European Society of Gastrointestinal Endoscopy (ESGE) Guidelines: flexible enteroscopy for diagnosis and treatment of small-bowel diseases

Introduction

Until recently, large parts of the small bowel were not accessible with nonsurgical endoscopic techniques. In this scenario, the advent of video capsule endoscopy and balloon-assisted enteroscopy represented a major breakthrough. Although capsule endoscopy is a safe method that may provide imaging of the entire small bowel, major drawbacks are that biopsy sampling and endoscopic treatment cannot be performed; moreover, in many cases interpretation of nonspecific findings remains a concern.

In contrast to capsule endoscopy, flexible enteroscopy with push enteroscopy or balloon-assisted enteroscopy is labour-intensive and more invasive but allows real-time-controlled observation with the option for tissue sampling and endoscopic treatment. Push enteroscopy was established during the 1980 s but due to excessive loop formation it allows only limited visualization of the small intestine. This limitation has been overcome by the invention of balloon-assisted enteroscopy, which may permit imaging of the entire small bowel by threading it onto the overtube, thereby minimizing looping and maximizing insertion. Initially, a double balloon enteroscopy (DBE) system was developed by Yamamoto and colleagues in 2001 [1]. This system has rapidly gained an established role in small-bowel investigation and therapy and is widely applied in clinical practice. Importantly, besides small-bowel endoscopy the DBE technique can be applied for additional indications, for example difficult colonoscopies, for gaining access to the pancreatic and biliary tract in patients with a surgically modified gastrointestinal tract, and access to the stomach in patients after bariatric surgery. Very recently, another balloon-assisted enteroscopy device with only one balloon at the tip of the overtube was introduced as the single balloon enteroscopy (SBE) system.

The present report constitutes a guide to the clinical application of flexible enteroscopy systems (push enteroscopy, DBE, and SBE) in the small bowel, based on published findings as well as personal experience of the authors ([Table 1]). Recommendations concerning DBE are partially derived from a consensus that was developed during the 2nd International Conference on DBE in Berlin, 14 – 15 June 2007.

Table 1 Summary of ESGE guidelines for flexible endoscopy including category of evidence and grading of recommendations (see Table 2) ESGE guidelines for flexible enteroscopy Category of evidence Grading of recommendation Diagnostic efficacy of DBE for mid-gastrointestinal bleeding is superior to push enteroscopy 37 38 1b A Diagnostic efficacy of DBE for mid-gastrointestinal bleeding is similar to video capsule endoscopy 42 43 44 1b A Patients with bleeding sites identified on capsule endoscopy should subsequently undergo flexible enteroscopy for endoscopic treatment 1 7 15 16 17 18 19 20 21 22 2b B Flexible enteroscopy is the preferred primary approach in patients with active ongoing mid-gastrointestinal bleeding with high probability of therapeutic interventions 2b B Intraperative endoscopy should be reserved for patients with persistent significant mid-gastrointestinal bleeding in whom the bleeding source remains undiagnosed by flexible enteroscopy 5 B Flexible enteroscopy is the preferred primary approach for small-bowel evaluation in patients with suspected stenoses or surgically modified anatomy 23 24 25 26 2b B The choice of either anal or oral route for the primary procedure depends on the suspected location of pathology within the small bowel (e. g. pathological findings detected by capsule endoscopy or other imaging modalities) 55 2b B Endoscopic balloon dilation of small-bowel fibrostenotic Crohn’s strictures is a valuable therapeutic option 24 25 26 4 C Resection of polyps within the small bowel can be performed with a complication risk similar to that of polyps in the right colon 24 62 63 4 C DBE allows endoscopic access to the biliary tree after Billroth II or Roux-en-Y operation 28 29 30 2b B DBE, double balloon enteroscopy; ESGE, European Society of Gastrointestinal Endoscopy.

Table 2 Levels of evidence and grades of recommendation based on the Oxford Centre for Evidence Based Medicine (http://www.clbm.net/index.aspx?0 = 1025) Level Individual study 1 a Systematic review with homogeneity level 1 diagnostic studies 1 b Validating cohort study with good reference standards 1 c Specificity is so high that a positive result rules in the diagnosis or sensitivity is so high that a negative study rules out the diagnosis 2 a Systematic review with homogeneity of level > 2 diagnostic studies 2 b Exploratory cohort study with good reference standards 3 a Systematic review with homogeneity of 3b and better studies 3 b Nonconsecutive study; or without consistently applied reference standards 4 Case–control study, poor or nonindependent reference standard 5 Expert opinion without explicit critical appraisal, or based on physiology, bench research, or ”first principle” Grades of recommendation A Consistent level 1 studies B Consistent level 2 or three studies or extrapolations from level 1 studies C Level 4 studies or extrapolations from level 2 or 3 studies D Level 5 evidence or troublingly inconsistent or inconclusive studies of any level

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