findings.16 We carried out enteroscopy in
subjects with abnormal, though not diagnostic, findings on radiological examination. The yield in such patients was 65%.

Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


Journal compilation 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

M Ramchandani et al.

Impact of single-balloon enteroscopy

Figure 6 (a) Enteroscopic picture showing


diffuse ulceration and mucosal edema involving the jejunum in a patient with chronic diarrhea. (b) Histology demonstrated many larvae
of Strongyloides stercoralis within mucosal
glands (H&E original magnification 100).

Figure 7 Jejunal arteriovenous malformation treated with argon plasma coagulation.

Figure 8 Sewing needle partially penetrating the jejunal wall was retrieved using biopsy
forceps.

Positive diagnosis was found by direct visual examination of the


small bowel mucosa and histology in 2264% of patients with
diarrhea. Enteroscopy yielded a diagnosis in 55% of the patients
with diarrhea in our study. Small bowel examination by SBE in
patients with celiac disease established the diagnosis of ulcerative
jejunitis in four patients with celiac disease who had partial
response to a gluten-free diet. None of the patients had evidence of
enteropathy-associated T-cell lymphoma on histology. SBE can be
the investigation of choice in patients with refractory celiac
disease as ulcers are more common in the jejunum and the ileum
rather than the duodenum.17,18 Strongyloidiasis and giardiasis were
important findings in patients with diarrhea in our study, this being
not unexpected in a developing country.11

Patients with polyposis syndromes need regular surveillance.19


SBE can be very valuable in this regard, especially newer enteroscopes with narrow band imaging. One of the most important
complications observed in these patients is recurrent intestinal
obstruction which can be very successfully treated by removing
the polyps.
Although there was no head-to-head comparison between SBE
and DBE in this study, the mean lengths of the small bowel
examined both with oral and anal approaches (255.8 84.5 cm
and 163 59.3 cm, respectively) were comparable with those of
DBE published in various studies.20 In this study, it was possible to
evaluate the entire small bowel in only five cases (25%). All of
these cases were two-stage procedures where initial enteroscopy

Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


Journal compilation 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

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M Ramchandani et al.

Figure 9 (a) Enteroscopic picture showing


large transverse ulcer with nodularity involving the jejunum. (b) Histological appearance of
macrogranuloma composed of loose epithelioid cells rimmed by lymphocytes, and fibroblasts with an occasional giant cell (H&E
original magnification 400).

was done through the oral route followed by the anal route. The
pan-enteroscopy rate appears to be inferior to DBE which has been
reported by Yamamoto et al.13 However, other studies from the
West have reported lesser success rates of examining the entire
small bowel with DBE.19,20 It needs to be evaluated whether the
balloon on the enteroscope of DBE holds the bowel better than the
angulated tip of the enteroscope of SBE.
SBE led to a new diagnosis in 46% of cases. In these patients, no
specific diagnosis was established in spite of numerous previous
examinations. Thus, the initial experience of SBE is very promising in terms of technical and clinical parameters similar to DBE.
Limitations of this study were that there was no head-to-head
comparison between other enteroscopic methods such as push
enteroscopy, CE or DBE. The obvious advantages of SBE are that
it is easy to assemble, easy to disinfect, a single person can operate
it and multiple polyps can be retrieved without removing the
overtube. To carry out cross-over studies in this subset of patients
would be difficult. It appears that small-bowel inspection can be
achieved adequately using SBE, but comparative studies are
needed to evaluate whether the ease of insertion and the ability to
inspect the small bowel are similar to those of DBE.
In conclusion, single-balloon enteroscopy is well tolerated and
has a good diagnostic yield, having a similar yield to previous
double-balloon enteroscopy reports.

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Journal of Gastroenterology and Hepatology 24 (2009) 16311638 2009 The Authors


Journal compilation 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd