Double-balloon enteroscopy, also known as push-and-pull

enteroscopy Enteroscopy is the procedure of using an endoscope for the direct visualization of the small bowel. Etymologically, the word could potentially refer to any bowel endoscopy ('' entero-'' + '' -scopy''), but idiomatically it is conventionally restr ...

, is an

endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

technique for visualization of the

small bowel The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the pa ...

. It was developed by Hironori Yamamoto in 2001. It is novel in the field of diagnostic

gastroenterology Gastroenterology (from the Greek gastḗr- “belly”, -énteron “intestine”, and -logía "study of") is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract ...

as it is the first endoscopic technique that allows for the entire

gastrointestinal tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organ (biology), organs of the digestive syste ...

to be visualized in real time.

Technique

The technique involves the use of a

balloon A balloon is a flexible bag that can be inflated with a gas, such as helium, hydrogen, nitrous oxide, oxygen, and air. For special tasks, balloons can be filled with smoke, liquid water, granular media (e.g. sand, flour or rice), or light so ...

at the end of a special enteroscope camera and an overtube, which is a tube that fits over the endoscope, and which is also fitted with a balloon. The procedure is usually done under general

anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...

, but may be done with the use of

conscious sedation Procedural sedation and analgesia (PSA) is a technique in which a sedating/dissociative medication is given, usually along with an analgesic medication, in order to perform non-surgical procedures on a patient. The overall goal is to induce a decr ...

. The enteroscope and overtube are inserted through the

mouth In animal anatomy, the mouth, also known as the oral cavity, or in Latin cavum oris, is the opening through which many animals take in food and issue vocal sounds. It is also the cavity lying at the upper end of the alimentary canal, bounded on ...

and passed in conventional fashion (that is, as with

gastroscopy Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered ...

) into the

. Following this, the endoscope is advanced a small distance in front of the overtube and the balloon at the end is inflated. Using the assistance of friction at the interface of the enteroscope and intestinal wall, the small bowel is accordioned back to the overtube. The overtube balloon is then deployed, and the enteroscope balloon is deflated. The process is then continued until the entire small bowel is visualized. The double-balloon enteroscope can also be passed in retrograde fashion, through the colon and into the

ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine ma ...

to visualize the end of the small bowel.

Indications

Double-balloon enteroscopy has found a niche application in the following settings: * Bleeding from the gastrointestinal tract of obscure cause *

Iron deficiency anemia Iron-deficiency anemia is anemia caused by a lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as feeling tired, weak, s ...

with normal

colonoscopy Colonoscopy () or coloscopy () is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (''e. ...

and gastroscopy * Visualization and therapeutic intervention on abnormalities seen on traditional small bowel imaging *

Endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skille ...

(ERCP) in post-surgical patients with long afferent limbs

Advantages

Double-balloon enteroscopy offers a number of advantages to other small bowel image techniques, including

barium Barium is a chemical element with the symbol Ba and atomic number 56. It is the fifth element in group 2 and is a soft, silvery alkaline earth metal. Because of its high chemical reactivity, barium is never found in nature as a free element. Th ...

imaging,

wireless capsule endoscopy Capsule endoscopy is a medical procedure used to record internal images of the gastrointestinal tract for use in disease diagnosis. Newer developments are also able to take biopsies and release medication at specific locations of the entire ...

and push enteroscopy: * It allows for visualization of the entire small bowel to the

terminal ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine ma ...

. * It allows for the application of therapeutics. * It allows for the sampling or

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...

ing of small bowel

mucosa A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It is ...

, for the resection of

polyps A polyp in zoology is one of two forms found in the phylum Cnidaria, the other being the medusa. Polyps are roughly cylindrical in shape and elongated at the axis of the vase-shaped body. In solitary polyps, the aboral (opposite to oral) end i ...

of the small bowel, and in the placement of

stent In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...

s or dilatation of strictures of the

. * It allows for access to the papilla in patients with long afferent limbs after Billroth II antrectomy.

Disadvantages

The key disadvantage of double-balloon enteroscopy is the time required to visualize the small bowel; this can exceed three hours, and may require that patients be admitted to hospital for the procedure. There have also been case reports of

acute pancreatitis Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes in order of frequency include: 1) a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; 2) heavy alcohol use; 3) systemic disea ...

(at a rate of 0.3%-0.4%, when the oral route is used) and intestinal necrosis associated with the technique. A 2015 study in the ''World Journal of Gastrointestinal Endoscopy'' reported that: "Due to prolonged procedure and air

insufflation In religious and magical practice, insufflation and exsufflation are ritual acts of blowing, breathing, hissing, or puffing that signify variously expulsion or renunciation of evil or of the devil (the Evil One), or infilling or blessing with go ...

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than ...

can be observed in up to 20% patients." Depending on whether the oral or rectal approach was used, a patient may experience a sore throat (following use of the oral route), upset stomach, vomiting, and painful bloating, cramping, or abdominal discomfort in reaction to the gas in the intestines.

References

{{Reflist Gastroenterology Endoscopy