矢野 智則

Double-balloon endoscopy (DBE) was developed as a new technique for visualization and intervention of the entire small intestine. It has been world-widely reported that DBE is very useful for not only diagnosis but also endoscopic therapy. In this paper, the principle of the DBE system and indication for DBE are described introductory. DBE should be performed considering differential diagnosis based on clinical information such as episode of bleeding, detailed case history and CT findings for making diagnosis efficiently.

Background: There are no studies to date using air as an enteral contrast medium for small bowel expansion in virtual enteroscopy. We examine the feasibility of air as an enteral contrast medium for virtual enteroscopy to achieve small bowel expansion. Patients and Methods: Two volunteers and six patients were examined. The six patients included three with small bowel tumors, one with small bowel hemorrhage and two with suspected cases of post-operative small bowel stenosis. A duodenal tube was inserted under fluoroscopy and approximately 2000 ml air was administered prior to scanning. A 16-detector row computed tomography apparatus was used with 2-mm thick slices. Intravenous contrast material was administered to the patients, but not to the volunteers. Computed tomography scanning was performed two to three times until the air reached the colon. Two examiners reconstructed multi-planar reformation, volume rendering and virtual endoscopy. These images were compared with double balloon enteroscopic findings and/or resected specimens. Results: There were no complications associated with this examination. In the volunteers the difference between the circular folds of the jejunum and those of the ileum was clearly visualized on virtual endoscopy. Angiodysplasia (9 mm), gastrointestinal stromal tumor (15 mm) and arteriovenous malformation were clearly detected by virtual endoscopy. In contrast, one tumor could not be detected because of inadequate intestinal distension. In the two suspected cases of the stenosis, the lesion was not identified because stenotic lesions were not differentiated from normal peristalsis of the small bowel. Conclusions: Air is a feasible enteral contrast material for virtual enteroscopy.

Background: The early diagnosis of small-bowel tumors (SBT) was a difficult task until the advent of capsule endoscopy (CE) and double-balloon endoscopy (DBE) allowed access to the disease sited. However, although CE and DBE have greatly simplified the task, DBE studies have yet to provide sufficient data on the diagnosis and outcome of patients with SBTs. Objective: To determine the efficacy of DBE examination in the detection and diagnosis of SBT. Design: A retrospective analysis of cross-sectional case series. Setting: Seven major medical centers in Japan. Patients: The first 1035 consecutive DBE cases at these major Japanese centers since the introduction of DBE. Main Outcome Measurements: The percentage of subjects with SBT and a diagnosis of SBT, their indications for DBE, and diagnostic and therapeutic DBE procedures carried out for SBT. Results: SBTs were identified in 144 of 1035 Subjects (13.9%) who underwent DBE between September 2000 and December 2005. For subjects with SBT, the most common indication for DBE was the Suspected presence of a SBT (61/144 [42.4%]). For subjects without SBT, the most common indication was obscure GI bleeding (OGIB) (419/891 [47.0%]). Malign

Double balloon endoscopy (DBE) was developed as a new technique for visualization and intervention of the entire small intestine. It has been world-widely reported that DBE is very useful for not only diagnosis but also endoscopic therapy. In this chapter, hemostatic procedure, polypectomy, dilation therapy for benign strictures, reduction of intussusception, removal of foreign bodies, and therapeutic ERCP in long-limb surgical bypass patients are described introductively. Diagnostic DBE is thought to be safe with a low complication rate, but it is reported that the complication rate in therapeutic DBE is higher than that associated with colonoscopy. The thin wall of the small intestine can explain this. Endoscopic therapy in the small intestine should be performed with special care to avoid complications such as bleeding and perforation.

Small-intestinal vascular lesions accounted for the bleeding source in a large percentage of the patients with mid-GI-bleeding. The progress of enteroscopy has been changing the diagnostic and therapeutic algorithm for them. There are 3 pathological conditions of vascular lesions. Angioectasia is characterized by venous/capillary lesions, Dieulafoy' s lesion is characterized by arterial lesions, and AVM is a condition in which arteries and veins are directly connected without capillary beds. We classified vascular lesions with consideration of the presence or absence of pulsatility. The presence or absence of arterial components provides important information in understanding the pathological conditions. This classification will be useful for selecting hemostatic procedure and outcome studies.

Objective. Capsule endoscopy has shown that non-steroidal anti-inflammatory drugs (NSAIDs) can damage the small intestine. The aim of this study was to determine the prevalence of NSAIDs enteropathy in subjects indicated for double-balloon endoscopy (DBE). Material and methods. The Japanese Study Group for Double-Balloon Endoscopy (JSG-DBE) established a database for the practical use of DBE in the Japanese population during a 2-year period from 2004 to 2005. Using this database, we identified subjects who had been taking NSAIDs within a month prior to DBE (NSAIDs group) and those free from NSAIDs use (control group). The clinical background and DBE findings were compared between the two groups. Results. Among 1035 patients registered in the JSG-DBE database, 61 subjects were classified as the NSAIDs group and 600 served as the control group. Patients in the NSAIDs group were older (62 +/- 18 versus 51 +/- 19 years, p<0.0001) and gastrointestinal bleeding was a more frequent indication for DBE (79% versus 44%, p<0.001) compared with in the control group. Non-specific mucosal breaks were detected by DBE in 31 patients in the NSAIDs group (51%) and 29 patients in the control group (5%, p<0.0001). Aspirin was less frequently prescribed and cardiovascular disease was a less frequent indication for NSAIDs use in patients with mucosal breaks than in those without breaks. Conclusions. In the cases indicated for enteroscopy, NSAIDs enteropathy occurred in half of the patients taking NSAIDs. Aspirin seems to be less harmful to the small intestine than other NSAIDs.

Background: Double balloon endoscopy (DBE) and videocapsule endoscopy (VCE) have been useful in managing Obscure GI bleeding (OGIB). Objective: This study evaluated the usefulness of DBE for diagnosis, treatment, and prognosis of OGIB and compared diagnostic yield between DBE and VCE in Japan. Methods: Detection rates of abnormalities and diagnostic yields between VCE and DBE were compared in 74 patients at 5 centers. Of 244 patients who underwent DBE at Nagova University Hospital, 130 (53%) with OGIB were enrolled for investigation of therapeutic procedures. Setting: Seven Japanese medical centers. Patients: Of 1034 patients who underwent DBE between September 2000 and December 2005 at 7 medical centers, 479 (46%) with OGIB were enrolled. Results: Overall diagnostic yield of DBE for OGIB was 277 of 479 (58%). In patients with overt-ongoing bleeding, overt-previous bleeding of sporadic type, overt-previous bleeding of first attack only, occult bleeding with continuous positive fecal occult blood test (FOBT), or occult bleeding with I positive FOBT with iron deficiency anemia, diagnostic yield was 24 of 31 (77%), 179 of 310 (58%), 34 of 72 (47%), 24 of 35 (71%), and 56 of 93 (60%),

En bloc resection of superficial tumors in the colon is challenging but beneficial for the precise diagnosis and treatment. We have been using a novel technique of endoscopic submucosal dissection with a viscous substance, sodium hyaluronate, and a needle knife in combination with a small-caliber-tip transparent hood and succeeded in the endoscopic en bloc resection of large superficial tumors in the colon. We endoscopically treated superficial tumors larger than 20 mm in diameter of the colon in 166 patients between June 1998 and March 2005. All the lesions were successfully resected endoscopically and en bloc resection was achieved in 77% of them. Even large superficial tumors in the colon can be resected in one piece by using this technique. © 2007 Birkhäuser Verlag.

Double balloon endoscopy is based on a new insertion mode in which two balloons at the distal ends of both an endoscope and an overtube are operated in combination. We have performed 419 enteroscopic examinations in 250 patients using the Fujinon double balloon endoscopy system between September 2000 and October 2005. Total enteroscopy was successfully achieved by the combination of both oral and anal approaches in 55 out of 71 cases in whom total enteroscopy was intended. Of 250 patients, ulcerative and/or erosive lesions were found in 49 cases and tumors/polyps were found in 49 cases. We also found 26 cases of vascular lesion, including angiodysplasia. Endoscopic treatments, including hemostasis using either clipping devices or electro coagulation, polypectomy, endoscopic mucosal resection, balloon dilation, and stent placement was successfully carried out. Double balloon enteroscopy is both feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders. © 2007 Birkhäuser Verlag.

A 43-year-old man presented with gastrointestinal bleeding. A tumor with central ulceration was observed in the jejunum, with the use of a new enteroscopy system called "double-balloon enteroscopy". Bleeding after biopsy sampling of the tumor was controlled endoscopically by using electrocoagulation. Histological findings of the biopsy specimens were consistent with gastrointestinal stromal tumor, and this was surgically resected. Double-balloon enteroscopy was useful for the diagnosis as well as the control of bleeding in this patient.

In the case presented here, we have succeeded in describing the endoscopic findings of anticoagulant ileus and evaluated the degree of bleeding as well as ischemia through endoscopic observation. We have demonstrated that enteroscopy using the double-balloon method is a useful diagnostic tool in the evaluation of a patient suspected to have anticoagulant ileus.

We showed a newly developed method, retrograde double-balloon enteroscopy, to be useful for preoperative diagnosis in a case of inflammatory fibroid polyp accompanied by small-bowel intussusception. A 64-year-old woman was admitted to our hospital with small-bowel intussusception. Results of radiographic and ultrasonographic examination were suggestive of a small-bowel mass. Retrograde double-balloon enteroscopy was performed in an attempt to make a preoperative diagnosis. Endoscopic observation, in combination with histological findings derived from endoscopic biopsy, was suggestive of an inflammatory fibroid polyp. The patient then underwent laparotomy with minimal incision, which revealed a polypoid mass leading to a jejunojejunal intussusception, without bowel necrosis, and a partial small-bowel resection was performed. The pathological diagnosis was an inflammatory fibroid polyp.