Upper and Small Bowel Endoscopy

Esophagus, stomach and duodenum may be involved by Crohn's disease [23]. Even in the upper gastrointestinal tract, aphthous ulcer is the most common lesion, but mucosal nodularity and stenosis may be seen [24]. The presence of inflamed mucosa in this portion of the digestive tract is important for differential diagnosis between Crohn's disease and UC. Radiologic procedures with barium as small-bowel follow-through or enteroclysis are important for diagnosis of Crohn's disease localised in the small bowel and for demonstration of strictures and fistu-lae [25]. However, a study comparing small-bowel barium examination with enteroclysis and ileoscopy showed that the radiology missed 27% of severe inflammatory changes and 50% of mild inflammatory changes [26]. Push enteroscopy allows evaluation of the proximal small bowel whereas intraoperative enteroscopy is used to explore the distal small intestine [27]. The former procedure is useful especially in patients without known Crohn's disease but who are suspected to have small-bowel involvement. However, a recent study reported that in patients with known Crohn's disease, capsule endoscopy has a higher yield in detecting mucosal involvement of the small bowel than does push enteroscopy and entero-clysis [28]. Intraoperative enteroscopy compared with preoperative radiography is able to find more intestinal lesions, especially small ulcers and inflammatory polyps [29].

A new method of carrying out enteroscopy consists of using a double-balloon technique in which a first balloon is placed on the tip of the enteroscope and the second balloon on the tip of the overtube. This technique allows far better insertability and maneuverability compared with conventional methods. Preliminary experience reported the performance of this procedure on eight patients with abdominal symptoms, three of whom were diagnosed with Crohn's disease [30]. Enteroscopy with the double-balloon technique was carried out using the oral approach in all patients and additionally with the anal approach in four patients. In two patients, it was possible to examine the whole small bowel, with a visualised total length of between 180 cm and 500 cm. Recently, Yamamoto reviewed the publications on double-balloon endoscopy, concluding that this method has the potential to be the standard of enteroscopy by replacing conventional push and intraoperative enteroscopy for diagnosis by means of bioptic specimens and therapeutic endoscopy of the small bowel [31].

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