Small Bowel and Advanced Endoscopic Techniques
Small bowel and advanced endoscopy
Video capsule endoscopy (VCE) is the first-line test for obscure GI bleeding after negative upper and lower endoscopy, and it is useful for suspected Crohn disease, celiac disease, polyposis syndromes, and NSAID enteropathy. A patency capsule should precede VCE when stricture is suspected; capsule retention occurs in about 1-2% and is higher in Crohn disease. Contraindications include known obstruction and inability to swallow; older pacemakers are no longer an absolute contraindication but should be checked.
Bowel preparation for VCE is debated; a clear liquid diet and split prep may improve visualization. Reading requires systematic review and reporting of transit time and findings.
For tissue diagnosis or therapy beyond the capsule, use push enteroscopy (proximal small bowel), single- or double-balloon enteroscopy, or spiral enteroscopy. Double-balloon enteroscopy allows deep intubation and is used for bleeding, stricture dilation, and polypectomy in Peutz-Jeghers syndrome. Advanced resection techniques include EMR, ESD, and full-thickness resection; POEM (peroral endoscopic myotomy) treats achalasia by creating a submucosal tunnel and dividing the lower esophageal sphincter.
Traps: proceeding to VCE in a patient with a known stricture, failing to use a patency capsule, and assuming a negative capsule excludes small bowel disease. Rule of thumb: if stricture is suspected, place a patency capsule first.
Worked example: a 45-year-old with recurrent iron deficiency anemia and negative EGD/colonoscopy undergoes VCE, which shows angioectasia in the jejunum; double-balloon enteroscopy allows argon plasma coagulation.