Endoscopic management of small bowel obstruction caused by intragastric balloon using antegrade single-balloon enteroscopy

A 44-year old woman with type 2 diabetes mellitus who underwent intragastric balloon (Spatz3) insertion 1 year ago presented with acute abdominal pain for 3 days. Abdominal examination showed mild tenderness at the epigastrium. Laboratory investigation showed a white blood cell count of 12,630 /mm³. An abdominal computed tomography (CT) scan revealed a distally migrated intragastric balloon in the mid-jejunum causing a small bowel obstruction ([Fig. 1]). After a discussion regarding treatment options, she decided to undergo endoscopic removal using antegrade single balloon-assisted enteroscopy.

Fig. 1 An abdominal computed tomography scan revealed a distally migrated intragastric balloon (white arrow) with evidence of luminal obstruction.

On endoscopy, an intragastric balloon filled with methylene blue completely occupied the jejunal lumen ([Fig. 2]). Duodenal and proximal jejunal mucosa, especially the surrounding area, was markedly inflamed and covered with exudates ([Fig. 3], [Fig. 4]). The balloon was punctured with a 25G needle, aspirated until completely collapsed, and then retrieved using a polypectomy snare ([Video 1], [Fig. 5]). A broad-spectrum intravenous antibiotic was given post-procedure. She was able to advance her diet and was safely discharged after hospitalization for 3 days.

Fig. 2 Migrated intragastric balloon at mid-jejunum totally occupied the lumen of the mid-jejunum.

Fig. 3 Proximal jejunum showed erythematous and edematous mucosa with circumferential ulceration.

Fig. 4 Endoscopic image of surrounding jejunal mucosa showed erythematous, edematous changes, and ulceration with overlying yellowish sludge.

Video 1 Removal of the migrated intragastric balloon using antegrade single balloon-assisted enteroscopy.

Fig. 5 The balloon was firmly grasped with a polypectomy snare before gentle removal.

Intragastric balloon insertion is a minimally invasive and effective procedure with favorable safety profiles. Migration of an intragastric balloon occurred in approximately one percent of cases whereas 0.3 percent had an intestinal obstruction [1]. The risk of spontaneous balloon deflation and possible subsequent migration increases over time, especially after 6 months [2]. An intragastric balloon causing obstruction in the proximal duodenum is likely to be successfully removed endoscopically, whereas more distal migrations have been successfully treated laparoscopically, with few reports of percutaneous aspiration [2] [3]. At present, only two cases of successful endoscopic treatment of a migrated intragastric balloon using double balloon-assisted enteroscopy have been reported [4] [5]. We reported the first experience using antegrade single-balloon enteroscopy to a remove a migrated intragastric balloon. Meticulous care should be taken while gently withdrawing the scope with the attached balloon tightly grasped. Trauma to surrounding inflamed mucosa should be kept to a minimum.

Endoscopy_UCTN_Code_CPL_1AH_2AJ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Abu Dayyeh BK, Kumar N, Edmundowicz SA. et al. ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. Gastrointest Endosc 2015; 82: 425-438
• 2 Hay D, Ryan G, Somasundaram M. et al. Laparoscopic management of a migrated intragastric balloon causing mechanical small bowel obstruction: a case report and review of the literature. Ann R Coll Surg Engl 2019; 101: e172-e177
• 3 Brooks J, Rimon U, BenSaid P. et al. Percutaneous needle aspiration of a partially deflated intragastric balloon: a forgotten modality? Review of the literature. Obes Surg 2018; 28: 1781-1784
• 4 Halm U, Grothoff M, Lamberts R. Gastric balloon causing small bowel obstruction: treatment by double-balloon enteroscopy. Endoscopy 2013; 45: E78-E79
• 5 Vlachou E, Direkz S, Murino A. et al. Small bowel obstruction caused by a migrated Obalon gastric bariatric balloon: nonsurgical management by antegrade double-balloon panenteroscopy. Endoscopy 2016; 48: E403-E404

Publikationsverlauf

Artikel online veröffentlicht:
26. Januar 2022