Advances in the Diagnosis and Treatment of Small Bowel Lesions with Crohn’s Disease using Double-balloon Endoscopy

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With the recent development of double-balloon endoscopy (DBE) and capsule endoscopy (CE), it has become possible to observe the entire small bowel endoscopically. DBE enables us to make detailed observations and at the same time takes biopsy samples. Single-balloon endoscopy (SBE), which has a balloon only at the tip of the overtube, has also been introduced. Since DBE and SBE are similar in the concept of insertion method, a general term ‘balloon-assisted endoscopy’ (BAE) is used when referring to these methods. Characteristic small bowel lesions observed with BAE in Crohn’s disease are aphthoid ulcers, round ulcers, irregular ulcers and longitudinal ulcers. These ulcers tend to be located on the mesenteric side of the small bowel. Since BAE can determine the location (mesenteric or antimesenteric side) of the ulceration, it is useful in distinguishing Crohn’s disease from other diseases that have ulcers in the small bowel. Strictures are a major clinical problem in the course of Crohn’s disease. Traditionally, surgery was the main choice for small bowel strictures. In some cases, strictures located in distal ileum or proximal jejunum have been dilated using standard enteroscopes. DBE now enables balloon dilatation to be performed endoscopically even in the deep small bowel.

Introduction

Crohn’s disease was first reported by Crohn et al. in 1932 as ‘regional ileitis’ with chronic granulomatous inflammation of the terminal ileum [Chron et al. 2000]. Today, Crohn’s disease is known to be a chronic inflammatory disease of unknown origin that can occur not only in the terminal ileum but anywhere in the gastrointestinal tract [Feagans et al. 2008].

Small bowel lesions occur frequently in Crohn’s disease. Traditionally, diagnosis and assessment of the small bowel lesions in Crohn’s disease has depended on X-ray tests, such as small bowel follow-through (SBFT) and computed tomography (CT). In recent years, however, new endoscopic modalities such as capsule endoscopy (CE) [Iddan et al. 2000] and balloon-assisted endoscopy (BAE) including both double-balloon endoscopy (DBE) [Monkemuller et al. 2007; Zhong et al. 2007; Heine et al. 2006; May and Ell, 2006; Yamamoto et al., 2001] and single-balloon endoscopy (SBE) have been developed. These instruments have enabled us to obtain clear endoscopic images of the small bowel which are useful in making more accurate diagnosis and evaluation of the small bowel lesions in Crohn’s disease [Oshitani et al. 2006]. Endoscopic-balloon dilation (EBD) for intestinal strictures has also become possible in a broader area of the small intestine with DBE [Fukumoto et al. 2007; Pohl et al. 2007]. In this report, we will discuss the diagnosis and treatment of small bowel lesions in Crohn’s disease, focusing on DBE, which was developed mainly in our hospital.

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Ther Adv Gastroenterol. 2009;2(6) © 2009 Sage Publications, Inc

Filed Under: GI

Tags: chronic granulomatous, computed tomography, Crohn's disease, featured, regional ileitis, single-balloon endoscopy