Double BALLOON ENDOSCOPY Max Brinsmead MB BS PhD May 2019 Double BALLOON ENDOSCOPY

Problem 76 year old male Caucasian with significant GIT haemorrhage No drugs/medication Colonoscopy and Oesaphogastroduodenoscopy negative Capsule Endoscopy (CE) GIT What might it find? What are the chances it will find something? What are the other options? Relative merits of other investigations?

Possible Causes of Small Intestinal Bleeding Angiodysplasia 50 – 60% Inflammatory lesions, ulcers and erosions Includes Crohn’sdisease Association with NSAID use More common in Asian series Polyp (5 – 10%) Malignancy rare Includes AdenoCa, Carcinoid and Lymphoma Diverticula incl. Meckels Active bleeding without focus

Etiology of obscure gastro-intestinal bleeding according to age Elderly  Middle-Aged  Young Adult  (>65 years)  (41-65 years)  (17-40 years)  Vascular anomalies Small intestinal ulcer NSAID enteropathy Small intestinal tumours Non-specific enteritis Celiac disease   Crohn’s disease Meckel’s diverticulum Dieulafoy’s lesion

Angiodysplasia GIT

Capsule Endoscopy

Has colour camera, battery, light source and Transmitter Capsule Endoscopy Capsule size 26 x 11 mm Has colour camera, battery, light source and Transmitter Data recorder worn as a belt Transit time 24 – 48 hours Takes 2 images/sec for 8 hours Will generate 50,000 images Retention rate 0.4 – 1.4% Crohn’s is a relative contraindication Will diagnose a lesion in about 66%

Ray’s Capsule Endoscopy

“Double Balloon Something or Other” What is it? How successful is it likely to be? Risks and complications? Other options?

Double Balloon Endoscopy Introduced by Yamamoto in 2001 Allows complete visualization, biopsy and treatment of the small bowel https://www.youtube.com/watch?v=7LYCtyvgBek

Double Balloon Endoscopy Essentially 100% successful with no learning curve 75% antegrade 25% retrograde Takes 45 – 90 min Can biopsy or snare polyps and argon laser angiodysplasia Best done with CO2 insufflation Complications more common with diseased bowel e.g Crohns

Meta analysis of Capsule Endoscopy (CE) vs Double Balloon Endoscopy (DBE) 712 patients in 12 studies Similar diagnostic yields for both when investigating obscure GIT bleeding DBE better for diagnosing diverticula CE better for diagnosing fresh bleeding and clots They are complimentary modalities And sometimes simply repeating conventional endoscopy is required

Other Options for Obscure GIT Bleeding CT and angiography Single balloon endosocopy Spiral endoscopy Operative endoscopy

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