Skip to main content
Log in

Exploring the Small Bowel: Update on Deep Enteroscopy

  • Small Intestine (D Sachar, Section Editor)
  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

Deep enteroscopy allows for the diagnosis and treatment of small bowel disorders that historically required operative intervention. There are a variety of endoscopic platforms using balloons and rotational overtubes to facilitate small bowel intubation and even allow for total enteroscopy. Obscure gastrointestinal bleeding is the most common indication for deep enteroscopy. By visualizing segments of the small bowel not possible through standard EGD or push enteroscopy, deep enteroscopy has an established high rate of identification and treatment of bleeding sources. In addition to obscure bleeding, other common indications include diagnosis and staging of Crohn’s disease, evaluation of findings on capsule endoscopy and investigation of possible small bowel tumors. Large endoscopy databases have shown deep enteroscopy to be not only effective but safe. Recent research has focused on comparing the diagnostic rates, efficacy, and total enteroscopy rates of the different endoscopic platforms.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Weaver LT, Austin S, Cole TJ. Small intestinal length: a factor essential for gut adaptation. Gut. 1991;32(11):1321–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Hounnou G, Destrieux C, Desme J, Bertrand P, Velut S. Anatomical study of the length of the human intestine. Surg Radiol Anat. 2002;24(5):290–4.

    Article  CAS  PubMed  Google Scholar 

  3. Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature. 2000;405:417.

    Article  CAS  PubMed  Google Scholar 

  4. Bonnet S, Douard R, Malamut G, Cellier C, Wind P. Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. Dig Liver Dis. 2013;45(4):277–84.

    Article  PubMed  Google Scholar 

  5. Khashab MA, Lennon AM, Dunbar KB, Singh VK, Chandrasekhara V, Giday S, et al. A comparative evaluation of single-balloon enteroscopy and spiral enteroscopy for patients with mid-gut disorders. Gastrointest Endosc. 2010;72(4):766–72.

    Article  PubMed  Google Scholar 

  6. ASGE Standards of Practice Committee, Khashab MA, Pasha SF, Muthusamy VR, Acosta RD, Bruining DH, et al. The role of deep enteroscopy in the management of small-bowel disorders. Gastrointest Endosc. 2015;82(4):600–7. ASGE guidelines revised in 2015 describing the current indications, contra-indications and procedural guidelines for deep enteroscopy.

    Article  Google Scholar 

  7. Lewis BS, Waye JD. Chronic gastrointestinal bleeding of obscure origin: role of small bowel enteroscopy. Gastroenterology. 1988;94(5 Pt 1):1117–20.

    CAS  PubMed  Google Scholar 

  8. Barkin JS, Schonfeld W, Thomsen S, Manten HD, Rogers AI. Enteroscopy and small bowel biopsy—an improved technique for the diagnosis of small bowel disease. Gastrointest Endosc. 1985;31(3):215–7.

    Article  CAS  PubMed  Google Scholar 

  9. Lewis BS, Waye JD. Small bowel enteroscopy in 1988: pros and cons. Am J Gastroenterol. 1988;83(8):799–802.

    CAS  PubMed  Google Scholar 

  10. Barkin JS, Lewis BS, Reiner DK, Waye JD, Goldberg RI, Phillips RS. Diagnostic and therapeutic jejunoscopy with a new, longer enteroscope. Gastrointest Endosc. 1992;38(1):55–8.

    Article  CAS  PubMed  Google Scholar 

  11. Dykman DD, Killian SE. Initial experience with the Pentax VSB-P2900 enteroscope. Am J Gastroenterol. 1993;88(4):570–3.

    CAS  PubMed  Google Scholar 

  12. Chong J, Tagle M, Barkin JS, Reiner DK. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol. 1994;89(12):2143–6.

    CAS  PubMed  Google Scholar 

  13. Chak A, Koehler MK, Sundaram SN, Cooper GS, Canto MI, Sivak MV. Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings. Gastrointest Endosc. 1998;47(1):18–22.

    Article  CAS  PubMed  Google Scholar 

  14. Hayat M, Axon AT, O’Mahony S. Diagnostic yield and effect on clinical outcomes of push enteroscopy in suspected small-bowel bleeding. Endoscopy. 2000;32(5):369–72.

    Article  CAS  PubMed  Google Scholar 

  15. Foutch PG, Sawyer R, Sanowski RA. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc. 1990;36(4):337–41.

    Article  CAS  PubMed  Google Scholar 

  16. Lo SK. Techniques, tricks, and complications of enteroscopy. Gastrointest Endosc Clin N Am. 2009;19(3):381–8.

    Article  PubMed  Google Scholar 

  17. Harewood GC, Gostout CJ, Farrell MA, Knipschield MA. Prospective controlled assessment of variable stiffness enteroscopy. Gastrointest Endosc. 2003;58(2):267–71.

    Article  PubMed  Google Scholar 

  18. Belaiche J, Van Kemseke C, Louis E. Use of the enteroscope for colo-ileoscopy: low yield in unexplained lower gastrointestinal bleeding. Endoscopy. 1999;31(4):298–301.

    Article  CAS  PubMed  Google Scholar 

  19. Yamamoto H, Sekine Y, Sato Y, Higashizawa T, Miyata T, Iino S, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc. 2001;53(2):216–20.

    Article  CAS  PubMed  Google Scholar 

  20. Pasha SF, Leighton JA. Endoscopic techniques for small bowel imaging. Radiol Clin North Am. 2013;51(1):177–87.

    Article  PubMed  Google Scholar 

  21. Shimatani M, Matsushita M, Takaoka M, Koyabu M, Ikeura T, Kato K, et al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy. 2009;41(10):849–54.

    Article  CAS  PubMed  Google Scholar 

  22. Gay G, Delvaux M, Fassler I. Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy. Endoscopy. 2006;38(1):49–58.

    Article  CAS  PubMed  Google Scholar 

  23. Sunada K, Yamamoto H. Double balloon enteroscopy: techniques. Tech Gastrointest Endosc. 2008;10(2):46–53.

    Article  Google Scholar 

  24. May A, Nachbar L, Schneider M, Ell C. Prospective comparison of push enteroscopy and push-and-pull enteroscopy in patients with suspected small-bowel bleeding. Am J Gastroenterol. 2006;101(9):2016–24.

    Article  PubMed  Google Scholar 

  25. Gross SA, Stark ME. Initial experience with double-balloon enteroscopy at a US center. Gastrointest Endosc. 2008;67(6):890–7.

    Article  PubMed  Google Scholar 

  26. Elena RM, Riccardo U, Rossella C, Bizzotto A, Domenico G, Guido C. Current status of device-assisted enteroscopy: technical matters, indication, limits and complications. World J Gastrointest Endosc. 2012;4(10):453–61.

    Article  PubMed  Google Scholar 

  27. Xin L, Liao Z, Jiang Y, Li Z. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc. 2011;74(3):563–70.

    Article  PubMed  Google Scholar 

  28. Tanaka S, Mitsui K, Yamada Y, Ehara A, Kobayashi T, Seo T, et al. Diagnostic yield of double-balloon endoscopy in patients with obscure GI bleeding. Gastrointest Endosc. 2008;68(4):683–91.

    Article  PubMed  Google Scholar 

  29. Seven G, Kozarek RA, Ross A, Irani S, Gluck M, Schembre D, et al. Double balloon enteroscopy in a North American setting: a large single center 5-year experience. Intestinal Research. 2013;11(1):34–40. A large single center database study of 335 patients that have undergone over 500 DBE over 5 years.They report a diagnostic yield of 52% with a complication rate of only 0.6%.

    Article  Google Scholar 

  30. Tsujikawa T, Saitoh Y, Andoh A, Imaeda H, Hata K, Minematsu H, et al. Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences. Endoscopy. 2008;40(1):11–5.

    Article  CAS  PubMed  Google Scholar 

  31. Kawamura T, Yasuda K, Tanaka K, Uno K, Ueda M, Sanada K, et al. Clinical evaluation of a newly developed single-balloon enteroscope. Gastrointest Endosc. 2008;68(6):1112–6.

    Article  PubMed  Google Scholar 

  32. Manno M, Barbera C, Bertani H, Manta R, Mirante VG, Dabizzi E, et al. Single balloon enteroscopy: technical aspects and clinical applications. World J Gastrointest Endosc. 2012;4(2):28–32.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Hartmann D, Eickhoff A, Tamm R, Riemann JF. Balloon-assisted enteroscopy using a single-balloon technique. Endoscopy. 2007;39 Suppl 1:E276.

    Article  PubMed  Google Scholar 

  34. Kawamura T, Uno K, Tanaka K, Yasuda K. Current status of single-balloon enteroscopy: insertability and clinical applications. World J Gastrointest Endosc. 2015;7(1):59.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Rao GV, et al. Diagnostic yield and therapeutic impact of single-balloon enteroscopy: series of 106 cases. J Gastroenterol Hepatol. 2009;24(10):1631–8.

    Article  PubMed  Google Scholar 

  36. Upchurch BR, Sanaka MR, Lopez AR, Vargo JJ. The clinical utility of single-balloon enteroscopy: a single-center experience of 172 procedures. Gastrointest Endosc. 2010;71(7):1218–23.

    Article  PubMed  Google Scholar 

  37. Li X, Zhao YJ, Dai J, Li XB, Xue HB, Zhang Y, et al. Carbon dioxide insufflation improves the intubation depth and total enteroscopy rate in single-balloon enteroscopy: a randomised, controlled, double-blind trial. Gut. 2014;63(10):1560–5. A randomized double blind clinical trial comparing CO2 to air as an insufflate for deep enteroscopy. The use of C02 significantly ncreased the depth of insertion, total enteroscopy rates while reducing the additional abdominal circumference post procedure.

    Article  PubMed  Google Scholar 

  38. May A, Färber M, Aschmoneit I, Pohl J, Manner H, Lotterer E, et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single-and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol. 2010;105(3):575–81.

    Article  PubMed  Google Scholar 

  39. Takano N, Yamada A, Watabe H, Togo G, Yamaji Y, Yoshida H, et al. Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial. Gastrointest Endosc. 2011;73(4):734–9.

    Article  PubMed  Google Scholar 

  40. Parikh DA, Mittal M, Leung FW, Mann SK. Efficacy of single balloon enteroscopy: a 2 year Veterans Affairs medical center experience with a systematic review of the literature. J Intervent Gastroenterol. 2013;3(4):116. A single center retrospective review of indications, efficacy and complication rates for patients undergoing SBE. The most common indication was obscure bleeding. They report a diagnostic yield of 79% without any significant advserse events. On subgroup analysis, the diagnostic yield was higher when preceeded by a positive VCE (89% v. 59%, p = 0.03).

    Google Scholar 

  41. Akerman PA, Cantero D, Agrawal D, Avila J, Pangtay J. Novel method of enteroscopy using EndoEase Discovery SB overtube. Gastrointest Endosc. 2007;65(5):AB125.

    Google Scholar 

  42. Akerman PA, Agrawal D, Cantero D, Pangtay J. Spiral enteroscopy with the new DSB overtube: a novel technique for deep peroral small-bowel intubation. Endoscopy. 2008;40(12):974–8.

    Article  CAS  PubMed  Google Scholar 

  43. Morgan D, Upchurch B, Draganov P, Binmoeller KF, Haluszka O, Jonnalagadda S, et al. Spiral enteroscopy: prospective US multicenter study in patients with small-bowel disorders. Gastrointest Endosc. 2010;72(5):992–8.

    Article  PubMed  PubMed Central  Google Scholar 

  44. May A, Manner H, Aschmoneit I, Ell C. Prospective, cross-over, single-center trial comparing oral double-balloon enteroscopy and oral spiral enteroscopy in patients with suspected small-bowel vascular malformations. Endoscopy. 2011;43(6):477–83.

    Article  CAS  PubMed  Google Scholar 

  45. Messer I, May A, Manner H, Ell C. Prospective, randomized, single-center trial comparing double-balloon enteroscopy and spiral enteroscopy in patients with suspected small-bowel disorders. Gastrointest Endosc. 2013;77(2):241–9. A randomized prospective trial comparing DBE to SE. There was a significant higher rate of total enteroscopy with DBE but no statistical difference between the diagnostic or therapeutic outcomes. Total procedure time was much shorter with SE.

    Article  PubMed  Google Scholar 

  46. Rahmi G, Samaha E, Vahedi K, Ponchon T, Fumex F, Filoche B, et al. Multicenter comparison of double‐balloon enteroscopy and spiral enteroscopy. J Gastroenterol Hepatol. 2013;28(6):992–8. A retrospective review from five medical centers who underwent deep enteroscopy for suspected small bowel lesions comparing DBE to SE. There was no significant different in diagnostic yield, treatment efficacy, procedure time and intubation length.

    Article  PubMed  Google Scholar 

  47. Pohl J, Delvaux M, Ell C, Gay G, May A, Mulder C, et al. European Society of Gastrointestinal Endoscopy (ESGE) Guidelines: flexible enteroscopy for diagnosis and treatment of small-bowel diseases. Endoscopy. 2008;40(07):609–18.

    Article  CAS  PubMed  Google Scholar 

  48. Dellon ES, Hawk JS, Grimm IS, Shaheen NJ. The use of carbon dioxide for insufflation during GI endoscopy: a systematic review. Gastrointest Endosc. 2009;69(4):843–9.

    Article  PubMed  Google Scholar 

  49. Li X, Zhao YJ, Dai J, Li XB, Xue HB, Zhang Y, et al. Carbon dioxide insufflation improves the intubation depth and total enteroscopy rate in single-balloon enteroscopy: a randomised, controlled, double-blind trial. Gut. 2014;63(10):1560–5.

    Article  PubMed  Google Scholar 

  50. Cangemi DJ, Stark ME, Cangemi JR, Lukens FJ, Gomez V. Double-balloon enteroscopy and outcomes in patients older than 80. Age Ageing. 2015;44(3):529–32. A retrospective single center experience with DBE in 130 patients age 80 or older who underwent DBE (mean age 83.6 ± 3.03). There were zero reported post procedure.

    Article  PubMed  Google Scholar 

  51. Byeon J, Mann NK, Jamil LH, Lo SK. Double balloon enteroscopy can be safely done in elderly patients with significant co‐morbidities. J Gastroenterol Hepatol. 2012;27(12):1831–6. A retrospective single center experience with DBE in 167 patients age 75 or older who underwent DBE (mean age 80.1 ± 3.7). 71% of the cohort was considered an ASA III or greater. Post procedure aspiration pneumonia occurred in only 2 patients (0.9%).

    Article  PubMed  Google Scholar 

  52. Moschler O, May A, Muller MK, Ell C, German DBE Study Group. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy. 2011;43(6):484–9.

    Article  CAS  PubMed  Google Scholar 

  53. Lipka S, Rabbanifard R, Kumar A, Brady P. Single versus double balloon enteroscopy for small bowel diagnostics: a systematic review and meta-analysis. J Clin Gastroenterol. 2015;49(3):177–84. A meta-analysis of four trials with 375 patients comparing SBE to DBE. There was no significant difference in diagnostic or therapeutic yield, insertion depths, procedure time, total enteroscopy, failure rates or adverse events.

    Article  PubMed  Google Scholar 

  54. Shishido T, Oka S, Tanaka S, Aoyama T, Watari I, Imagawa H, et al. Diagnostic yield of capsule endoscopy vs. double-balloon endoscopy for patients who have undergone total enteroscopy with obscure gastrointestinal bleeding. Hepatogastroenterology. 2012;59:955–9. One-eighteen patients underwent consecutive VCE followed by DBE for occult GI bleeding. The sensitivity and specificity of the VCE for DBE findings was 89.3% and 100%. Positive predictive and negative predictive values of VCE for DBE findings were 100% and 89.7%.

    PubMed  Google Scholar 

  55. Freeman ML, Guda NM. ERCP cannulation: a review of reported techniques. Gastrointest Endosc. 2005;61(1):112–25.

    Article  PubMed  Google Scholar 

  56. Chahal P, Baron TH, Topazian MD, Petersen BT, Levy MJ, Gostout CJ. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy. 2006;38(12):1241–5.

    Article  CAS  PubMed  Google Scholar 

  57. Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et al. A multicenter, US experience of single-balloon, double-balloon, and rotational overtube–assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77(4):593–600. A retrospective multicenter study of 129 patients who underwent enteroscopy assisted ERCP in surgically altered anatomy. ERCP was successful in 63% of the cases. Success was similar amongst SBE, DBE and SE.

    Article  PubMed  Google Scholar 

  58. Skinner M, Popa D, Neumann H, Wilcox CM, Monkemuller K. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy. 2014;46(7):560–72. A systematic review of 23 cases series including a total of 679 patients undergoing enteroscopy assisted ERCP in surgically altered anatomy. ERCP success was 90% in Billroth II anatomy while only 70% in roux-en-y gastric bypass anatomy.

    Article  PubMed  Google Scholar 

  59. ASGE Standards of Practice Committee, Shergill AK, Lightdale JR, Bruining DH, Acosta RD, Chandrasekhara V, et al. The role of endoscopy in inflammatory bowel disease. Gastrointest Endosc. 2015;81(5):1101–21.e1-13. ASGE guidelines revised in 2015 describing the current indications, contra-indications and procedural guidelines for endoscopy in inflammatory bowel diseases.

    Article  Google Scholar 

  60. Di Nardo G, Oliva S, Aloi M, Rossi P, Casciani E, Masselli G, et al. Usefulness of single-balloon enteroscopy in pediatric Crohn’s disease. Gastrointest Endosc. 2012;75(1):80–6. A prospective cohort study of 30 pediatric patients who underwent SBE for the diagnosis, staging and intervention in Crohn’s disease. SBE was useful in providing a definitive diagnosis in patients with suggestive VCE findings.

    Article  PubMed  Google Scholar 

  61. de Ridder L, Mensink PB, Lequin MH, Aktas H, de Krijger RR, van der Woude CJ, et al. Single-balloon enteroscopy, magnetic resonance enterography, and abdominal US useful for evaluation of small-bowel disease in children with (suspected) Crohn’s disease. Gastrointest Endosc. 2012;75(1):87–94. A prospective study of 20 pediatric patients who underwent SBE for the diagnosis, staging and intervention in Crohn’s disease. 60% of patients were found to have have Crohn’s that was not within reach of standard EGD and colonoscopy.

    Article  PubMed  Google Scholar 

  62. Schulz C, Mönkemüller K, Salheiser M, Bellutti M, Schütte K, Malfertheiner P. Double-balloon enteroscopy in the diagnosis of suspected isolated Crohn’s disease of the small bowel. Dig Endosc. 2014;26(2):236–42. A retrospective study of 17 patients who underwent DBE for evaluation of isolated small bowel Crohn’s disease. In 44% of patients, abnormal findings on DBE confirmed the diagnosis of CD.

    Article  PubMed  Google Scholar 

  63. Kroner PT, Brahmbhatt BS, Bartel MJ, Stark ME, Lukens FJ. Yield of double-balloon enteroscopy in the diagnosis and treatment of small bowel strictures. Digestive and Liver Disease 2015. A retrospective study of 71 patients who underwent DBE for evaluation of suspected small bowel strictures. The most common etiology was NSAID use (32%). Sensitivity of CT and VCE for detection of small bowel strictures was 61% and 43% respectively.

  64. Gill RS, Kaffes AJ. Small bowel stricture characterization and outcomes of dilatation by double-balloon enteroscopy: a single-centre experience. Therapeutic advances in gastroenterology 2013:1756283X13513995. A retrospective study of 32 patients with suspected small bowel strictures who underwent DBE. Dilation was possible in 15 patients up to a mean diameter of 14 mm. There were 2 perforations.

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Christopher J. DiMaio.

Ethics declarations

Conflicts of Interest

BPR and CJDM declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal studies performed by either of the authors.

Additional information

This article is part of the Topical Collection on Small Intestine

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Riff, B.P., DiMaio, C.J. Exploring the Small Bowel: Update on Deep Enteroscopy. Curr Gastroenterol Rep 18, 28 (2016). https://doi.org/10.1007/s11894-016-0503-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11894-016-0503-3

Keywords

Navigation