Small Bowel Endoscopic Exploration Spanish GI Endoscopy Society Recommendations

• 1. Introduction
• 2. Equipment
• 3. Techniques
• 4. Diagnostic concordance betweeen CE and FE and other imaging techniques
• 5. Indications
• 5.1. MID gastrointestinal bleeding
• 5.2. Crohn’s disease
• 5.3. SB obstruction
• 5.4. Celiac disease
• 5.5. Other causes of malabsorption
• 5.6. Tumours
• 5.7. Polyposis
• 5.8. Graft-versus-host disease
• 5.9. Special diagnostic and therapeutic techniques in SB endoscopy
• 5.10. Using CE in the follow-up of FE therapy
• 6. Contraindications
• Endoscopic management algorithm of OGIB
• References

Project Directors: E. Pérez-Cuadrado, V. Pons.

Task Committee: J. M. Bordas.

Reading Committee: B. González, J. Llach, P. Menchén, F. Pellicer, S. Rodríguez.

1. Introduction

The technological advances in capsule endoscopy (CE) and flexible enteroscopy (FE) have now allowed endoscopic access to the whole small bowel (SB). These procedures complement each other, both offering a diagnostic as well as a therapeutic approach [1] [2] [3] [4] [5] [6]. The aim of these recommendations is to provide a reference document for the members of the SEED (Spanish Society for Digestive Endoscopy) on the endoscopic management of SB diseases.

2. Equipment

Capsule endoscopy. The CE system includes a workstation (a computer with specific software), a belt, antenna, a data recorder and the capsule itself (this being 26 × 11 mm and made up of a sensor which captures the images), a battery, light diodes and antenna to transmit the images. The CE is swallowed by the patient and progresses by peristalsis, taking images with the frequency of two frames per second. There are a number of different CE models on the market ([ Table 1 ]): Pillcam SB^® (Given Imaging Ltd, Yoqneam, Israel); Olympus Endocapsule^® (Olympus, Japan); MiroCam^® (IntroMedic, Seoul, Korea) and recently, the OMOM^® (Jinshan Science and Technology Group, Chongqing, China). The Pillcam^® uses the CMOS (Complementary metal-oxide-semiconductor) to capture images whilst the others use a CCD (charge-coupled device). The Pillcam^® and the Endocapsule^® use radio signals to transmit the data, whereas the Mirocam^® uses “human body communications” which have lower battery consumption [7]. The Given Imaging^® unit consists of the CE and a data recorder (the latest DR2 model has a screen which allows patient identification and visualization of the study in real time, the belt with incorporated sensors or on previous models the belt and antennas). All these systems have a workstation with a PC and viewing software (Rapid Reader^® 7.0 for Given).

Flexible enteroscopy. Although conventional endoscopy (colonoscopy) allows examination of about 60 cm of the SB, from the Treitz flexure [8] or 50 cm from Bauhin’s valve, FE is the technique of choice. Double balloon enteroscopy (DBE) was first introduced 10 years ago by Yamamoto et al. [9] and replaced intraoperatory enteroscopy and push enteroscopy (PE) (with or without overtube) as the reference standard in the SB, allowing examination of the whole SB via the oral approach (OA). Contrary to PE, in which the force is only transmitted through pushing, DBE incorporates the concept of pushing and pulling with simultaneous traction on the overtube and enteroscope with inflated balloons, which rectify and fold the SB loops whilst advancing [10]. Single balloon enteroscopy (SBE) [11] and spiral enteroscopy [12] were developed after DBE. SBE uses only one balloon on the overtube and the overtube and anchored flexed enteroscope are withdrawn using endoscopic flexion. On the other hand, spiral enteroscopy is a different system which does not use balloons. In spiral enteroscopy, the overtube has raised helices on the outside and advances by rotating in a clockwise direction. This device can be used with different flexible enteroscopes and paediatric colonoscopes ([ Table 2 ]). Other systems with balloons incorporated onto the endoscope have proven to be less useful [13]. Similar personnel and operating theatres are required for FE as for conventional endoscopy (paediatric colonoscopy). For balloon-assisted FE pressure monitoring equipment is also needed. Since it is usually performed under deep sedation, equipment is required to monitor vital signs as well as to perform cardio pulmonary resuscitation, if needed. X-ray equipment [2] made be required for certain cases and when performing ERCP, extraction of foreign bodies, stricture dilatation, placement of enteral prostheses, anterograde enteroclysis by FE with water-soluble contrast or filling of structures ([ Fig. 1 ]). Radiology may also be useful at the start of the learning process. The use of CO₂ has been shown to be useful for reducing time and increasing the depth of the examination [14] [15]. The accessories should all be of the right length and width for each enteroscope. All the material designed for conventional colonoscopy can be used in therapeutic DBE (tDBE) and SBE. However, in order to access the bile duct, sphinctertomes and longer Fogarty balloons etc. are required and only the 7 Fr prosthesis can be implanted. One advantage of the double-balloon colonoscope is that it is shorter facilitating the use of ERCP accessories of up to 2.9 mm. Specific material is needed (1.8 mm diameter) for diagnostic DBE (dDBE). For spiral endoscopy, the accessory material depends on the enteroscope or colonoscope to be used. In cases of adherences or paediatric patients, the lesser calibre FE such as the dDBE should be chosen.

3. Techniques

The technique for CE is simple and requires only limited human and infrastructural resources. The patient swallows the capsule with water and is allowed to drink after two hours and consume solids in small quantities after 4 hours. The patient should return to the department after 8 hours to withdraw the system and be reminded of the need to control the expulsion of the capsule. The images are then downloaded to the workstation for viewing.

Personnel. The connection and disconnection of the antennas can be performed by trained nursing staff, but a doctor should perform the reading. No more than 3 – 4 studies should be viewed by a single doctor during a 7-hour work day because of the concentration required for the reading. Moreover, these readings should be alternated with rests or changes in activity.

Room. The CE can be applied in a conventional endoscopy room. It is preferable to fit out an area close to the workstation with a bed in order prepare the patient (placing the antennas). In patients who have difficulties in swallowing the capsule, either because of age or illness, it can be introduced using an endoscope and a specifically designed introducer. The reading should be done in an adequate room with quiet and soft lighting.

Performance or reading times. The times for downloading and viewing the CE have been shortened with the current software. The length of the viewing ranges from 30 to 60 minutes depending on the disease, the experience of the endoscopist and the SB transit time. Although there are different viewing forms and speeds, it is advisable to view single images at a speed of 17 – 19 frames per second. High levels of concentration are required since lesions may sometimes only appear on one of the stills. When in the so-called automatic mode, the software can eliminate frames with identical content, using algorithms. The time required to prepare the equipment is slightly longer for DBE (the enteroscope needs to be placed in its overtube to manually fix the balloon and check the pressure of both balloons) than for SBE and spiral endoscopy (the enteroscope only needs to be placed in its overtube) [16] [17], and the preparation is usually performed by the nursing staff. The OA is more reliable when quantifying the total time because in almost a quarter of the cases the ileocecal valve cannot be passed (or its cannulation is difficult) with the anal approach (AA) [18]. In general spiral endoscopy is quicker (45 min) than DBE (70 min) or SBE [19], although different distances may be reached. Thus, in an 8 hour day, 4 – 5 CE or 2 – 3 balloon-assisted FE may be programmed.

Training and learning curve. Positioning the CE is simple and does not require any training. However, experience in digestive endoscopy and having learnt how to use the specific software (having performed about 20 examinations) are necessary to carry out the reviewing process. No studies have specifically determined the number of procedures necessary to acquire a sufficient level of skill. Expert supervision of the procedure is required until the end of the learning curve. The learning curve for FE is similar and acceptable for the three techniques [20] [21] [22] but training for balloon-assisted FE is different from that for spiral endoscopy and is also different according to the route chosen, with AA being the most difficult [18]. The introduction/withdrawal manoeuvres and the manometric control of the FE techniques are similar, with the difference arising in the manoeuvrability of the instruments for spiral endoscopy, which in some cases may be difficult via the OA because it is thicker. In Spain the resident training programme (MIR) requires experience in both FE and CE in order to qualify as a Gastroenterologist, and it is recommended that residents participate in specific training courses such as those sponsored by the SEED.

Patient preparation. There is no unanimous consensus on the best preparation for CE. Various studies support bowel preparation with purgatives and/or prokinetic agents to improve image quality [23], although the results are not uniform. A prospective multicentre [24] report has recently been published in which the three different types of preparation (liquid diet, polyethylene glycol and sodium phosphate) were randomly administered. In this series of 291 patients no differences were observed in the quality of the preparation among the three groups, although improved tolerance was associated with the liquid diet. Thus, patients should be requested to follow a fibre-free diet 3 – 4 days before the study, to avoid drugs which may affect intestinal motility, to not take iron orally one week before, to follow a strictly clear liquid diet the day before the test, and to come to the appointment on an empty stomach. Eight hours of fasting are required for OA in FE, with additional anterograde evacuation preparation for the colonoscope in the case of AA. With regard to anti-coagulants, some authors prefer their administration to be continued, although the data to establish this recommendation are insufficient.

Complications. The CE technique has a high level of tolerance and few complications, with the latter being limited to retention of the capsule which is understood as not being expulsed spontaneously within a period of 15 days [25]. The risk of capsule retention ranges from 0 % to 13% [26] , depending on the type of patients included. Some extensive series of CE in patients with Crohn’s disease have reported a percentage of retention of 13 %, with retention of only 1.6 % in patients suspected of having this disease [27] [28] [29]. Some cases of bronchoaspiration of the CE have also been described, some with totally asymptomatic evolution [30] or even with spontaneous resolution [31]. To avoid retention the Agile Patency^® capsule (second generation) has been developed ([ Fig. 2 ]). It is the same size and shape as the CE but is made up of a small nucleus which can be identified by radiofrequency, covered with a layer of lactose, with two windows at the ends thereby allowing it to degrade/ decompose when in contact with intestinal juices for longer than 30 hours. Its natural expulsion intact confirms the permeability of the digestive tract and reduces the incidence of retention. Radiological techniques have not shown to be particularly efficient in avoiding CE [32] retention, whereas in cases in which stenosis is suspected, either by the clinical or by imaging techniques, the use of the Patency^® capsule avoids retention in a high percentage of cases [33]. The use of this latter capsule is recommended in patients with symptoms of obstruction, known or suspected Crohn’s disease, prior surgery, intestinal radiotherapy or chronic use of NSAID. Other less frequent complications are perforation and obstruction of the SB requiring emergency care and sometimes even surgery [34] [35] [36] [37].

During the introduction of the FE by the OA lesions may be induced in the mesenteric axis, which (attach) fix the SB loops along about 13 cm [38]. Some laparoscopic studies [39] have reported greater mesenteric damage with spiral endoscopy than with DBE. In a multicentre study performed in 10 centres on four continents [40], the 40 complications (1.7 %) observed in a total of 2,362 DBE were related to those of conventional therapeutic endoscopy. These complications were mainly related to therapeutic manoeuvres such as polypectomy. Adrenaline should be injected at a dilution of 1 /100,000 because parietal necrosis has been described using the standard dilution [41]. Perforation in diagnostic DBE (0.06 %) and diagnostic and therapeutic DBE procedures (0.3 %) and haemorrhage (0.06 % and 0.8 %) are the main complications in these procedures [40]. Although the physio-pathological mechanism in post-DBE pancreatits [42] [43] remains unknown, inflation of the balloons is recommended with balloon-assisted FE once the papilla of Vater has been passed, since despite the low incidence of pancreatitis (0.3 %), it can be a severe complication. In a study in 1,750 patients undergoing spiral endoscopy, Akerman et al [44] described perforation in 0.34 % (6 cases), with SB invagination being reported as a specific complication of this procedure. DBE should not be used in patients who are allergic to latex as, unlike those of SBE, the balloons in DBE contain latex.

Technical problems. Although false negative results may be obtained they are less frequent in CE than in the other techniques available for study of the SB. The percentage of missed lesions by the CE is around 0.5 % for ulcerous diseases and about 18.9 % for neoplastic diseases [45]. This may be due to factors such as incomplete studies (CE does not reach the cecum in 15 – 20 %), technical limitations (battery duration, CE field of vision, or insufficient cleanliness of the SB, mainly in distal locations [46]). In patients with problems for swallowing the CE, those in whom a delay in gastric emptying is foreseen or in cases with anatomical modifications (previous surgery) which may prevent correct transit of the CE, the capsule may be introduced with help of an endoscope (AdvanCE^® introducer. US Endoscopy) which allows its introduction and release to the SB. If the overtube in DBE slips more distally than it should, displacement of the distal balloon and cap may occur and these may remain as foreign bodies [47]. Deep insertion of the instruments during balloon-assisted FE and the presence of kinks in the SB may hinder the passage of accessories down the operative channel.

Exploration depth. The CE travels along the digestive tube via peristalsis and is expulsed naturally, thereby allowing the whole SB to be viewed. In some cases prokinetic agents may be recommended, although their use is controversial [48] [49]. Incomplete studies may be due to either a delay in gastric emptying such as in diabetic patients or limited CE retention by incomplete stenosis or tumours which may finally allow passage of the capsule. This delay may lead to the battery running out before reaching the cecum [50] [51] [52] [53]. On the other hand the CE does not enable the lesion viewed to be located precisely. Nevertheless, use of the Rapid^® software allows approximate localization to help subsequent access via FE or surgery. As a general rule, if the point to be reached is within the first 60 % of the SB examination time, FE access should be anterograde (OA), being retrograde (AA) if within the remaining 40 %. The most commonly used practice for complete SB exploration by FE is a combination of the two OA and the AA, tattooing the distal end reached with the first, which is identified by the second. Complete SB exploration is more frequent using DBE than SBE (66 % vs. 22% [54]). DBE is the only technique to reach the cecum via the OA in a significant percentage of cases [55] [56], this percentage being less frequent with the use of SBE [57]. In order to explore more deeply, manual compression of the abdominal wall and a change in posture can help, which may also be useful for the retrograde approach via the Bauhin valve (in decubitus prone position). To aid ileocecal intubation it is helpful to anchor the overtube balloon in the ascending colon at a certain distance from the valve. The methodology for studying the length reached varies for the three techniques. Thus, for balloon-assisted FE the method proposed by May et al [10] is used, adding up the advances of the enteroscope in the successive push and pull cycles. Another method has recently been validated which measures the insertion of the overtube (once the overtube and endoscope have been tractioned; 5 cm of overtube advancement is the equivalent of about 40 cm in the SB, in a series with surgical evaluation [58]). The depth achieved with SE seems to be less than that obtained by balloon-assisted FE. It should be taken into consideration that with FE CO₂ insufflation increases the length explored in comparison with air [14] [15]. On the other hand, it is not always necessary to view the whole mucous surface of the SB on detection of diffuse or dominant lesions, stenosis or a pathological foci by an imaging technique. The data obtained by CE generally allow selection of the insertion route for FE and thus CE should be performed first. In addition the FE tattoo at the distance reached (and of treated lesions) may play an important part in future CE controls.

4. Diagnostic concordance betweeen CE and FE and other imaging techniques

The diagnostic capacity of CE in Obscure Gastrointestinal Bleeding (OGIB) is from 38 to 83 % and higher than 91 % when the study is performed in the first two weeks of bleeding. These results are similar for DBE [59]. Thus, given that CE is a non-invasive technique which is well tolerated and has a high negative predictive value it should be the initial technique of choice for OGIB, with DBE being the second choice in patients with positive CE who require a biopsy or therapy. DBE may also be the technique of choice in patients with active bleeding with haemodynamic instability [60], although for massive or active severe haemorrhage vascular radiology should be used. In cases of OGIB, CE and DBE show strong agreement for vascular and inflammatory lesions but only show moderate concordance for neoplastic lesions and polyps [61]. In patients with suspected Crohn’s disease CE is clearly superior (22 – 47 %) to SB radiology, CT enterography and colonoscopy with ileoscopy [60]. CE is also more efficient in patients with Crohn’s disease as compared to CT, PE or SB radiology. The advantage of the radiological techniques such as CT and MRI is their capacity to evaluate transmural involvement in Crohn´s disease, making them complementary techniques to CE.

5. Indications

5.1. MID gastrointestinal bleeding

Defined by its origin between the papilla of Vater and Bauhin’s valve, mid gastrointestinal bleeding (MGIB) is the most common indication of CE after one or two inconclusive upper and lower endoscopies [61] ([ Fig. 3 ]). CE is the first line of study of the SB in patients with OGIB followed by FE. In active OGIB, CE should be performed within the first 48 hours of bleeding as this significantly improves its performance [62] [63] [64], as it does for severe OGIB [65]. Only in these cases may FE be considered as the first choice procedure, based on the experience of each centre. The diagnostic yield of CE in OGIB is high, being from 75 to 80 %. Although recent studies show worse results, some meta-analyses have shown CE to be more effective than radiology and push FE in the study of OGIB [66]. However, there do not appear to be any differences between CE and DBE [67] [68]. In the long term studies, negative CE is associated with a low recurrence rate [69]. On recurrence of OGIB after a negative CE study, FE should be performed or repeated. FE should be the first exploration undertaken in patients with severe active OGIB if therapeutic possibilities are considered, in patients with a history of Roux-en-Y surgery or suspected stenosis. FE is used for therapeutic treatment of lesions found using CE. Angiodysplasia is treated with low flux, short pulse argon plasma cautery (40 w and 0.5 l/m) following injection with 1 /100000 adrenaline, which is recommended to prevent perforation. Good long term results with respect to the recurrence of OGIB have been reported [70]. The heater probe (HPU) provides similar results [71]. The current trend is to use a mixed method (injection and thermal or injection and mechanical) in the case of vascular lesions and aggressive treatment in lesions such as Dieulafoy’s because of high haemorrhage recurrence. In these cases it is advisable to tattoo the treated lesion. The use of mechanical methods such as clips or loops has similar results those obtained in upper endoscopy and colonoscopy. In multiple polypectomies, a therapeutic DBE overtube can be used with a diagnostic DBE enteroscope, which allows its withdrawal and recovery for histopathology, in spite of the limitations of a narrower working channel.

5.2. Crohn’s disease

The high sensitivity of CE for detecting superficial lesions, and its specificity and negative predictive values of over 90 % make it an ideal technique to study these patients and place it in a special position in the diagnostic algorithm for Crohn’s disease, only behind ileocolonoscopy. CE is indicated both for suspected non-stenosing Crohn’s disease with negative biopsies and ileocolonoscopy and for known non-stenosing Crohn’s disease to evaluate disease recurrence [72], the extension of the effects and the response to treatment (mucous lesion healing) [73]. The only problem associated with CE use is the presence of stenosis inducing the risk of CE retention, although the use of the patency^® capsule reduces this problem. There are different Crohn’s activity indexes to assess Crohn’s disease activity by means of CE (I. Lewis, Gralnex, CECDAI) [74]. However, the use of this technique in Crohn’s disease remains low because of the poor interobserver agreement and the relatively complex application.

FE is used to diagnose Crohn’s disease [75], determine its extension, detect recurrence and for dilatation. More than 30 % of patients with this disease will develop a stenosing phenotype in the SB [76]. These stenoses may be inflammatory, cicatricial or related to the anastomosis after SB resection and may have associated fistulas. All of these factors are important to consider for making FE therapeutic decisions [77] [78]. Dilatation is accepted in selected symptomatic cases with short stenosis (less than 5 cm) and a favourable anatomy [79] [80] [81] (absence of multiplicity or marked angulation etc.), although further studies with long term follow-up are needed because of the risk of recurrence. Contrast with x-ray control should be used to determine the length of the stenosis. The presence of fistulas may be evaluated using DBE by instilling contrast between the two balloons (“sandwich” technique, described by Kato et al [78]). Short series of dilatation have been published using a combination of corticoids (triamcinolone) or infliximab^® [82] [83]. These series showed good initial results, although there are no randomised clinical trials which compare the different methods of endoscopic dilatation (associated or not with corticoid or infliximab^® injection) with biodegradable prostheses or surgery which do not allow recommendations to be established.

5.3. SB obstruction

FE is indicated for diagnostic confirmation and in selected cases for therapy (dilatation, implantation of self-expanding prostheses [84]).

5.4. Celiac disease

Duodenal biopsy is still the gold standard for the diagnosis of celiac disease. CE has shown a sensitivity of over 90 % in detecting this disease, with a specificity of 100 % [85]. The main role of CE is its use in refractory disease and in the diagnosis of the complications (ulcerative jejunitis and intestinal lymphoma). FE is used to confirm ulcerative jejunitis in celiac disease or with atypical symptoms, sometimes detecting patchy lesions or suspected SB tumours (T-cell lymphoma, adenocarcinoma, B-cell lymphoma).

5.5. Other causes of malabsorption

FE is indicated for sample taking in patients with HIV (to rule out lymphomas and superinfections such as mycobacteria, cytomegalovirus leishmania etc.), common variable immunodeficiency, amyloidosis, SB tuberculosis (common in eastern series) and selected cases of Whipple’s disease not diagnosed by standard UGI endoscopy [86]. The parasites may be microscopic, such as giardia lamblia or worms (roundworm, tape worm), common in eastern series as a cause of OGIB and malabsorption. Mechanical causes of malabsorption may involve the short length of the distal loop of the SB after a gastric by-pass and this may be detected by DBE via the OA or AA measuring from the jejuno-jejunal anastomosis to Bauhin’s valve.

5.6. Tumours

Tumours in the SB represent 1 – 3 % of gastrointestinal tumours. The incidence per year is of 1.4 cases per 100,000 inhabitants and approximately half of the cases are malignant. After the introduction of the CE into clinical practice the frequency of these tumours has risen by from 2.4 to 9.6 % [87]. CE can confirm the presence of tumours which are suspected through other techniques, although most diagnoses are achieved in patients in whom CE is performed for OGIB.

When CE does not detect the presence of a tumour a CT or MRI scan is recommended to evaluate the presence of extraintestinal disorders or metastatic disease. In cases in which the probability of having a tumour is high, the indication of FE or surgery should be evaluated. Most of the tumours identified by CE are adenocarcinomas, followed by carcinoid tumours, lymphomas, sarcomas and hamartomas. GIST are the most frequent benign neoplasias while melanomas are the most frequent SB metastatic tumour.

FE is useful for assessing the anastomosis line following surgery for SB tumours. Some of these tumours such as desmoid tumors have a high recurrence rate. In patients with Lynch S, the FE may be useful to assess adenomatous lesions since SB adenocarcinomas are 100-fold more frequent in patients [88] with MLH1 and MSH2 mutations. On the other hand, in patients with MSH6 mutations [89] [90] screening is not necessary.

5.7. Polyposis

Peutz-Jeghers syndrome polyps are most frequently found in the jejunum and the ileum, and may be present in large numbers requiring repeated laparotomies. The risk of cancer is low, but these polyps tend to grow in size and produce complications such as intestinal invagination, intestinal obstruction or gastrointestinal bleeding. FE [91] [92] is the technique of choice to resect polyps found using CE. The strategy involves resection of all the lesions larger than 1 cm to prevent invagination and thereby avoid laparotomies. CE is better than contrast radiology or MRI enterography in the diagnosis of intestinal polyps in this syndrome. Early detection of these polyps is important taking into account that 60 – 70 % of the patients with Familial Adenomatous Polyposis (FAP) also develop adenomatous polyps in the SB, with a higher risk of further degeneration in the duodenal adenomas than in the jejunum and ileum. The sensitivity of CE in viewing duodenal lesions is low and thus, FAP should be followed with the use of duodenoscopy, with CE only being recommended in stages III and IV of Spiegelmann’s score, and FE in case of positive results with CE.

5.8. Graft-versus-host disease

This is the main cause of morbimortality in patients undergoing allogeneic haematopoietic progenitor transplant. In these patients immunosuppression also increases the susceptibility to infectious diseases, making early diagnosis essential, since the therapeutic management of the two conditions is very different. Diagnosis is first achieved by conventional endoscopy and sample taking (antrum, duodenum, rectum), however, on clinical suspicion based on the possible presence of lesions in the SB (organ most commonly affected [93]), CE and histopathology may detect polymorphic lesions and evaluate their severity [94] [95] ([ Fig. 4 ]). Patients with GVHD have an underlying hypomotility which has been related to an increase in CE retention in the stomach of up to 18 % [96].

5.9. Special diagnostic and therapeutic techniques in SB endoscopy

CE can benefit from the technology previously used for FE, such as intelligent chromoscopy. The use of FICE^® (Fuji Film. Japan) in the Pillcam^® may improve the vascular images [7] [97] using the blue filter.

There are certain situations which require special techniques with FE, such as accessing the excluded stomach after Roux-en-Y gastric bypass. The jejunojejunal anastomosis may be accessed using FE [98] ([ Fig. 5 ]) and may be identified by marking with a tattoo on entry in the loop examined. The indications for FE in these patients are to explore the lesions in the gastric stump (gastroduodenal ulcer, as cancer of the stump is unusual [99]) and the duodenal and jejunal loops from the anastomosis to the gastric stump in special circumstances such as in the control of FAP [100]. In addition, using FE therapeutic ERCP can be performed, albeit with some difficulties [101] [102] [103] [104]. The difficulty in accessing the ampullary area when the loop is longer than 150 cm has also been described. Laparoscopy-assisted ERCP is an alternative in these patients [105]. In patients with Roux-en-Y and hepatic jejunostomy, the bile duct and the pancreas are accessible to FE with a high rate of biliary cannulation (88 %) [106]. FE may also be used as a rescue ERCP in patients with Billroth II when the papilla region is not accessible with the use of standard duodenoscopy, or after duodenopancreatectomy. The use of double-balloon colonoscope should be considered in ERCP by FE since it has a shorter channel through which the conventional ERCP accessories may pass [107]. Self-expanding enteral prostheses are unable to pass through the enteroscope and may therefore be placed in the SB using FE by passing the introducer system through the overtube once the enteroscope has been removed. Foreign bodies can be retrieved using conventional techniques (a Roth net in cases of a retained CE), preferably OA since the retrograde approach may find strictures which makes it difficult [108]. The intraoperatory enteroscope should be the last examination performed, although surgeons may sometimes need it to find a lesion during laparotomy.

Percutaneous endoscopic jejunostomy may be performed using FE with a similar technique and accessories to those of conventional procedures [109]. Good transillumination is essential to guarantee that no structures are interposed between the abdominal wall and the SB. The technique may be more difficult in the presence of adhesions due to previous surgery, although the use of FE faciliates the selection of the most suitable jejunal loop. This technique may also be used in the stomach for feeding or to create a fistulous access channel for ERCP in patients with a Roux-en-Y bypass [110].

The use of CO₂ is preferable to avoid more difficult closure of the abdominal wall because of the air. Intraoperative enteroscopy has specific complications such as prolonged postoperative paralytic ileum, traumatic serosal or mucosal lesions, infection in the case of enterotomy and mesenteric vascular lesion. Laparotomy-assisted FE should be restricted to centres with a large experience due to the difficulty and considerably longer length of this procedure. Echo-endoscopy using miniprobes via DBE (12, 15 or 20 MHZ) enables the identification of 5 layers of the wall and is particularly useful for extrinsic compressions or submucosal tumours, despite the limited reports [111], and passage through the work channel is difficult in distal lesions.

5.10. Using CE in the follow-up of FE therapy

CE can detect scars from previous FE treatment, clips and the presence of haematic remnants in the area treated and also the connection with the tattoo, which can serve to locate a previously diagnosed lesion or to determine the distance achieved by the FE if incomplete, in order to detect synchronic lesions.

6. Contraindications

Since the most frequent complication is CE retention, its administration is contraindicated in patients in whom the presence of stenosis in the digestive tract is confirmed using the patency^® capsule (Given Imaging. Israel). It is also contraindicated during pregnancy as there are no data on the safety of its administration. Nonetheless, it has been shown to be safe in patients with pacemakers or an implantable defibrillator [112]. Swallowing problems, whether neurological or organic (Zenker’s diverticulum), are considered relatively contraindicated, although in these cases the CE can be introduced using the endoscope and an introducer [113]. For diagnostic FE the contraindications are similar to those for conventional endoscopy with deep sedation. Deep or multiple ulcers in the SB (Crohn´s disease, chemotherapy), multiple substenosis (particularly when inflammation is present) and recent anastomosis need special consideration as they may be risk factors for perforation. Proximal perforation has been described far from the distal point reached [114], and the risk of SB perforation in ileoanal anastomosis is particularly high. Systemic connective tissue diseases such as the Ehlers-Danlos syndrome are also contraindication for FE because of the risk of perforation.

Endoscopic management algorithm of OGIB

Various clinical practice guidelines from different societies [1] [2] [8] as well as systematic reviews [115] and studies have analysed the cost in relationship to the effectiveness of these procedures [116]. Although CE is the first line approach in the evaluation of the SB, FE should be used in special circumstances such as bariatric surgery or in patients with a Roux-en-Y bypass, or when CE is contraindicated.

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