Preface

Since the time when endoscopy and colonoscopy were first introduced, small bowel disorders have remained a diagnostic challenge. The small bowel or the midgut is difficult to assess due to its location and distance from the oral and anal openings. Whereas endoscopy and colonoscopy were commonly used for the diagnosis and treatment of acid peptic, neoplastic, and inflammatory gastrointestinal disorders, the midgut remained an endoscopic mystery. With the exception of surgically assisted scope insertion through a jejunal enterotomy, entry to the small bowel was limited to the edges reaching only to the proximal jejunum or terminal ileum. Imaging modalities like barium studies and computed tomography scans were the options initially used for small bowel assessment.

The past few decades have seen many developments in imaging modalities for the small bowel, leading to better diagnosis and focused therapy. This includes the innovation of capsule endoscopy, which was a revolution in small bowel imaging and led to a change in the diagnostic algorithm for obscure gastrointestinal (GI) bleeding. Later advances like double balloon and spiral enteroscopy now provide a therapeutic option for small bowel diseases. Although this book mainly covers the endoscopic aspect of small bowel diseases, we have included a separate chapter on radiological imaging in inflammatory bowel diseases (IBD). Radiological imaging is an important complementary tool for the diagnosis of small bowel diseases.

This book reviews not only the history and art of small bowel endoscopy but also covers other aspects like endoscopic ultrasound assessment of the duodenal wall, intra-operative endoscopy, and management of small bowel perforations. We hope it will help readers in the management of patients with small bowel diseases.

> **Mahesh Kumar Goenka and Gajanan A. Rodge** Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, Kolkata, India

**Usha Goenka** Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospital, Kolkata, India

**1**

Section 1

Introduction

Section 1 Introduction

**3**

**Chapter 1**

**1. Introduction**

Introductory Chapter: Endoscopy

The small bowel diseases are known to pose a diagnostic challenge for the clinicians in a day-to-day practice. Different small bowel pathologies can broadly be divided as vascular, inflammatory or neoplastic disorders. The most common indication for imaging of small bowel in clinical practice is obscure gastro-intestinal (GI) bleeding. Other indications for small bowel evaluation include Crohn's disease, tuberculosis, NSAID induced ulcers, small bowel malignancies, polyposis syn-

The routine means of endoscopic evaluation in the form of upper gastrointestinal (GI) endoscopy and lower GI endoscopy limit the assessment of GI tract upto the duodenum and ileum respectively. The small bowel was initially out of reach for the diagnostic and therapeutic endoscopy procedures. In 1982 Shinya first reported the use of push enteroscopy and described finding of a small bowel tumour [1]. Use of push enteroscopy was later reported in different studies in the subsequent years [2–4]. Later came the sonde (French word for probe) enteroscopy which involves passage of a thin trans-nasal endoscope with a hood or balloon on its tip that is dragged distally by peristaltic movements of the intestine. It took a period of 13 years for its development [5]. Lewis et al., reported the use of sonde enteroscopy and found the small bowel bleeding site in 33% of patients who presented with obscure GI bleeding (60 patients) [6]. However due to the disadvantages as requirement of longer time, limited passage in presence of adhesions, strictures, and motility disturbances it was later found to be inefficient and lost its popularity. Barium imaging and computed tomography (CT) scans were the mainstay of small bowel imaging till the year 2000. The innovation of wireless capsule endoscopy has revolutionised the small bowel imaging and has made its own place in the diagnostic algorithm for various small bowel diseases. A randomised trial comparing wireless capsule and push enteroscopy for detecting small bowel lesions in nine canine small bowels showed that the capsules significantly performed better than push enteroscopy [7]. Subsequent studies also showed that capsule endoscopy had higher diagnostic yield and was better than push enteroscopy in patients with chronic GI bleeding [8]. Even in today's date video capsule endoscopy plays an important role in the diagnosis of small bowel diseases. However, the disadvantage lies in the inability to sample small bowel mucosa and perform therapeutic interventions. Hironori Yamamoto introduced the technique of double balloon enterosocpy (DBE) and showed that the double balloon method facilitates passage of endoscope to the small intestine. This advent of DBE was a major breakthrough for the diagnosis and treatment of small bowel disorders [9]. Single-balloon enteroscopy

in Small Bowel Diseases

*Usha Goenka, Gajanan Ashokrao Rodge* 

*and Mahesh Kumar Goenka*

dromes and malabsorptive disorders.
