What is the recommended procedure and preparation for balloon enteroscopy in patients with suspected small bowel disorders?

From the Guidelines

Balloon enteroscopy is recommended for patients with suspected small bowel disorders, particularly when other imaging modalities have been inconclusive or when therapeutic intervention is a key aim, with a thorough preparation protocol to ensure optimal visualization and minimize risks. The preparation for balloon enteroscopy should include a clear liquid diet for 24 hours before the procedure, followed by an 8-12 hour fast, as well as stopping blood thinners like warfarin 5-7 days prior, aspirin and NSAIDs 7 days prior, and direct oral anticoagulants 48 hours before the procedure, all under physician guidance 1. Diabetic patients need medication adjustments, with oral hypoglycemics typically held the morning of the procedure and insulin doses reduced. Bowel preparation includes 2-4 liters of polyethylene glycol solution the evening before, ensuring complete consumption 4 hours before the scheduled procedure time. Patients should arrange transportation home as sedation prevents driving for 24 hours post-procedure. Prophylactic antibiotics are generally not required except for specific conditions like prosthetic heart valves. Some key points to consider when deciding to perform a balloon enteroscopy include:

• The ability to visualize the entire small bowel and take biopsies, which can lead to a change in management in up to 75% of patients 1
• The risks associated with the procedure, including a perforation rate of 0.12% without therapeutic intervention and 1.74% with therapeutic intervention, as well as a bleeding risk of approximately 2.5% 1
• The importance of reserving this test for patients with high clinical suspicion of small bowel disorders despite negative other imaging modalities, or in scenarios where therapeutic intervention is a key aim 1. It is essential to weigh the benefits and risks of balloon enteroscopy and to carefully select patients who will undergo this procedure, as the real-world data on both the benefits and complications are skewed by selection bias 1.

From the Research

Preparation for Balloon Enterostomy

• Patients with suspected small bowel disorders should undergo a thorough medical evaluation before balloon enteroscopy, including a review of their medical history, physical examination, and laboratory tests 2, 3, 4.
• The European Society of Gastrointestinal Endoscopy (ESGE) recommends small-bowel capsule endoscopy as the first-line examination for suspected small-bowel bleeding, given its excellent safety profile and potential to visualize the entire small-bowel mucosa 5.
• Patients should be informed about the procedure, its potential risks and benefits, and the possibility of therapeutic interventions during the procedure 3, 4.

Procedure for Balloon Enterostomy

• Balloon enteroscopy can be performed using single-balloon or double-balloon enteroscopy, with single-balloon enteroscopy being a safe and effective technique for diagnosing small bowel diseases 2, 3, 4.
• The procedure involves the insertion of a flexible tube with a balloon at the tip, which is used to advance the tube through the small intestine and visualize the mucosa 2, 3, 4.
• The ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy 5.

Diagnostic Yield and Therapeutic Interventions

• The diagnostic yield of balloon enteroscopy varies depending on the indication, with higher yields reported for patients with obscure gastrointestinal bleeding and abdominal pain 2, 3, 4.
• Therapeutic interventions, such as bleeding control and polyp removal, can be performed during balloon enteroscopy, with a therapeutic yield reported in up to 28% of cases 3, 4.
• The ESGE recommends device-assisted enteroscopy as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction 5.

Complications and Safety

• Balloon enteroscopy is generally a safe procedure, with minor complications, such as bleeding and mild acute pancreatitis, reported in a small percentage of cases 3, 4.
• The ESGE recommends the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate in patients with established Crohn's disease 5.
• Patients should be monitored closely during and after the procedure for any signs of complications, and emergency procedures should be available in case of adverse events 3, 4.