Enteroscopy

Enteroscopy as one of the types of medical endoscopy is aimed at a visual examination of the most remote part of our body in terms of access – the small intestine.

For many years, the only way to examine the small intestine was fluoroscopy, with the use of a contrast agent. With the introduction of modern endoscopic devices, it became possible to conduct not only a visual, but also a histological examination for this part of the intestine, as well as perform a number of therapeutic manipulations without opening the abdominal cavity.

Historical information

The first mention of endoscopy and its primitive instruments appeared in Ancient Egypt (1600-1700 BC), later, in 460-377 BC. e., Hippocrates described the procedure for examining the rectum.

The first attempts to carry out endoscopic examinations date back to the end of the 18th century, and the beginning of the 19th century (1809) was marked by the invention of the first endoscope.^[1]. However, the instrument created by the Austrian F. Bozzini was met with hostility by society, it did not find practical application.

Over the past two centuries, more than one follower of Bozzini had a hand in improving the device, until in 2001 the technology of video capsule endoscopy was certified in the USA.^[2]. A new invention – a small swallowable capsule with a built-in video camera – makes it possible to visually diagnose the small intestine, but does not allow biopsy and medical manipulations.

The possibility of conducting a comprehensive examination of the small intestine appeared after the introduction of balloon enteroscopy.

Purpose of an enteroscopy

The small intestine is the longest, from five to six meters, and the most difficult part of the gastrointestinal tract in terms of visual inspection. The difficulty of the study, in addition to its considerable length, is due to the localization and high mobility of the small intestine.

Visualization of the lumen of the small intestine with the help of special equipment allows you to identify pathologies throughout the small intestine. This invasive examination method is called enteroscopy or intestinoscopy.

The most modern technologies allow, during the examination of the inner surface of the small intestine, to conduct a biopsy (take a tissue sample) for histological examination. If bleeding is detected, it can be stopped without surgical intervention, as well as the removal of foreign bodies, polyps and stricture (narrowing) of the intestine. During enteroscopy, it is also possible to diagnose benign and malignant neoplasms, diffuse adenomatosis and Crohn’s disease.

Types of enteroscopy

Depending on the target part of the intestine and the equipment used, two methods of manipulation are possible: the introduction of the endoscope can be carried out through the mouth (orally) or through the anus (orally).

Several types of enteroscopy of the small intestine are given below:

1. Ejunoscopy allows you to examine the upper sections of the small intestine with access through the mouth. This procedure is called fibrogastroscopy due to the modified device with which it is carried out – fibrogastroduodenoscope.
2. Ileoscopy allows you to examine the final sections of the small intestine through the anal ring. A procedure called fibrocolonoscopy uses a special device called a colonoscope, which has a wide biopsy channel to insert a guided endoscope.
3. Intestinoscopy is carried out using special transintestinal conductors and long colonoscopes. This method is not always available due to difficulties in passing the apparatus and splinting device through the intestinal folds.
4. Capsule enteroscopy consists in swallowing a capsule with a miniature video camera that captures the state of the small intestine, and a transmitter that transmits the information received to the doctor’s computer.
5. Balloon enteroscopy is performed using a telescopic system – an enteroscope and an external tube, which is equipped with balloons and an air pump.

The first three of the above procedures have a number of disadvantages that limit their application. The breakthrough came after the introduction of video capsule enteroscopy. With this method of research, the patient does not experience discomfort associated with the introduction of the endoscope. However, it also has a number of disadvantages, including poor image quality, the impossibility of biopsy and medical manipulations, and obstruction of the capsule in the narrowed areas of the intestine.

The most progressive is balloon enteroscopy, which allows you to examine the small intestine in detail, take material for histological examination, stop bleeding and carry out a number of therapeutic manipulations. It, unlike all other diagnostic methods, is carried out in a hospital and requires anesthesia, due to pain in the intestines after air is injected into it.

Indications and contraindications for enteroscopy

Like any other diagnosis, enteroscopy has a number of indications and contraindications for its implementation.

Indications for the examination are the following situations:

1. Examination of the intestinal walls in order to identify pathology.
2. Intestinal bleeding that cannot be stopped by any means.
3. Suspicions of the presence in the small intestine of neoplasms, both benign and malignant.
4. Neoplastic syndrome: weight loss, chronic fatigue, anemia and malnutrition in the background of dyspeptic disorder.
5. Identification and removal of polyps and foreign bodies.
6. Definition of diffuse adenomatosis and Crohn’s disease.
7. Monitoring the effectiveness of treatment.

There are no absolute contraindications for enteroscopy. However, the following situations may be grounds for refusing to conduct it:

1. The patient is in critical condition.
2. Difficulty in the passage of the device, caused by a number of concomitant diseases, such as goiter, changes in the cervical spine, strictures in the digestive tract, aortic aneurysm.
3. Cerebral circulation disorder.
4. Myocardial infarction.
5. Cardiopulmonary insufficiency in the stage of decompensation.
6. Condition after surgery in the abdominal cavity.
7. Severe strictures and tumors of the small intestine, detected by X-ray examination.

Examination of patients with blood diseases, mental disorders, severe hypertension, as well as inflammatory processes of the upper respiratory tract and oral cavity can be scheduled after a consultation of specialists.

Preparation for the survey

There are general rules for preparing for fibrogastroscopy with jejunoscopy and colonoscopy, as well as ileoscopy. A day before such procedures, it is recommended to follow a drinking diet, and on the eve of the examination, the intestines should be cleansed with appropriate medications.

Two days before the capsule and balloon enteroscopy, a slag-free diet is indicated. These days you should manage with a minimum amount of food. It is allowed to consume lean meats and fish, low-fat dairy products, dietary soups, dried white bread, rice, boiled vegetables. From drinks, juices, compotes and weak tea are recommended, and the intake of sweets is limited to jam and honey.

You should stop eating fatty meats and fish, canned food, smoked meats, cereals, flour products, fresh and dried vegetables and fruits, rich first courses, spices, alcohol and coffee.

On the eve of the examination, you can have breakfast, and for lunch only drinking is allowed (clear liquids and weak broth). On the evening before the examination, a laxative is indicated, and at 22:XNUMX – the drug Espumizan. On the day of the examination, eating is contraindicated. Water can be drunk only with the permission of a doctor.

For patients with a labile nervous system, sedatives are indicated on the evening before the manipulation. Taking sedatives is stopped in the first half of the day on which the procedure is scheduled.

The order of the enteroscopy

Fibrogastroscopy

This diagnostic procedure lasts five to seven minutes. The patient lying on his left side swallows an endoscopic probe with a sensor at the end. Before fibrogastroscopy, the patient undergoes anesthesia of the larynx with a special anesthetic spray.

During the manipulation, the patient must hold the mouthpiece through which the probe is inserted through the mouth. Information about the state of the small intestine is displayed on the monitor. During the procedure, the patient experiences some discomfort, and within a day after it feels persistent pain in the throat.

Colonoscopy

This diagnostic procedure lasts from fifteen minutes to half an hour. After preliminary anesthesia of the anal ring with a special gel or ointment, a flexible tourniquet with an optical system, called a fibrocolonoscope, is inserted through the anus.

The procedure is quite unpleasant: during it, the patient experiences bloating, and within a day after diagnosis, some soreness due to stretching of the anus. To alleviate the condition of the most impressionable patients, it is practiced to introduce them into drug-induced sleep.

During this procedure, the specialist can perform the following manipulations.

1. Examine the intestinal wall for the presence of adhesions, tumors, tuberculous caverns.
2. Perform a biopsy, with the collection of a piece of tissue for histological examination.
3. Removal of small polyps or benign tumors without surgery.

The patient is informed about the results of the diagnostics immediately after the procedure.

Capsule enteroscopy

This type of enteroscopy has become a real breakthrough in gastroenterological diagnostics. Despite the fact that this procedure takes all day, the capsule enteroscopy method does not cause discomfort and is positioned as the most informative and least invasive.

The device is a “pill” of a rather large size, which has a built-in color camera and four pulsed LEDs. The device is equipped with a power source, a transmitter unit and an antenna. The shell of the device is made of biologically neutral material. The device is stored in a special container and activated when it is opened.

Before diagnosis, a special sensor is fixed on the patient’s body under the clothes, which fixes the location of the capsule. A miniature receiving device with a color display is attached to the belt, which is programmed specifically for this person. The patient is offered to swallow a disposable video capsule, information about the “journey” of which through the gastrointestinal tract under the influence of wave peristalsis is displayed on the monitor in real time. During the first half hour, the patient is under the supervision of specialists who need to make sure that the endocapsule has freely left the stomach and ended up in the small intestine.

The video camera continues to scan the mucous membrane of the small intestine, transmitting to the recording device, depending on the modification of the device, from 2 to 35 frames per second. At this time, the patient can go about their business, leaving the medical facility. He needs to move more, helping to move the capsule with his breath. Tips are provided to correct his behavior depending on the circumstances. After the capsule passes through the duodenum, the patient is allowed a light lunch.

After the capsule naturally leaves the intestines, the video information obtained with the help of it is processed by a special computer program that analyzes the images.

Despite the high information content, safety, simplicity, lack of discomfort and painlessness during and after the procedure, capsule diagnostics still has a number of disadvantages, including the following:

1. Possibility of video capsule getting stuck in the upper gastrointestinal tract due to weak intestinal motility.
2. The inaccessibility of some parts of the small intestine due to the inability to control the capsule from the outside in order to straighten the intestinal folds.
3. The inability to perform a biopsy, stop bleeding, remove polyps and other procedures during capsule enteroscopy.
4. Limitation of wide use due to the high cost of the capsule.

To detect places of narrowing of the intestine (stricture), specialists use a special capsule, in which a microchip is embedded instead of a camera. If its patency is limited, such a capsule dissolves in two days, and the microchip remains in the intestine, fixing the narrowing of the lumen.

In the future, it is excreted from the body naturally.

Balloon enteroscopy

Simultaneously with the certification of capsule enteroscopy, a double-balloon video endoscope appeared. His invention made a breakthrough in the field of research and treatment of the small intestine. With the introduction of the new device, endoscopists have the opportunity to detect pathological changes in the deepest parts of the small intestine with simultaneous therapeutic manipulations aimed at taking a biopsy, stopping bleeding, removing polyps and foreign bodies from the intestinal lumen and dilating strictures.

Balloon enteroscopy is performed under general anesthesia.

Due to the considerable length of the intestine, enteroscopy of the small intestine is provided from two places: through the esophagus and stomach (transoral) and through the rectum (transrectal). The procedure begins with the introduction of the endoscope through the mouth. In the event that a pathology is detected, the study is completed, and if not, then the specialist marks the place to which the endoscope has reached and proceeds to examination through the rectum.

The diagnostics in full is evidenced by the exit to the left mark from the second access (through the rectum).

Types of balloon enteroscopy

In practical endoscopy, two methods of balloon examination of the small intestine have been used: one- and two-balloon enteroscopy. According to diagnostic indicators, they are practically indistinguishable from each other.

As for the technical side, the single-balloon enteroscope, which was designed a few years later (in 2006)^[3] after the introduction of a two-cylinder, in practice demonstrated a number of advantages.

In particular, it turned out to be easier to use, accelerated the research procedure and does not require the presence of an assistant. The only thing is that it takes time to gain practical skills for working with a single-balloon enteroscope.

Two-balloon enteroscopy

The system for examining the small intestine through double-balloon enteroscopy includes: an enteroscope, a tube-tube, at the distal end of which two inflatable balloons are placed at some distance from each other, and a console with the ability to display the image on the screen.

The enteroscope is equipped with a channel designed for medical manipulations: performing a biopsy, stopping bleeding in the small intestine, removing small tumors, etc. The 1-meter long tube is made of soft silicone. A special coating and a movable design of the nozzle relative to the endoscope ensures unhindered movement of the probe through the small intestine, which is recorded by a video camera.

The research technique is as follows. The advancement of the probe inserted through the tube-tube to the required depth is ensured by the successive inflation and deflation of each of the balloons, the first of which is controlled by the doctor, and the second by his assistant. The position of the tube is displayed on the screen by the controlling device.

Single-balloon enteroscopy

The system for performing single-balloon enteroscopy of the small intestine includes an endoscope and a tube with a silicone balloon at the distal end, and a radiopaque cone-shaped tip. With the help of the latter, the passage of the tube through the gastrointestinal tract is monitored.

The technique of single-balloon enteroscopy consists in passing the endoscope through the oral cavity into the esophagus and further along the gastrointestinal tract to the small intestine and advancing along it with the collection of the small intestine by inflating and deflating the balloon. Information about the condition of the rectum is recorded by the control device. At the stage of removing the endoscope, a thorough examination of the mucous membrane of the small intestine is performed by segmentally pulling up the tube and inflating the balloon.

The control unit allows you to control the air supply and pressure (from -6,0 to +6,0 mmHg) during the study.

Preparation for balloon enteroscopy

Two to three days before the study, you should stop eating foods that are difficult for digestion and provoke flatulence (legumes, fatty meats, fish, dairy, nuts). The day before endoscopy, all foods should be excluded from the diet, except for a clear liquid (water, weak broth, weak tea, juices without pulp).

On the evening before the study, a laxative is indicated, and in the morning on the day of the manipulation, cleansing enemas are indicated.

Possible complications after the procedure

The most serious complications during enteroscopy include perforation (violation of the integrity) of the intestinal wall and bleeding. The first of these is quite rare and requires immediate surgical intervention. Bleeding may result from a biopsy or removal of small growths (polyps) and usually stops during endoscopy.

The most common complications after enteroscopy include sore throat, damage to tooth enamel, and individual intolerance to pain medications.

It should be noted that in some cases even experienced specialists cannot determine the pathology of the mucosa.

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