Complications of enteroscopy: how to avoid them and manage them when they arise

[Use of Device-Assisted Enteroscopy in Small Bowel Disease: An Expert Consensus Statement by the Korean Association for the Study of Intestinal Diseases]

The introduction of device-assisted enteroscopy (DAE) in the beginning of the 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of small bowel diseases, DAE has the unique advantages of allowing the observation of the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how it is to be performed and what technical factors should be taken into consideration. In response to these needs, the Korean Association for the Study of Intestinal Diseases has developed an expert consensus statement on the performance of DAE by reviewing current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases

The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Intraductal pressure in experimental models of acute and chronic pancreatitis in mice

BACKGROUND/OBJECTIVES

Pancreatic intraductal pressure is related to the development of pancreatitis, including post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. In this study, we investigate pancreatic intraductal pressure in various mouse models of acute and chronic pancreatitis.

METHODS

Post-ERCP pancreatitis was induced by retrograde infusion of normal saline or radiocontrast at the constant rate of 10 or 20 μL/min. Obstructive pancreatitis was induced by ligation of the pancreatic duct followed by a single injection of caerulein and the changes of intraductal pressure were recorded in day 3 for obstructive acute pancreatitis and day 14 for obstructive chronic pancreatitis. Non-obstructive pancreatitis was induced by repetitive intraperitoneal injections of caerulein. The changes of intraductal pressure were recorded right after the last caerulein injection for non-obstructive acute pancreatitis and after the completion of 4-week caerulein injections for non-obstructive chronic pancreatitis.

RESULTS

Elevated pancreatic intraductal pressure was observed in both normal saline and radiocontrast infusion groups and was furtherly indicated that was positively correlated with the viscosity of solution but not genders. In the models of obstructive pancreatitis, a rise in intraductal pressure was observed in both acute and chronic pancreatitis; whereas in the models of non-obstructive pancreatitis, a rise in intraductal pressure was only observed in chronic, but not acute pancreatitis.

CONCLUSIONS

During ERCP, the elevations in pancreatic intraductal pressure are induced by increasing rate or viscous solution of infusion. During different forms of experimental acute and chronic pancreatitis, obstructive or non-obstructive etiologies of pancreatitis also induces the elevations in pancreatic intraductal pressure.

Tips for successful deep enteroscopy

PURPOSE OF REVIEW

The aim of this study was to provide practical tips to readers on how to perform deep enteroscopy efficiently.

RECENT FINDINGS

Deep enteroscopy has revolutionized the diagnosis and management of small intestinal conditions in recent years. They are extremely valuable, but may be technically challenging to perform, regardless if it is double balloon enteroscopy, single balloon enteroscopy or spiral enteroscopy. The common issues to these procedures are repetitive motion, extended procedure duration and physical exertion during scope advancement. These situations may in turn lead to a variety of ergonomic issues that need to be addressed accordingly to prevent occupational injuries to the endoscopists and their assistants. Depending on the clinical indications, the technical approach and execution of these procedures may be carried out differently. Some guiding principles may be applied to make performing these procedures more smoothly, effectively and deeply.

SUMMARY

Careful planning and skilful manipulations are essential to performing an efficient and stress-free deep enteroscopy. There are many simple ways to improve on the ergonomics and performance of these procedures.

Device-assisted enteroscopy: An update on techniques, clinical indications and safety

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Comparison of characteristic computed tomographic findings of gastrointestinal and non-gastrointestinal stromal tumors in the small intestine

PURPOSE

We aimed to reveal specific findings of gastrointestinal stromal tumors (GISTs) in the small intestine on contrast-enhanced computed tomography (CT) by comparing GISTs with non-GISTs.

METHODS

We enrolled 28 patients with 39 GISTs and 20 patients with 22 non-GISTs who underwent enterectomy with a preoperative diagnosis of small intestinal tumor. All lesions were diagnosed by histopathological examination. Two radiologists independently evaluated internal homogeneity, growth pattern, calcification, intratumoral hemorrhage, degeneration, ulceration, and lymphadenopathy and measured the maximum diameter of the tumor and contrast-enhanced CT (CECT) value of the solid portion as well as the diameter and CT value of the feeding artery and drainage vein on CECT in the arterial and venous phases.

RESULTS

Intratumoral hemorrhage was seen in 15.4% and 25.6% of GISTs and in 0% and 0% of non-GISTs (p = 0.079 and 0.010), with good interobserver agreement (κ = 0.715). The drainage vein diameter correlated well with the maximum diameter of the tumor (r = 0.744, p < 0.001). The CT value of the solid tumor part in the arterial and venous phases (p < 0.01) and the CT value of the drainage vein in the arterial phase (p < 0.05) were higher for GISTs than for non-GISTs (p < 0.01).

CONCLUSIONS

Strong parenchymal enhancement with the peak in the arterial phase and the CT value of the drainage vein in the arterial phase was characteristics findings of GIST compared with non-GISTs. The diameter of the drainage vein was proportional to the maximum diameter of GISTs.

Transient High Pressure in Pancreatic Ducts Promotes Inflammation and Alters Tight Junctions via Calcineurin Signaling in Mice

BACKGROUND & AIMS

Pancreatitis after endoscopic retrograde cholangiopancreatography (PEP) is thought to be provoked by pancreatic ductal hypertension, via unknown mechanisms. We investigated the effects of hydrostatic pressures on the development of pancreatitis in mice.

METHODS

We performed studies with Swiss Webster mice, B6129 mice (controls), and B6129 mice with disruption of the protein phosphatase 3, catalytic subunit, βisoform gene (Cnab-/- mice). Acute pancreatitis was induced in mice by retrograde biliopancreatic ductal or intraductal infusion of saline with a constant hydrostatic pressure while the proximal common bile duct was clamped -these mice were used as a model of PEP. Some mice were given pancreatic infusions of adeno-associated virus 6-nuclear factor of activated T-cells-luciferase to monitor calcineurin activity or the calcineurin inhibitor FK506. Blood samples and pancreas were collected at 6 and 24 hours and analyzed by enzyme-linked immunosorbent assay, histology, immunohistochemistry, or fluorescence microscopy. Ca2+ signaling and mitochondrial permeability were measured in pancreatic acinar cells isolated 15 minutes after PEP induction. Ca2+-activated phosphatase calcineurin within the pancreas was tracked in vivo over 24 hours.

RESULTS

Intraductal pressures of up to 130 mm Hg were observed in the previously reported model of PEP; we found that application of hydrostatic pressures of 100 and 150 mm Hg for 10 minutes consistently induced pancreatitis. Pancreatic tissues had markers of inflammation (increased levels of interleukin [IL] 6, IL1B, and tumor necrosis factor), activation of signal transducer and activator of transcription 3, increased serum amylase and IL6, and loss of tight junction integrity. Transiently high pressures dysregulated Ca2+ processing (reduced Ca2+ oscillations and an increased peak plateau Ca2+ signal) and reduced the mitochondrial membrane potential. We observed activation of pancreatic calcineurin in the pancreas in mice. Cnab-/- mice, which lack the catalytic subunit of calcineurin, and mice given FK506 did not develop pressure-induced pancreatic inflammation, edema, or loss of tight junction integrity.

CONCLUSIONS

Transient high ductal pressure produces pancreatic inflammation and loss of tight junction integrity in a mouse model of PEP. These processes require calcineurin signaling. Calcineurin inhibitors might be used to prevent acute pancreatitis that results from obstruction.

Evidences supporting the vascular etiology of post-double balloon enteroscopy pancreatitis: Study in porcine model

Double balloon enteroscopy (DBE) is an endoscopic technique broadly used to diagnose and treat small bowel diseases. Among the associated complications of the oral DBE, post-procedure pancreatitis has taken the most attention due to its gravity and the thought that it might be associated to the technique itself and anatomical features of the pancreas. However, as the etiology has not been clarified yet, this paper aims to review the published literature and adds new results from a porcine animal model. Biochemical markers, histological sections and the vascular perfusion of the pancreas were monitored in the pig during DBE practice. A reduced perfusion of the pancreas and bowel, the presence of defined hypoxic areas and disseminated necrotic zones were found in the pancreatic tissue of pigs. All these evidences contribute to support a vascular distress as the most likely etiology of the post-DBE pancreatitis.

Neoplastic Diseases of the Small Bowel

The incidence of small bowel tumors is increasing over time. Until recently, their diagnosis was delayed and it was often reached only at the time of surgery. New diagnostic tools, such as capsule endoscopy, device-assisted enteroscopy, and dedicated small bowel cross-sectional imaging techniques, have been introduced recently in clinical practice. The combination of these tools allows medical practitioners to detect small bowel tumors at an early stage and to reach a definite diagnosis before surgery, thus enabling minimally invasive treatments.

Effect of the manipulation of the duodenal papilla during double balloon enteroscopy

AIM: To determine the hypothesis that inflating the balloons in the duodenal papilla determines changes in the biochemical markers of pancreatitis.

METHODS: Four groups of pigs were used: Group papilla (GP), the overtube’s balloon was inflated in the area of the papilla; GP + double balloon enteroscopy (GP + DBE), the overtube’s balloon was kept inflated in the area of the papilla for 20 min before a DBE; Group DBE (GDBE), DBE was carried out after insuring the balloon’s inflation far from the pancreatic papilla; and Group control (GC). Serum concentrations of amylase, lipase and C-reactive protein (CRP) were evaluated. Pancreases were processed for histopathology examination.

RESULTS: Main changes occurred 24 h after the procedure compared with baseline levels. Amylase levels increased significantly in GP (59.2% higher) and were moderately higher in groups GP + DBE and GDBE (22.7% and 20%, respectively). Lipase increased in GP and GP + DBE, whereas it hardly changed in GDBE and in GC. CRP increased significantly in GP, GP + DBE and GDBE, while no changes were reported for GC. No statistically significant difference between groups GP and GP + DBE was found for the histopathological findings, except for vacuolization and necrosis of the pancreatic parenchyma that was higher in GP than in GP + DBE.

CONCLUSION: The manipulation of the duodenal papilla by the inflated overtube’s balloon during DBE causes pancreatic structural damage and increased biochemical markers associated with pancreatitis.