**7. Further diagnostic applications of the endoscopic examination**

*Device-assisted enteroscopy* (DAE) is a generic term for endoluminal examination of the small bowel by any endoscopic technique that includes assisted progression (e. g. by a balloon, overtube, or other stiffening device) [2]. DAE can be used to diagnose Crohn's disease, because histological corroboration is available.

A fundamental endoscopic application in the follow-up of IBD affected patients is the endoscopic surveillance for any dysplasia (a high-grade dysplasia evolve to invasive carcinoma in 33-100% of cases) [1]. As reported by the American Gastroenterology Society guidelines, the risk of neoplasia increases in cases of a long lasting disease with early onset, severe extension of disease, familiarity for cancer of colon-rectum, presence of backwash ileitis and history of sclerosing cholangitis [3]. Furthermore carcinogenesis correlates with the activity of inflammation [4-5].

Aiming to the surveillance and early diagnosis of any arising neoplasia, the ideal number of biopsies to be taken during an endoscopic examination is 2-4 every 10 cm (and on 4 quadrants). For the paediatric age, such a surveillance schedule is indicated for cases with disease duration > 8 years [4].

Techniques like chromoendoscopy and AFI (auto-florescence imaging) increase from 2 to 5 times the sensitivity for the identification of any neoplastic lesion; on the contrary no significant advantages have been observed with NBI (narrow binding imaging) technique, with respect to traditional endoscopy [1].

An endoscopic examination is recommended, after 2-3 months since the beginning of treatment in patients with a new diagnosis, in order to evaluate the efficacy of the ongoing therapy to get mucosal healing.

Another major role of the endoscopic examination involves those patients with IBD that undergo a surgical intervention with confectioning of ileal-pouch [3][10]. A post-surgical pouchitis is- in fact- common: it can be mild to severe and generally does not involve the last ileal oxbow (23-46% of cases at 10-11 years of age). A surveillance of the macro- and microscopic inflammation is possible through scheduled post-operative controls.

Endoscopy in Paediatric Inflammatory Bowel Disease (IBD) 247

differentiation between CD (with transparietal involvement) and UC may be set through echoendoscopy, UC in phase of activity can in certain cases manifest with findings which

Other useful parameters which can be evaluated through echoendoscopic doppler are velocity of maximal flux in the superior mesentheric artery and the increase in transparietal

*The high magnification endoscopy* (HMCC) allows a magnification of up to 100 times. The images obtained close in on the histological findings both for the segments of normal mucosa and for those with clearly evident lesions; it is not possible, however, to identify those mild mucosal alterations, which are-on the contrary-recognizable at histology [4]. This technique is particularly useful for the execution of targeted biopsies and can be taken into consideration also for the surveillance of the development of neoplasia in IBD affected

*Confocal Laser Endomicroscopy* (CLE) is a technology developed in the last 5 years which focalises on a single point of a laser illumination at a low power [4-5]. The distal extremity of the endoscope contains a channel for air and water, two guide lights, an operating channel with diameter 2.8 mm and an auxiliary channel for water. The sodium-fluorescein administered i.v. at the beginning of the procedure is used as a mean of contrast. Cellular and subcellular microscopic images are obtained. This technique allows the execution of targeted biopsies in IBD affected patients, reducing the number of bioptic samples to be

*Intraoperative enteroscopy (IOE)* is defined as an endoluminal examination of the small bowel during abdominal surgery with manual external assistance for endoscope progression. By definition, IOE is an exploration of the small intestine with an endoscope (gastroscope,

*Spiral enteroscopy* is a recently developed technique. An enteroscope, introduced orally, is passed through a single-use overtube, which has helical spirals at its distal end and rotates independently from the enteroscope. The enteroscope can be locked in the overtube allowing the option of spiral enteroscopy, or unlocked and advanced through the overtube

Beside diagnostic endoscopy, operative endoscopy also has a determinant role in the

In particular, CD patients have an elevated risk of relapses in the sites of surgical anastomosis where strictures can appear [3]. At this level, pneumatic endoscopic dilatations (balloons of 12-18 mm with pressures of 25-50 psi are used) as well as the placement of coated stents are techniques of important efficacy for the rechanneling of severe strictures

Before the advent of pneumatic perendoscopic dilators, patients with significant strictures necessary underwent a surgical intervention of resection of intestinal segments, with a risk

The response to operative endoscopy techniques has been demonstrated significantly higher, observing a minor risk of surgical intervention in those cases with extension of the stricture being ≤ 4 cm [1]. A recent study by Stienecker K [11], examined 31 strictures in a group of CD affected patients: in 30 of them balloon dilatation was successful in a single

colonoscope, pediatric colonoscope, or enteroscope) during a surgical procedure [2].

are referable to CD [4-5].

vascularisation [4-5].

patients.

taken [4-5].

[2].

**8. Operative endoscopy** 

of short bowel syndrome [3].

practical management of IBD affected patients [3].

(early efficacy in 86% of cases; late efficacy in 55% of cases) [1].

The *push enteroscopy*, per os or laparoscopic, is an evolving technique which is useful for diagnostic evaluation of the small bowel [4-5]. It consists in an endoluminal examination of the proximal jejunum using a long, flexible endoscope [2]. At present, endoscopes with length up to 230 cm, diameter of 10 mm and deflexion grades up to 160-180^ are used. Per os, it is possible to reach a length of 120-180 cm beyond Treitz ligament; with laparoscopic assistance, also the terminal ileum is reached.

Push enteroscopy allows tissue sampling, polypectomy, and treatment of bleeding lesions [2].

In recent years, balloon-assisted endoscopic techniques have largely replaced push enteroscopy in examination of the small bowel.

More recently, advanced endoscopic techniques of *balloon-assisted* and *spiral enteroscopy* have allowed direct tissue sampling for histopathology and therapeutic procedures in the small bowel. However the role of these investigations in the diagnosis and management of IBD is unclear [2][3].

*Balloon-assisted enteroscopy* (BAE) is a generic term for endoluminal examination of the small bowel by any endoscopic technique that includes balloon-assisted progression [2].

*Single-balloon enteroscopy* (SBE) is defined as endoluminal examination of the small bowel using a single-balloon endoscope [2].

*Double-balloon enteroscopy* (DBE) is defined as endoluminal examination of the small bowel using a double-balloon endoscope [2]. DBE, first described by Yamamoto and colleagues in 2001, allows deep (even complete) intubation of the small bowel by pleating the bowel onto a long, flexible endoscope fitted with an overtube [2].

DBE needs to be performed under deep sedation or general anesthesia which allows the execution of biopsies as well as of therapeutical procedures such as emostasis and dilatations [4]. The DBE system consists in a video-enteroscope (length of 200 cm, diameter of 8.5 mm), with overtube and elevate resolution. On the overtube as well as on the extremity of the instrument, two balloons are placed; these can be inflated and deflated with air, throughout a pressure-regulated control system (P max 45 mmHg). Both are deflated at the beginning of the procedure. Once duodenum is reached, the balloon on the overtube is inflated to stabilize the tube which is pushed foreword as much as possible. Subsequently, the balloon on the enteroscope is inflated while the one on the overtube is deflated, so that the overtube can be pushed foreword to the tip of the instrument. By repeating the procedure with the same order, the instrument progressively advances visualizing the entire small bowel.

DBE is particularly useful for patients with obscure gastrointestinal bleeding as well as for those with suspicion of CD but with negative ileoscopy and imaging. It allows us to identify early lesions like aphthae, erosions and small ulcers. Large portions of the small bowel can be visualized directly; oral and anal routes, alone or in combination, are used to achieve complete small-bowel examination [2].

*Endosonography* uses a colonoscope with frontal vision and with a transducer (emitting sound waves with a frequency of 7.5 Hz) placed on the rigid extremity or being introduced through the operative tube. A fluid of interface is necessary and can be obtained through filling the balloon with water as well as in the intestinal segment to be examined [4]. In the paediatric age, indications to this technique can include suspicion of neoplasia (early identification of adenoma), evaluation of the extension and depth of lesions (in particular perirectal and pericolonic abscesses), strictures, fistula and anastomosis [4-5].

Characteristic findings of IBD from endosonography are bowel wall thickening with loss of the normal structure, which is secondary to progressive inflammation. Although the

The *push enteroscopy*, per os or laparoscopic, is an evolving technique which is useful for diagnostic evaluation of the small bowel [4-5]. It consists in an endoluminal examination of the proximal jejunum using a long, flexible endoscope [2]. At present, endoscopes with length up to 230 cm, diameter of 10 mm and deflexion grades up to 160-180^ are used. Per os, it is possible to reach a length of 120-180 cm beyond Treitz ligament; with laparoscopic

Push enteroscopy allows tissue sampling, polypectomy, and treatment of bleeding lesions

In recent years, balloon-assisted endoscopic techniques have largely replaced push

More recently, advanced endoscopic techniques of *balloon-assisted* and *spiral enteroscopy* have allowed direct tissue sampling for histopathology and therapeutic procedures in the small bowel. However the role of these investigations in the diagnosis and management of IBD is

*Balloon-assisted enteroscopy* (BAE) is a generic term for endoluminal examination of the small

*Single-balloon enteroscopy* (SBE) is defined as endoluminal examination of the small bowel

*Double-balloon enteroscopy* (DBE) is defined as endoluminal examination of the small bowel using a double-balloon endoscope [2]. DBE, first described by Yamamoto and colleagues in 2001, allows deep (even complete) intubation of the small bowel by pleating the bowel onto

DBE needs to be performed under deep sedation or general anesthesia which allows the execution of biopsies as well as of therapeutical procedures such as emostasis and dilatations [4]. The DBE system consists in a video-enteroscope (length of 200 cm, diameter of 8.5 mm), with overtube and elevate resolution. On the overtube as well as on the extremity of the instrument, two balloons are placed; these can be inflated and deflated with air, throughout a pressure-regulated control system (P max 45 mmHg). Both are deflated at the beginning of the procedure. Once duodenum is reached, the balloon on the overtube is inflated to stabilize the tube which is pushed foreword as much as possible. Subsequently, the balloon on the enteroscope is inflated while the one on the overtube is deflated, so that the overtube can be pushed foreword to the tip of the instrument. By repeating the procedure with the same order, the instrument progressively advances visualizing the entire small bowel. DBE is particularly useful for patients with obscure gastrointestinal bleeding as well as for those with suspicion of CD but with negative ileoscopy and imaging. It allows us to identify early lesions like aphthae, erosions and small ulcers. Large portions of the small bowel can be visualized directly; oral and anal routes, alone or in combination, are used to achieve

*Endosonography* uses a colonoscope with frontal vision and with a transducer (emitting sound waves with a frequency of 7.5 Hz) placed on the rigid extremity or being introduced through the operative tube. A fluid of interface is necessary and can be obtained through filling the balloon with water as well as in the intestinal segment to be examined [4]. In the paediatric age, indications to this technique can include suspicion of neoplasia (early identification of adenoma), evaluation of the extension and depth of lesions (in particular

Characteristic findings of IBD from endosonography are bowel wall thickening with loss of the normal structure, which is secondary to progressive inflammation. Although the

perirectal and pericolonic abscesses), strictures, fistula and anastomosis [4-5].

bowel by any endoscopic technique that includes balloon-assisted progression [2].

assistance, also the terminal ileum is reached.

enteroscopy in examination of the small bowel.

a long, flexible endoscope fitted with an overtube [2].

using a single-balloon endoscope [2].

complete small-bowel examination [2].

[2].

unclear [2][3].

differentiation between CD (with transparietal involvement) and UC may be set through echoendoscopy, UC in phase of activity can in certain cases manifest with findings which are referable to CD [4-5].

Other useful parameters which can be evaluated through echoendoscopic doppler are velocity of maximal flux in the superior mesentheric artery and the increase in transparietal vascularisation [4-5].

*The high magnification endoscopy* (HMCC) allows a magnification of up to 100 times. The images obtained close in on the histological findings both for the segments of normal mucosa and for those with clearly evident lesions; it is not possible, however, to identify those mild mucosal alterations, which are-on the contrary-recognizable at histology [4]. This technique is particularly useful for the execution of targeted biopsies and can be taken into consideration also for the surveillance of the development of neoplasia in IBD affected patients.

*Confocal Laser Endomicroscopy* (CLE) is a technology developed in the last 5 years which focalises on a single point of a laser illumination at a low power [4-5]. The distal extremity of the endoscope contains a channel for air and water, two guide lights, an operating channel with diameter 2.8 mm and an auxiliary channel for water. The sodium-fluorescein administered i.v. at the beginning of the procedure is used as a mean of contrast. Cellular and subcellular microscopic images are obtained. This technique allows the execution of targeted biopsies in IBD affected patients, reducing the number of bioptic samples to be taken [4-5].

*Intraoperative enteroscopy (IOE)* is defined as an endoluminal examination of the small bowel during abdominal surgery with manual external assistance for endoscope progression. By definition, IOE is an exploration of the small intestine with an endoscope (gastroscope, colonoscope, pediatric colonoscope, or enteroscope) during a surgical procedure [2].

*Spiral enteroscopy* is a recently developed technique. An enteroscope, introduced orally, is passed through a single-use overtube, which has helical spirals at its distal end and rotates independently from the enteroscope. The enteroscope can be locked in the overtube allowing the option of spiral enteroscopy, or unlocked and advanced through the overtube [2].
