Pre-Procedure Evaluation and Preparation for Small Bowel Enteroscopy
For oral (antegrade) device-assisted enteroscopy, patients must fast for at least 12 hours and avoid all liquids for 4 hours before the procedure, while retrograde examination requires full colonoscopy bowel preparation. 1
Patient Selection and Risk Assessment
Device-assisted enteroscopy should only be performed when a change in clinical management is intended or expected, given the 0.7% major complication rate. 1
Pre-Procedure Evaluation Requirements
- Obtain informed consent detailing risks, benefits, and expected outcomes of the procedure 1
- Review complete blood count and coagulation parameters with recommended thresholds of platelet count >50,000/mL and INR <1.5 1
- Assess for contraindications including known or suspected small bowel obstruction, strictures, or altered anatomy that may complicate the procedure 2
- Consider patency capsule in patients with established Crohn's disease before capsule endoscopy to decrease retention risk 2
Antithrombotic Management
- Continue dual-antiplatelet therapy without interruption for enteroscopy, as no significant increase in bleeding risk has been reported 1
- Hold oral anticoagulants for the procedure but resume with the evening dose after placement 1
- Hold unfractionated heparin for placement but can administer 2-6 hours after the procedure 1
- If antithrombotics are held, resume as soon as possible in consultation with the prescribing service 1
Bowel Preparation Protocol
For Antegrade (Oral) Approach
- Fasting for at least 12 hours from all solid foods is required 1, 3
- Avoid liquid consumption for 4 hours immediately before the procedure 1, 3
- No bowel purgative preparation is needed for the oral approach, unlike colonoscopy 1
For Retrograde (Anal) Approach
- Standard colonoscopy preparation is mandatory, identical to conventional colonoscopy requirements 1, 3
- Split-dose polyethylene glycol (PEG)-based purgative is recommended when bowel preparation is required 1
Antibiotic Prophylaxis
- Administer single-dose first-generation cephalosporin immediately before percutaneous enteral access procedures to reduce peristomal infection risk 1
- Alternative agents include clindamycin or vancomycin in patients with documented cephalosporin allergy 1
- No additional prophylaxis needed if patient is already on systemic antibiotics 1
Sedation and Anesthesia Planning
- Deep sedation or general anesthesia is required for device-assisted enteroscopy due to the clinically challenging nature of the procedure 1, 3
- Arrange appropriate anesthesia support before scheduling the procedure 1
Equipment and Technical Preparation
- CO2 insufflation instead of room air is highly recommended as it improves intubation depth and reduces post-procedural discomfort, particularly preventing paralytic ileus 1, 3
- Ensure availability of device-assisted enteroscopy equipment (single-balloon, double-balloon, or spiral enteroscopy systems) 1
Common Pitfalls to Avoid
- Failure to use CO2 insufflation is the single most important modifiable risk factor for complications, particularly paralytic ileus—always use CO2 instead of room air 3
- Inadequate bowel preparation for retrograde approach can lead to premature termination and poor visualization—ensure full colonoscopy-level preparation 3
- Proceeding without appropriate sedation planning will result in procedure failure given the technical demands 1
- Performing the procedure without clear indication exposes patients to unnecessary 0.7% major complication risk 1
Special Populations
Inflammatory Bowel Disease Patients
- Bowel preparation with split-dose PEG-based purgative is recommended for IBD endoscopy 1
- Use of bowel preparation and simeticone is recommended for capsule endoscopy in IBD patients 1
- The procedure is as safe in IBD patients as in other populations with similar complication rates 1