Motorized Spiral Enteroscopy for Occult Bleeding

Obscure Bleeding from a Metastatic Small Bowel Tumor Diagnosed Using Motorized Spiral Enteroscopy: A Case Study and a Literature Review

Small bowel tumors are relatively rare, representing only around 5% of all gastrointestinal neoplasms, with a progressively increasing incidence. Currently, there are no established guidelines for diagnostic approaches, screening procedures, or management strategies for small bowel tumors. We present here the case of a patient with a rare type of metastatic tumor of the small bowel originating from primary lung adenocarcinoma who presented with abdominal pain, severe iron-deficiency anemia, and melena. The initial investigations, gastroscopy and colonoscopy, failed to identify the bleeding source. The obscure bleeding source and diagnosis were achieved through power motorized spiral enteroscopy (MSE), which allowed the visualization and biopsy of the tumor. Histopathological examination established the presence of a poorly differentiated non-mucinous adenocarcinoma originating from the lung. This case is reported to provide evidence of the efficiency of MSE in the diagnosis of small bowel tumors, with the method providing higher insertion depth in a reduced amount of time.

Endoscopic Treatment of Small Bowel Bleeding

Approximately 5% of all gastrointestinal (GI) bleeding originates from the small bowel. Endoscopic therapy of small bowel bleeding should only be undertaken after consideration of the different options, and the risks, benefits, and alternatives of each option. Endoscopic therapy options for small bowel bleeding are like those treatments used for other forms of bleeding in the upper and lower GI tract. Available endoscopic treatment options include thermal therapy (eg, argon plasma coagulation and bipolar cautery), mechanical therapy (eg, hemoclips), and medical therapy (eg, diluted epinephrine injection). Patients with complicated comorbidities would benefit from evaluation and planning of available treatment options, including conservative and/or medical treatments, beyond endoscopic therapy.

[Episodic bleeding events due to arteriovenous malformation (AVM) in the region of the distal ileum in a young male patient]

We report the case of a 32-year-old male patient who presented with episodic, self-limiting gastrointestinal bleeding events. After both esophagogastroduodenoscopy (EGD) and colonoscopy remained unremarkable, capsule endoscopy revealed an unexplained mucosal lesion that presented as an ulcerated process on spiral enteroscopy. Appropriate enteroscopic ink marking was followed by surgical partial resection of the distal ileum, with histopathology revealing evidence of an arteriovenous malformation (AVM). This case emphasizes the importance of deep enteroscopy both in the diagnosis and to facilitate therapeutic resection in rare gastrointestinal bleeding events affecting young people.

Motorized Power Spiral Enteroscopy (MSE): Is Routine Bougienage of the Upper Esophageal Sphincter (UES) Necessary?

Introduction Wire-guided bougienage of the upper esophageal sphincter (UES) was performed routinely before per-oral motorized power spiral enteroscopy (MSE). In the present study, we aimed to answer the clinical question of whether routine bougienage of UES is required. Methods This was a retrospective study that included 20 patients who underwent antegrade spiral enteroscopy for various indications. The feasibility and safety of anterograde MSE without prior bougie dilatation of the upper esophageal sphincter were assessed. The technical success rate (TSR), diagnostic yield, and adverse events (AEs) were also assessed. Results In 16 out of the 20 patients, a spiral enteroscope was taken directly across UES into the esophagus without a prior bougie dilatation. The spiral enteroscope could not be negotiated across UES only in one patient, and bougie dilatation was done. The technical success rate was 100%. The diagnostic yield was 80%. Four patients reported AEs. Conclusions MSE had a good technical success rate and diagnostic yield. Routine dilatation of the UES before the procedure may be unnecessary.

Performance and safety of motorized spiral enteroscopy: a systematic review and meta-analysis

BACKGROUND AND AIMS

The introduction of motorized spiral enteroscopy (mSE) into clinical practice holds diagnostic and therapeutic potential for small-bowel investigations. This systematic review and meta-analysis aims to evaluate the performance of this modality in diagnosing and treating small-bowel lesions.

METHODS

A systematic search of MEDLINE, Cochrane, and ClinicalTrials.gov databases were performed through September 2022. The primary outcome was diagnostic success, defined as the identification of a lesion relative to the indication. Secondary outcomes were successful therapeutic manipulation, total enteroscopy rate (examination from the duodenojejunal flexion to the cecum), technical success (passage from the ligament of Treitz or ileocecal valve for anterograde and retrograde approach, respectively), and adverse event rates. We performed meta-analyses using a random-effects model, and the results are reported as percentages with 95% confidence intervals (CIs).

RESULTS

From 2016 to 2022, 9 studies (959 patients; 42% women; mean age >45 years; 474 patients [49.4%] investigated for mid-GI bleeding/anemia) were considered eligible and included in analysis. The diagnostic success rate of mSE was 78% (95% CI, 72-84; I2 = 78.3%). Considering secondary outcomes, total enteroscopy was attempted in 460 cases and completed with a rate of 51% (95% CI, 30-72; I2 = 96.2%), whereas therapeutic interventions were successful in 98% of cases (95% CI, 96-100; I2 = 79.8%) where attempted. Technical success rates were 96% (95% CI, 94-97; I2 = 1.5%) for anterograde and 97% (95% CI, 94-100; I2 = 38.6%) for retrograde approaches, respectively. Finally, the incidence of adverse events was 17% (95% CI, 13-21; I2 = 65.1%), albeit most were minor adverse events (16%; 95% CI, 11-20; I2 = 67.2%) versus major adverse events (1%; 95% CI, 0-1; I2 = 0%).

CONCLUSIONS

mSE provides high rates of diagnostic and therapeutic success with a low prevalence of severe adverse events.

Motorized Spiral Enteroscopy Is Effective in Patients with Prior Abdominal Surgery

BACKGROUND

Motorized Spiral Enteroscopy (MSE) reduces procedure time and increases insertion depth into the small bowel; however, there is scarce evidence on factors affecting MSE efficacy.

AIMS

To evaluate diagnostic yield and adverse events of MSE including patients with prior major abdominal surgery.

METHODS

A prospective observational study was conducted on patients undergoing MSE from June 2019 to December 2021. Demographic characteristics, procedure time, depth of maximum insertion (DMI), technical success, diagnostic yield, and adverse events were collected.

RESULTS

Seventy-four anterograde (54.4%) and 62 retrograde (45.6%) enteroscopies were performed in 117 patients (64 males, median age 67 years). Fifty patients (42.7%) had prior major abdominal surgery. Technical success was 91.9% for anterograde and 90.3% for retrograde route. Diagnostic yield was 71.6% and 61.3%, respectively. The median DMI was 415 cm (264-585) for anterograde and 120 cm (37-225) for retrograde enteroscopy. In patients with prior major abdominal surgery, MSE showed significantly longer small bowel insertion time (38 vs 29 min, p = 0.004), with similar diagnostic yield (61 vs 71.4%, p = 0.201) and DMI (315 vs 204 cm, p = 0.226). The overall adverse event rate was 10.3% (SAE 1.5%), with no differences related to prior abdominal surgery (p = 0.598). Patients with prior surgeries directly involving the gastrointestinal tract showed lower DMI (189 vs 374 cm, p = 0.019) with equal exploration time (37.5 vs 38 min, p = 0.642) compared to those with other abdominal surgeries.

CONCLUSIONS

MSE is effective and safe in patients with major abdominal surgery, although longer procedure times were observed. A lower depth of insertion was detected in patients with gastrointestinal surgery.

Power Spiral Enteroscopy: A Quick and Powerful Dive Deep Inside the Small Bowel!

A comprehensive and detailed small bowel evaluation became possible since 2001 with the advent of a wireless capsule endoscope that was primarily used for diagnostic purposes. Simultaneously, the development of balloon-assisted enteroscope made detailed evaluation and therapy possible in the deeper small bowel. A novel motorized spiral enteroscope, introduced in 2015, is the most recent addition to the list of device-assisted enteroscopes. The rotational movements of the spiral overtube controlled by the integrated motor are transmitted into a linear force causing forward and backward propulsion of the scope in the bowel. There is emerging evidence about its safety and efficacy in the diagnosis and therapy of various small bowel diseases.

Acute Upper Non-variceal and Lower Gastrointestinal Bleeding

Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.

The Role of Provocative Testing and Localization of the Video Capsule Endoscope in the Management of Small Intestinal Bleeding

The cause of small intestinal bleeding (SIB) may be elusive despite exhaustive testing. This article describes the current understanding of SIB regarding evaluation, with emphasis on the use of video capsule endoscopy (VCE) as a diagnostic procedure. This article addresses the utility of provocative testing in challenging cases and the performance of endoscopic procedures on active antithrombotic therapy. Specific recommendations accompany this article, including use of antithrombotic agents to stimulate bleeding when clearly indicated; performance of endoscopic procedures on active antithrombotic therapy; and progressive adoption of VCE and device-assisted enteroscopy in the inpatient setting.

A spiraling journey into the small bowel: a case series of novel motorized power spiral enteroscopies

BACKGROUND AND AIMS

The small bowel has, to date, remained a difficult area to access via endoscopy. The novel motorized power spiral enteroscopy, recently introduced, has more depth of insertion and is of shorter duration. Presented here is a case series of motorized spiral enteroscopies.

METHODS

Motorized spiral enteroscopy is indicated for patients requiring deep enteroscopy (eg, for a diagnosis of obscure GI bleeding, suspected inflammatory bowel disorder) and for therapeutic interventions, such as polypectomy, hemostasis, or stricture dilatation. It is contraindicated in patients who are not eligible for general anesthesia, with perforation, or with coagulopathy and in the pediatric population. The contraindications for the anterograde route are gastroesophageal varices, foregut stenosis, eosinophilic esophagitis, and so on. The retrograde approach is contraindicated in active colitis, anal stenosis, or colonic stricture. Informed consent was sought from all the patients.

RESULTS

The procedure was successful in 13 of 14 (92.8%) in that the target site was reached or panenteroscopy was confirmed. The diagnoses were stricture and ulcers of the jejunum or ileum. The procedures performed were argon plasma coagulation and stricture dilation. The average duration of anterograde enteroscopy was 61.1 minutes and retrograde enteroscopy was 90 minutes. The major adverse events were hypothermia (3 of 14) and pancreatitis (1 of 14), from which the patients recovered fully.

CONCLUSIONS

Novel motorized power spiral enteroscopy is a great tool in small-bowel diagnostics and therapeutics. Speed and ease add to the attractiveness of the procedure.

Enteroscopy in children and adults with inflammatory bowel disease

Inflammatory bowel disease (IBD) includes Crohn’s disease (CD), ulcerative colitis and unclassified entities. CD commonly involves the terminal ileum and colon but at the time of diagnosis it can be confined to the small bowel (SB) in about 30% of the patients, especially in the young ones. Management of isolated SB-CD can be challenging and objective evaluation of the SB mucosa is essential in differentiating CD from other enteropathies to achieve therapeutic decisions and to plan the follow-up. The introduction of cross-sectional imaging techniques and capsule endoscopy (CE) have significantly expanded the ability to diagnose SB diseases providing a non-invasive test for the visualization of the entire SB mucosa. The main CE limitations are the low specificity, the lack of therapeutic capabilities and the impossibility to take biopsies. Device assisted enteroscopy (DAE) enables histological confirmation when traditional endoscopy, capsule endoscopy and cross-sectional imaging are inconclusive and also allows therapeutic interventions such as balloon stricture dilation, intralesional steroid injection, capsule retrieval and more recently stent insertion. In the current review we will discuss technical aspect, indications and safety profile of DAE in children and adults with IBD.

New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review

Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.

Sending in the ViCE Squad: Evaluation and Management of Patients with Small Intestinal Bleeding

Bleeding from the small intestine remains a clinically challenging diagnostic and therapeutic problem. It may be minor, requiring only supplemental iron treatment, to patients who have severe overt bleeding that requires multimodal intervention. This article provides an up-to-date review of the state-of-the-art of diagnosis and treatment of small intestinal bleeding.

Are we experiencing a technological revolution? The novel motorized PowerSpiral enteroscope (PSE): a case of total oral enteroscopy

The novel motorized spiral rnteroscope (PowerSpiral®, Olympus) (PSE) has been recently commercialized with promising results in relation to insertion depth and time of exploration. We herewith report our first case of a total small bowel exploration with PSE.

The evolution of lower gastrointestinal endoscopy: where are we now?

Lower gastrointestinal endoscopy has evolved over time, fulfilling a widening diagnostic and therapeutic remit. As our understanding of colorectal cancer and its prevention has improved, endoscopy has progressed with improved diagnostic technologies and advancing endoscopic therapies. Despite this, the fundamental design of the endoscope has remained similar since its inception. This review presents the important role lower gastrointestinal endoscopy serves in the prevention of colorectal cancer and the desirable characteristics of the endoscope that would enhance this. A brief history of the endoscope is presented. Current and future robotic endoscopic platforms, which may fulfil these desirable characteristics, are discussed. The incorporation of new technologies from allied scientific disciplines will help the endoscope fulfil its maximum potential in preventing the increasing global burden of colorectal cancer. There are a number of endoscopic platforms under development, which show significant promise.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.

Endoscopic ultrasonography and small-bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small-bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device-assisted enteroscopy have quickly become the reference standard for the diagnosis of small-bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up-to-date overview of the latest advances in endoscopic ultrasonography and small-bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.