When the gastroenterologists at Nationwide Children’s first began using double balloon enteroscopy (DBE) in August 2006, it was a relatively new technology that had not been adapted for use in pediatric patients. Over the years it has become more widely recognized as a safe and effective way to address problems in the small intestine not only in adults but in children as well and is now performed an average of one time per month at Nationwide Children’s Hospital on children as young as 6 years of age.
The use of capsule endoscopy in combination with DBE allows for more simple, less invasive diagnostic screening which complements the therapeutic capabilities of DBE in the small intestine. The DBE endoscope is smaller in diameter yet longer in length than a conventional colonoscope. It utilizes a standard working channel that accepts most endoscopic instruments allowing for biopsy of the intestinal mucosal surface as well as the sampling and possible removal of small intestinal tumors or polyps. The identification and treatment of bleeding lesions, vascular abnormalities and congenital birth defects is also a standard modality for DBE. See case studies within this article. This technique can also be used to remove trapped foreign bodies from the small intestine.
“Many of the anomalies of the gastrointestinal tract occur in the middle 25-30 feet of small intestine that is inaccessible by traditional endoscopy. In this region of the digestive tract, capsule endoscopy in combination with double balloon enteroscopy can be highly effective diagnostic and therapeutic tools.”
Capsules and Balloons
The small intestine is an area of the digestive tract that has been inaccessible by standard endoscopic techniques due to the length of the digestive tract and the free floating nature of the small intestine. Standard endoscopy can be used to examine the esophagus, stomach and upper duodenum which is approximately 3 feet in length. Colonoscopy can be used to explore the large intestine and terminal ileum which is approximately 4 to 5 feet in length. (See GI Tract Illustration.) The small intestine which can be 25-30 feet in an adult has only recently been accessible for study thanks to newer methodologies like capsule endoscopy. Although helpful, capsule endoscopy has limitations in resolution and can miss larger lesions due to erratic movement and poor visualization.
Illustration of the Digestive Tract (the lengths as measured in an adult male)
“Using these two techniques in sequence to first diagnose and then treat, we have experienced great success for some of our most challenging patients with diseases of the small intestine such as hereditary polyposis, bleeding lesions or inflammatory disorders.” -Dr. Erdman
Digestive Tract Illustration Key:
• Upper GI Tract: esophagus, stomach, and half the duodenum = 3 ft. (yellow)
• Middle GI Tract: the rest of the duodenum, jejunum and ileum = 25 to 30 ft. (blue)
• Lower GI Tract: colon = 5 to 6 ft. (pink)
• The middle GI tract has traditionally been the area that has not been completely accessible by conventional endoscopy.
Double balloon enteroscopy (DBE) uses a sliding overtube on the enteroscope with an inflatable balloon on the end of both the overtube and scope. A special pump device regulates volume and pressure of the balloons to avoid bowel wall injury. When inflated, the balloon anchors either the overtube or enteroscope. By inflating and deflating the balloons in sequence, the instrument can be advanced through the small intestine. This method allows physicians to examine the small intestine from an oral approach or in a retrograde fashion through the colon allowing for complete examination of the small intestine.
The Section of Gastroenterology, Hepatology and Nutrition (GI) at Nationwide Children’s Hospital continues to raise the bar on diagnostic and minimally invasive GI procedures. The GI team has a program that ranks among the best pediatric gastroenterology programs nationally, providing comprehensive patient care for a broad range of gastrointestinal, liver and nutritional problems. Nationwide Children’s strives for excellence in research, teaching and clinical care and maintains a cadre of physician scientists committed to improving the care of children with a variety of gastrointestinal disorders. For more information about gastroenterology and the use of these minimally invasive techniques click here.
“Nationwide Children’s is one of the first pediatric hospitals to use capsule endoscopy with DBE in the care of children and adolescents and these techniques have been of great help and success as you can read in the case studies outlined in this article.” - Dr. Erdman
Steven H. Erdman, MD, is the director of the Pediatric Gastroenterology Fellowship Program at Nationwide Children’s Hospital and supervises all educational activities for the Section. He is a Professor of Clinical Pediatrics at the Ohio State University College of Medicine. His clinical and research interests are in the area of hereditary colorectal cancer and the polyposis syndromes of childhood. He remains one of the leaders in the use of double balloon enteroscopy in the treatment of children with small intestinal disease. He serves as Executive Council of the Collaborative Group of the Americas on Inherited Colorectal Cancer and was elected President of that organization, beginning his term in October 2009. He was also appointed to the Training Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and serves on the Training Guidelines Taskforce that will be responsible for revising the training guidelines of pediatric gastroenterology for NASPGHAN.
This loss of genetic material affects more than 40 genes that include two important tumor suppressor genes that are each associated with hereditary colorectal cancer, BMPR1A and PTEN. With disruption of both genes, patients with this genetic disorder are at significant risk for the development of adenocarcinoma throughout the gastrointestinal tract at a very early age.
Diagnosis: Following an initial clinic visit, a follow-up esophagogastroduodenoscopy was done with recovery of entire polyps by snare polypectomy and deployment of the capsule directly into the duodenum. Due to the child’s developmental disabilities, she was unable to swallow the capsule and direct deployment into the duodenum avoided the possibility of the stomach retaining the capsule.
Treatment/Outcome: Upon review of the capsule endoscopy study, several large irregular polyp-like structures were identified in the duodenum and upper jejunum with the rest of the jejunum and ileum showing no abnormalities. With the goal of removal and recovery, Double Balloon Enteroscopy (DBE) was performed entering the digestive tract through the mouth. Four large irregular pedunculated polyps were found in the upper jejunum. (See Image 1a.)
One of these lesions had not been identified in the capsule study. The polyps were removed using a polyp snare and electrocautery, which is a standard endoscopic technique. Due to the limitations of capsule endoscopy, the DBE scope was advanced an additional 200 cm into the small intestine to confirm the absence of other polyp lesions. Upon reaching the farthest depth in the small intestine, a small India ink mark was left in the wall of the proximal ileum at the further point of the current study. This mark will be an important landmark if future capsule or DBE studies are needed. (See Image 1b.)
The duodenal polyps and four jejunal polyps removed by DBE underwent complete histologic examination. Despite their concerning appearance, all polyp lesions fortunately showed no evidence of dysplasia or early cancerous transformation providing tremendous relief for the patient’s family. Nationwide Children’s gastroenterologists were able to perform these procedures and treatments using minimally invasive techniques. The combination of capsule endoscopy and DBE, allowed direct visualization of the mucosal lining of entire small intestine as well as removal of any suspect lesions. By avoiding major surgery this patient was able to drink liquids the evening of the procedure and left the hospital the following morning. As part of a surveillance plan, the combination of these procedures will be used in the future for this patient to monitor any further polyp development in the small intestine.
Presentation: An 8-year-old female presented with significant iron deficiency anemia that was initially detected during a routine exam. She was not experiencing any digestive symptoms such as nausea, pain, vomiting or diarrhea but was found to have small amounts of blood in her stools by Hemoccult testing. She underwent upper endoscopy and colonoscopy without identification of a bleeding source, directing attention to the small intestine.
Diagnosis: Further diagnostic tests offered no further information as did traditional endoscopic procedures. Her capsule endoscopy study at Nationwide Children’s identified a suspicious area suggestive of active bleeding in the middle of the small intestine prompting a need for double balloon enteroscopy (DBE) to diagnose and possibly treat the cause for her bleeding. At the initial deployment of DBE the patient’s duodenum and jejunum showed a healthy mucosal pattern. However, after about 27 minutes into the procedure, covering a distance of approximately 140 to 150 centimeters, an area of concern was encountered. A region of mucosal irregularity spanning approximately 10 centimeters in length and representing two-thirds of the bowel lumen was encountered. (See Image 2a.)
This lesion was lobulated, irregular and inflamed with small areas spontaneous bleeding; all features that raised concern for possible malignancy. The depth of penetration into the bowel wall could not be determined at that point. Because of the size and nature of the lesion, consultation with Pediatric Surgery was obtained immediately while the patient was still undergoing the procedure allowing the surgeons to view the lesion directly. Upon surgical review, the patient was admitted for further testing and treatment.
Treatment/Outcome: No abnormal serum tumor markers were detected and an abdominal CT scan did not visualize the lesion well nor were other abnormalities noted. During surgery, inspection of the intestinal wall revealed a vascular abnormality known as a hemangioma that involved the bowel wall from inner mucosa to outer serosal layer. The vascular abnormality was limited making resection relatively easy and curing her of the problem. (See Images 2b and 2c showing the hemangioma once removed.) She made a full and uneventful recovery.