Abiodun O Laoye, MD, Gorcey A Steven, MD. Jersey Shore University Medical Center.
Case: An 80 year old female with chronic paroxysmal atrial flutter on Aspirin and Coumadin presented as an outpatient for evaluation of iron deficiency anemia. She denied any abdominal pain, weight loss, hematemesis, melena or hematochezia. Physical examination was normal; hemoglobin was 11.5, hematocrit was 34.9.
Upper endoscopy and colonoscopy were performed and found to be negative. A video capsule endoscopy revealed a suspicious area that was oozing fresh blood. Visualization was poor and neoplasm could not be ruled out. Localization was difficult and thus single balloon enteroscopy was performed. We were able to advance the scope to the ileum confirmed by biopsy. After tattooing the most distal point, withdrawal began. Using the pause button on the Olympus inflator device we achieved partial balloon deflation. The proper amount of deflation was determined by trial and error. After 2 seconds of deflation we pressed the pause button and checked the resistance to withdrawal. Adequate deflation was considered the point where withdrawal was controlled with minimal resistance. In this way we were able to prevent rapid unplaiting of the small bowel off the over tube, and flatten the small bowel folds for better visualization. Glucagon was also utilized to reduce motility. The area in question was found, biopsied and tattooed. Pathology revealed chronic inflammation with a hyperplastic component. NSAID enteropathy secondary to the patient’s daily aspirin was the most likely diagnosis.
The small bowel had long been considered a black box for endoscopists due to its long length, and multiple complex loops, making it impossible to evaluate with conventional endoscopy. Although the wireless video capsule allows for the visualization of the small bowel its major drawbacks are the inability to accurately localize and biopsy lesions as well as a high negative predictive value. In 2007 single balloon enteroscopy was introduced, allowing endoscopists to intubate deep into the small bowel by plaiting it onto the scope and over tube. The single balloon system consists of an Olympus 200 cm enteroscope, a disposable silicone splinting tube with an inflatable balloon, and an inflation control unit. After deep intubation of the small bowel, which is a timely and tedious process, the conventional technique for withdrawal is to deflate the over tube balloon and retract both the scope and over tube together. The drawback of this technique is rapid unplaiting of the small bowel off the over tube, often resulting in incomplete visualization. Using our technique of partial balloon deflation described above we were able to achieve a smooth controlled withdrawal with excellent visualization. In addition, the balloon allows for traction of bowel folds, similar to the traction obtained in cap assisted endoscopy. With more video capsule endoscopies being performed, more small bowel lesions are being discovered. Single balloon enteroscopy provides a way to localized, diagnose and treat them. As studies with colonoscopy have shown, controlled withdrawal increases lesion detection and therefore is desirable. With partial balloon deflation in single balloon enteroscopy one can achieve a similar degree of controlled withdrawal to that of colonoscopy