Double-balloon enteroscopy, also known as push-and-pull

enteroscopy Enteroscopy is the procedure of using an endoscope for the direct visualization of the small bowel. Etymologically, the word could potentially refer to any bowel endoscopy ('' entero-'' + '' -scopy''), but idiomatically it is conventionally rest ...

, is an

endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

technique for visualization of the

small bowel The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the p ...

. It was developed by Hironori Yamamoto in 2001. It is novel in the field of diagnostic

gastroenterology Gastroenterology (from the Greek gastḗr- "belly", -énteron "intestine", and -logía "study of") is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometime ...

as it is the first endoscopic technique that allows for the entire

gastrointestinal tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the Digestion, digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascula ...

to be visualized in real time.

Technique

The technique involves the use of a

balloon A balloon is a flexible membrane bag that can be inflated with a gas, such as helium, hydrogen, nitrous oxide, oxygen, or air. For special purposes, balloons can be filled with smoke, liquid water, granular media (e.g. sand, flour or rice), ...

at the end of a special enteroscope camera and an overtube, which is a tube that fits over the endoscope, and which is also fitted with a balloon. The procedure is usually done under general

anesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...

, but may be done with the use of

conscious sedation Procedural sedation and analgesia (PSA) is a technique in which a sedating/dissociative medication is given, usually along with an analgesic medication, in order to perform non-surgical procedures on a patient. The overall goal is to induce a decr ...

. The enteroscope and overtube are inserted through the

mouth A mouth also referred to as the oral is the body orifice through which many animals ingest food and animal communication#Auditory, vocalize. The body cavity immediately behind the mouth opening, known as the oral cavity (or in Latin), is also t ...

and passed in conventional fashion (that is, as with

gastroscopy Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered ...

) into the

. Following this, the endoscope is advanced a small distance in front of the overtube and the balloon at the end is inflated. Using the assistance of friction at the interface of the enteroscope and intestinal wall, the small bowel is accordioned back to the overtube. The overtube balloon is then deployed, and the enteroscope balloon is deflated. The process is then continued until the entire small bowel is visualized. The double-balloon enteroscope can also be passed in retrograde fashion, through the colon and into the

ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine may ...

to visualize the end of the small bowel.

Indications

Double-balloon enteroscopy has found a niche application in the following settings: * Bleeding from the gastrointestinal tract of obscure cause *

Iron deficiency anemia Iron-deficiency anemia is anemia caused by a lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as feeling tired, weak, sh ...

with normal

colonoscopy Colonoscopy () or coloscopy () is a medical procedure involving the Endoscopy, endoscopic examination of the large bowel (colon) and the distal portion of the small bowel. This examination is performed using either a Charge-coupled device, CCD ...

and gastroscopy * Visualization and therapeutic intervention on abnormalities seen on traditional small bowel imaging *

Endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior ...

(ERCP) in post-surgical patients with long afferent limbs

Advantages

Double-balloon enteroscopy offers a number of advantages to other small bowel image techniques, including

barium Barium is a chemical element; it has symbol Ba and atomic number 56. It is the fifth element in group 2 and is a soft, silvery alkaline earth metal. Because of its high chemical reactivity, barium is never found in nature as a free element. Th ...

imaging, wireless capsule endoscopy and push enteroscopy: * It allows for visualization of the entire small bowel to the

terminal ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine ma ...

. * It allows for the application of therapeutics. * It allows for the sampling or

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, an interventional radiologist, or an interventional cardiology, interventional cardiologist. The process involves the extraction of sampling (medicine), sample ...

ing of small bowel

mucosa A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It ...

, for the resection of polyps of the small bowel, and in the placement of

stent In medicine, a stent is a tube usually constructed of a metallic alloy or a polymer. It is inserted into the Lumen (anatomy), lumen (hollow space) of an anatomic vessel or duct to keep the passageway open. Stenting refers to the placement of ...

s or dilatation of strictures of the

. * It allows for access to the papilla in patients with long afferent limbs after Billroth II antrectomy.

Disadvantages

The key disadvantage of double-balloon enteroscopy is the time required to visualize the small bowel; this can exceed three hours, and may require that patients be admitted to hospital for the procedure. There have also been case reports of

acute pancreatitis Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes include a gallstone impacted in the common bile duct or the pancreatic duct, heavy alcohol use, systemic disease, trauma, elevated calcium levels, hypertriglyceridemia (w ...

(at a rate of 0.3%–0.4%, when the oral route is used) and intestinal necrosis associated with the technique. A 2015 study in the ''World Journal of Gastrointestinal Endoscopy'' reported that: "Due to prolonged procedure and air insufflation,

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...

can be observed in up to 20% patients." Depending on whether the oral or rectal approach was used, a patient may experience a sore throat (following use of the oral route), upset stomach, vomiting, and painful bloating, cramping, or abdominal discomfort in reaction to the gas in the intestines.

References

{{Reflist Diagnostic gastroenterology Digestive system imaging Endoscopy