*5.4.2 Therapeutic DAE*

*Endoscopy in Small Bowel Diseases*

**58**

**Author**

**DAE** 

**Patient** 

**Study design**

**Suspected** 

**Known** 

**Diagnostic yield** 

**Diagnostic yield** 

**Impact on** 

**Impact on** 

**management:** 

**confirmed CD (%)**

**management:** 

**suspected CD (%)**

75

**confirmed CD** 

**(%)**

**suspected CD** 

**(%)**

**CD (n)**

**CD (n)**

**system**

**Mensink et al,** 

DBE

Adult CD

Retrospective

0

40 *Summary of studies on diagnostic yield of device assisted enteroscopy (DAE) in Crohn's disease (CD); SBE- single balloon enteroscopy, DBE- double balloon enteroscopy, BGE- balloon guided* 

60

**2009**

**Table 3.**

*enteroscopy [69–78, 81–86]*

**subgroup**

DAE can be performed with therapeutic intent in established CD to dilate short (<5 cm), non-inflammatory strictures (4E-F), insert stents, inject intra-lesional steroid, remove foreign body like capsule or Bezoar and rarely to treat major haemorrhage in CD. Reported technical success for stricture dilatation ranges from 60–80% and perforation rates as high as 9% has been described [69].

Strictures in Crohn's disease (CD) are secondary to inflammation, fibrosis, or both. The risk of fibrotic stricture increases with the disease duration; such strictures are seen in 30% to 35% of patients within 10 years of diagnosis of CD [36]. Despite biologic use, the incidence of strictures remains unchanged in CD [70]. Endoscopic stricturotomy and balloon dilatation are the most common endoscopic procedures performed for CD strictures. However, both are associated with a high risk of recurrence, re-intervention and surgery.

The use of self-expanding metal stents (SEMS) have been reported for CD strictures with high technical success rate. However, it is associated with risk of perforation, stent migration, and fistula [71, 72]. Premature stent failure is the drawback of biodegradable stents, used to circumvent adverse events of SEMS. Currently available biodegradable stents are not specifically designed for CD strictures [73–75].

In a recent single-center series of CD patients, removable SEMS therapy for short (6 cm) fibrostenotic strictures of terminal ileum/ ileocolonic anastomoses was technically successful in 95.8%. The stents were removed within 7 days. On long-term follow-up (3–50 months), none of the patients required stricture-related surgery [76]. The global interventional inflammatory bowel disease (IBD) group recommendations has positioned fully covered SEMS for refractory strictures in selected patients failing balloon dilatation and endoscopic stricturotomy [77].

The technical success rate (defined as successful dilatation leading to endoscope passage) of endoscopic balloon dilatation (EBD) for CD strictures varies from 72% to 100% (**Table 4**). The clinical success, defined as in improvement in patient's obstructive symptoms, is around 60%.

The dilatation diameter varied from 12.4 to 17 mm with maximum of 20 mm. The recurrence rate varied from 14% to 78.5% based on duration of follow up. In studies with more than 3 years of follow up, the recurrence rates were 48% and 78.5%, respectively. Overall, most recurrences can be successfully treated with repeat balloon dilatation with a cumulative surgery free rate of 78% at 3 years. So, long term high recurrence rates and need for repeated dilatation or surgery should be kept in mind prior to EBD for CD strictures [69, 78–82].

### *5.4.3 DAE in paediatric patients*

DAE is safe and effective for children aged >3 years and weight > 14 kg. DAE is challenging in children due to small abdominal cavity, thinner small bowel wall and a narrow lumen requiring considerable expertise. Five studies (2 SBE, 2 DBE and 1 BGE) have evaluated the role of DAE in paediatric IBD. In these studies, DAE either led to treatment escalation or was used to perform stricture dilatation. Definitive IBD type was ascertained in patients with IBD-U after BGE in a feasibility and safety study. These studies did not report any major complications with diagnostic or therapeutic DAE. DAE related complications in paediatric patients are reported


*Endoscopy in Small Bowel Diseases*

**60**

**Table 4.**

**61**

*Role of Small Bowel Endoscopy in Diagnosis and Management of Inflammatory Bowel Disease…*

Major complications like bleeding, perforation or pancreatitis with DAE are found in about 0.72% (which may be higher in patients with Crohn's disease). Rate of perforation with DAE is around 0.11% according to results of a large Japanese registry of nearly thirty thousand patients. The risk of perforation was nine fold higher in IBD patients on steroids [88]. The rate of perforation with endoscopic balloon dilatation can be as high as 9% [60]. Bleeding after DAE has been reported in around 2.5% which is mostly self limiting [61]. Pancreatitis can occur in upto 0.3% patients after DAE from antegrade approach [89]. In paediatric IBD settings, although overall complication rates 0f upto 5.4% is reported, none reported major

Earlier studies have shown that IOE has useful role in surgical decision making in ulcers and strictures in CD [90, 91]. In our experience (unpublished observation), IOE helped to identify ulcers/strictures missed on initial preoperative evaluation (31.8%, 7/22) (**Figure 1D**). In case of multiple strictures, IOE also helped in deciding the extent of surgical resection. In 30% (6/20) of the cases, strictures were severe (not allowing enteroscope passage) and rest had mild, passable strictures. Of the subjects with severe strictures (6/20), 3 were judged to have mild stricture on inspection and palpation during laparotomy. Hence, IOE has important role in guiding surgical management of small intesti

Small bowel endoscopy is essential for both diagnostic and therapeutic pur

poses in suspected and confirmed CD. This is particularly valuable for diagnosis when upper endoscopy, ileo-colonoscopy and cross sectional small bowel imaging are non-contributory or non-diagnostic. VCE is useful if there are no obstruc

tive symptoms or known stenosis although DAE guided biopsy is important in scenarios when alternative pathology requires exclusion specially in countries where tuberculosis is endemic. Newer devices like motorised spiral enteroscopy and balloon guided enteroscopy have revolutionised the management of small bowel CD. DAE is be safe and effective in both adults and children with CD. Apart from therapeutic interventions like foreign body retrieval, endoscopic balloon dilatation, stent placement and haemostasis; small bowel endoscopy could be useful in postoperative CD recurrence detection and document mucosal healing




mostly with therapeutic DAE. Overall complications with a large DBE series (n = 257) is 5.4% (10.4% in patients <10 years). The largest SBE series (n = 189) does not report any major adverse events except for transient pain and distension

(28%) and one case of self limited bleeding [48, 73, 81–87].

complications even with therapeutic procedures [75].

**6. Intra-operative enteroscopy in CD**

nal ulcers/strictures [82, 83].

and response to therapy.

**Conflicts of interest**

None.

**7. Conclusion**

*DOI: http://dx.doi.org/10.5772/intechopen.96006*

*5.4.4 Complications of DAE*

*Summary of studies on endoscopic balloon dilatation of Crohn's disease small bowel strictures with device assisted enteroscopy (DAE); SBE- single balloon enteroscopy, DBE- double balloon enteroscopy, BGE- balloon guided enteroscopy [78–82].*

#### *Role of Small Bowel Endoscopy in Diagnosis and Management of Inflammatory Bowel Disease… DOI: http://dx.doi.org/10.5772/intechopen.96006*

mostly with therapeutic DAE. Overall complications with a large DBE series (n = 257) is 5.4% (10.4% in patients <10 years). The largest SBE series (n = 189) does not report any major adverse events except for transient pain and distension (28%) and one case of self limited bleeding [48, 73, 81–87].
