**3. Treatment**

*Endoscopy in Small Bowel Diseases*

intervention.

**Figure 3.**

*Crohn's disease.*

retention.

Device-assisted endoscopy is not part of routine diagnostic testing in patients with suspected CD and should not be the first-line procedure in the evaluation of small bowel [1]. However, it may provide additional information when it is required biopsy of small bowel tissue to histological corroboration. Indeed, compared with video capsule endoscopy and small bowel imaging techniques, the advantages of device-assisted endoscopy include the evaluation of atypical lesions, the ability to obtain biopsies for histopathology and the potential for therapeutic

*Device-assisted endoscopy images showing mucosal inflammation and ulcerations consistent with a diagnosis of* 

Device-assisted endoscopy studies in individuals with suspected CD have not included large numbers of patients but report a diagnostic yield as high as 80% [35]. In fact, device-assisted endoscopy is more sensitive in detecting lesions in patients with suspected CD than multiple radiographic imaging techniques. Nevertheless, because of the invasive and potentially time-consuming nature of the exam, it should be reserved for patients with high clinical suspicion of CD despite negative conventional studies (including ileocolonoscopy, video capsule endoscopy and radiographic imaging), particularly if endoscopic and histologic finding would alter disease management or potential therapeutic intervention is required [36]. In a prospective trial, positive findings at device-assisted enteroscopy led to a step-up of medical therapy in 74% of patients, leading to clinical remission in 88% [37]. In addition, device-assisted endoscopy may be preferable to video capsule endoscopy if there is a clinical suspicion of obstruction because it may allow therapeutic intervention and be safer, simply by avoiding capsule

In patients with established CD, device-assisted endoscopy is indicated when endoscopic visualization and biopsies are necessary from areas of the small bowel inaccessible to conventional endoscopy [1]. Usually, previous video capsule endoscopy provides information on the optimal route of approach (oral or rectal) and lesion location. Adhesions may limit examination by device-assisted endoscopy and, in these circumstances, double-balloon enteroscopy may be preferred to single-balloon enteroscopy. In addition, device-assisted endoscopy has the capacity for endoscopic therapy, including dilation of small bowel strictures, removal of

Overall, diagnostic device-assisted endoscopy is safe, with few reports of complications (<1%) [38]. However, there appears to be an increased risk of complications in the case of active CD or previous intestinal surgery. The risk of perforation is 0.12% without therapeutic intervention and 1.74% with therapeutic intervention, the majority of which occurred after stricture dilatation [39]. Bleeding occurs in approximately 2.5%. In addition, device-assisted endoscopy involves risks related to sedation, in contrast to video capsule endoscopy

impacted capsules and treatment of bleeding lesions (*vide infra*).

**34**

where no sedation is required.
