SHORT REPORT

Single-balloon enteroscopy: A single-center experienceof 48 procedures

Rajiv Baijal & Praveen Kumar & Deepakkumar Trilokinath Gupta &

Nimish Shah & Sandeep Kulkarni & Soham Doshi

Received: 17 June 2013 /Accepted: 9 September 2013 /Published online: 10 October 2013# Indian Society of Gastroenterology 2013

Abstract The aim of this study was to report the analysis of asingle-center experience with single-balloon enteroscopy(SBE). A retrospective analysis of patients with small-boweldisorder who underwent SBE procedure from February 2011to February 2013 was carried out. A total of 40 patientsunderwent 48 SBE procedures. Antegrade and retrograde ap-proaches were used in 68.8 % and 31.2 % of subjects, respec-tively. The main indications were obscure gastrointestinalbleeding (n =28), chronic diarrhea (n =6), and chronic abdom-inal pain (n =6). Average (SD) insertion length by antegradeapproach was 150.6 (31.4) cm (range 90–210 cm) beyond theduodenojejunal flexure and by retrograde approach was 106.6(29.4) cm (range 40–140 cm) proximal to the ileocecal junc-tion. Average procedure time for antegrade approach was 46.3(9.0) min (range 25–60 min) and for retrograde approach was61.3 (12.8) min (range 45–90 min). Panendoscopy was notpossible in any of the eight patients in whom antegrade andretrograde approaches were performed. Overall diagnosticyield was 55 % and therapeutic procedures were done in20 % of patients. There were no significant complications.SBE is a safe and effective method to diagnose patients withsmall-bowel disease and provides a useful tool for intervention.

Keywords Endoscopy . Obscure gastrointestinal bleed .

Small bowel

Introduction

The small bowel is considered to be a black box for theendoscopist. However, it can be visualized bywireless capsule

endoscopy (WCE) which allows only visualization of thebowel mucosa. WCE has no therapeutic interventional capac-ity and has a high risk of retention in patients with an obstruc-tive lesion [1]. Double-balloon enteroscopy (DBE) has revo-lutionized the enteroscopy field in which therapeutic interven-tion can also be performed thereby overcoming the limitationof WCE [2]. The limitation of DBE is that it requires consid-erable expertise, involves high cost, and is a cumbersomeprocedure. Single-balloon enteroscopy (SBE) simplifies thedouble-balloon concept and is easier to set up [3, 4]. It offersabilities similar to DBE for evaluation of the small bowel.There is limited data on SBE from India [5]. We analyzed ourexperience with SBE.

Methods

A total of 48 procedures were carried out in 40 patientsfrom February 2011 to February 2013. Demographic,clinical indication for enteroscopy, findings of prioresophagogastroduodenoscopy, colonoscopy, radiologicalimaging (abdominal ultrasonography, barium meal fol-low through, and computed tomography (CT) of the abdo-men or CT enteroclysis), procedural data, findings, and com-plications were recorded. All patients provided written con-sent prior to SBE procedure, and the study was approved bythe hospital institutional review board for presentation of theretrospective data analysis. SBE was offered to patients withsuspected small-bowel disease after negative EGD and colo-noscopy and/or localization of small-bowel pathology byimaging studies and denied if they had acute intestinal ob-struction or refused to give consent.

Antegrade procedure was performed on overnight fastingpatients. Retrograde procedure was carried out after preparationwith 2–4 l of polyethylene glycol. All patients were sedatedwith injection of propofol, midazolam, and pentazocine by an

R. Baijal : P. Kumar :D. T. Gupta (*) :N. Shah : S. Kulkarni :S. DoshiDepartment of Gastroenterology, Jagjivanram Hospital, BehindMaratha Mandir, Mumbai 400 008, Indiae-mail: drdeeptideepak@gmail.com

Indian J Gastroenterol (January–February 2014) 33(1):55–58DOI 10.1007/s12664-013-0411-5

anesthetist. Fluoroscopy was used in all the procedures toovercome technical difficulty and determine the depth of inser-tion of the enteroscope. The total procedure time was de-fined as the period of insertion to complete withdrawal ofthe enteroscope. The length of insertion, identified on fluo-roscopy, was measured beyond the ligament of Treitz in theantegrade approach and proximal to the ileocecal valve in theretrograde approach. The depth of insertion can be measuredin centimeters by the total number of 40-cm push and pullcycles on insertion as defined by May et al. [6] or by countingthe amount of small bowel traversed on withdrawal in 5- to10-cm increments. In this series, we have used the latter. Theroute of insertion was guided by radiological imaging orWCE(performed in four patients). If no lesion was found in theantegrade approach, the retrograde approach was attemptedsubsequently. All procedures were carried out by the sameendoscopist and any single nursing staff. Enteroscopy failurewas defined as an inability to pass beyond 60 cm from theduodenojejunal flexure in the antegrade approach or 20 cmproximal to the ileocecal valve in the retrograde approach.Enteroscopic failure was based on recognized typical limits ofpush enteroscopy and colonoscopy with ileal intubation,respectively [7, 8]. Therapeutic procedures were performedas and when necessary depending on the findings onenteroscopy. Tissue sampling was performed as clinicallyappropriate.

Statistics

Descriptive statistics were calculated for the patient’s data pre-senting the mean and range (minimum–maximum) of clinicalparameters.

Results

A total of 40 patients underwent 48 SBE procedures. Therewere 30males and 10 females.Mean (SD) age was 47.9 (13.5)with a range of 18 to 65 years. The most common indicationwas obscure gastrointestinal bleed (OGIB in 28 patients),followed by chronic diarrhea in 6 and abdominal pain in 6.In OGIB, painless bleed was seen in 21 patients and painfulbleed in 7 patients. In chronic diarrhea, painless diarrhea wasseen in five patients and diarrhea with abdominal pain in onepatient.

Patients with abdominal pain and diarrhea who were con-sidered for SBE had clinical features indicating an organiccause like weight loss, features of intermittent subacute intes-tinal obstruction, anemia, nutrient deficiency or growth retar-dation, and abnormal stool tests. Ten out of these 12 patientswith abdominal pain and diarrhea had abnormal small-bowelimaging findings.

On small-bowel imaging, 18 patients had localized find-ings (CT enteroclysis 14, WCE 4). The CT enteroclysis find-ings were irregular folds with localized or diffuse ulcerationsin six patients, narrowing in the distal jejunum and proximalileum with or without proximal dilatation in three, localized ordiffuse thickening of small intestinal loops in four, and masslesion in one.

A total of 48 procedures were performed, out of which 33(68.7%) were antegrade and 15 (31.2%) were retrograde. Theroute preferred was as per the small-bowel imaging findings.If imaging findings were inconclusive, the antegrade approachwas preferred.

Technical details Average depth of insertion in the antegradeapproach was 150.6 (31.4) cm (range 90–210 cm) beyond theduodenojejunal flexure. The average depth of insertion in theretrograde approach was 106.6 (29.4) cm (range 40–140 cm)proximal to the ileocecal valve. Average time for the proce-dure in the antegrade approach was 46.3 (9.0) min (range 25–60min), and in the retrograde approach, it was 61.3 (12.8) min(range 45–90 min).

Findings The abnormalities detected at enteroscopy are listedin Table 1. Biopsies were performed in patients with ulcers anderosions, strictures, and loss of mucosal folds and were ana-lyzed by a histopathologist. In submucosal lesions, biopsy wasnot performed as gastrointestinal stromal tumor (GIST) wassuspected. Most common biopsy findings were nonspecificchronic inflammatory changes (13), noncaseating granuloma(1), and total villous atrophy (1). There were normal findings in25 SBE procedures with 1 enteroscopic failure (Figs. 1 and 2).

Therapeutic procedures Thesewere performed in eight patients(argon plasma coagulation (APC) in six and dilatation in two).Dilatation and hemostasis was achieved in all patients. However,one patient of multiple telangiectasia had recurrence of

Fig. 1 Circumferential ulceration in the jejunum

56 Indian J Gastroenterol (January–February 2014) 33(1):55–58

symptoms. On follow up for 12 months, among the six patientswho underwent APC for telangiectasias (five patients) and ulcer(one patient), only one had recurrence of symptoms (Fig. 3).

Diagnostic yield Overall diagnostic yield of SBE was 55 %.SBE confirmed 10 out of 14 findings on CT and 2 out of 4findings on WCE. This may be because of nonspecific find-ings on imaging or inability to do a panendoscopy. Out of the22 patients with normal small-bowel imaging, SBE detectedlesions in 10 patients.

In three patients with localized narrowing and proximaldilatation, on imaging, SBEwas done to confirm the diagnosisand with therapeutic intent. In one patient with multiple tel-angiectasias, retrograde SBE was done with prior therapeuticintent.

Normal SBE was seen in 18 patients, of whom 9 patientswere asymptomatic. On follow up, three patients had recurrentOGIB but the cause could not be determined, while six pa-tients were lost to follow up.

Enteroscopic failure was seen in one patient undergoingretrograde SBE. Retrograde enteroscopic failure is mainly dueto dipping of the enteroscope in the pelvis. Due to routine use

of fluoroscopy in our patients, this was seen in only 1 patientout of 15 retrograde enteroscopies.

Complications No significant complications occurred relatedto the procedure. Two patients reported pain after the proce-dure which was managed with analgesics.

Discussion

Single-balloon enteroscopy provides a diagnostic and thera-peutic modality for the small bowel which was previouslyinaccessible by upper and lower endoscopy. This retrospectivestudy of our initial experience with SBE demonstrates theability of the SBE system to provide a diagnostic yield insmall-bowel pathology. In our center, WCE is not availableroutinely, so many patients had undergone radiological

Fig. 2 Discrete single ulcer in the mid ileum

Fig. 3 Telangiectasia in the distaljejunum coagulated with argonplasma coagulation

Table 1 Utility of single-balloon enteroscopy in various clinicalindications

Indications(n =40)

Positive imagingfindings (n =18)

SBE lesions(n =22)

SBE findings(n =22)

OGIB (n=28) Total—8 16 (57) Ulcers—9

Telangiectasias—5CT scan—5

Erosion—1

WCE—3 Submucosallesion—1

Abdominal pain(n =6)

Total—5 3 (50) Stricture—2

Diaphragm—1CT scan—5

WCE—0

Chronic diarrhea(n =6)

Total—5 3 (50) Ulcers—2

Mucosal atrophy—1CT scan—4

WCE—1

Values in parentheses are in percent

SBE single-balloon enteroscopy, OGIB obscure gastrointestinal bleed,WCE wireless capsule endoscopy

Indian J Gastroenterol (January–February 2014) 33(1):55–58 57

imaging prior to SBE except in four patients who underwentWCE at other centers. Concordance was noted in only twopatients on follow up with SBE. In our experience, SBEdemonstrated a yield of 55 %, which compares favorablywith that of other published studies in SBE [3, 5]. Thetherapeutic procedures were done in eight patients wheredilatation and hemostasis was achieved. However, one patientwith multiple telangiectasias had recurrence of symptoms.The depth of insertion of SBE averaged less than that ofDBE [9, 10] but was comparable to other studies of SBE[5, 11]. The depth of insertion in retrograde SBE wasless as compared to antegrade SBE by approximately40 cm. This has been consistently seen in other studies too,mostly due to technical reasons [5, 8]. It should be notedthat there were no total enteroscopies achieved in thisearly experience. In other reports of SBE in the West, thetotal enteroscopy rates also range from 0 % to 5 % [3, 5, 12].In our study, only two patients experienced postprocedurepain which has been reported in a small percentage of patientsafter SBE and DBE. Adhesions have been suggested to play arole in postprocedure pain by some [13]. SBE mainly helpedin the diagnosis of OGIB (57 %) and therapeutic utility in theform of hemostasis. In spite of its clinical utility, SBE wasnormal in 12 patients which may be due to incompletepanendoscopy or intermittent or absence of active bleeding.SBE was useful in confirming suspected stricture on imaging,in the diagnosis with the help of tissue biopsy and therapeuticintervention like dilatation.

The limitations of this study include the single-center ret-rospective setting and the absence of long-term follow updata. Larger prospective studies are needed to further assessthe diagnostic and therapeutic potential of SBE.

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