Bowel trouble? DBE helps avoid surgery

Double Balloon Enteroscopy (DBE) has transformed endoscopic evaluation of the small intestine by allowing access to areas beyond the reach of conventional endoscopes. DBE is a 200 cm-long endoscope with two balloons attached to it. Unlike conventional push enteroscopy, which stretches and lengthens the patient’s bowel as the endoscope advances, DBE uses a push-and-pull technique that effectively shortens the intestine. This is achieved by alternately inflating and deflating two balloons — one mounted on a plastic overtube fitted over the endoscope and the other on the scope’s distal end — which pleat the intestine over the enteroscope as it progresses step-wise through the small bowel.

DBE procedures are usually carried out in hospital as day cases. You will probably be offered general anaesthetic, sedatives and/or painkillers to make you more comfortable while the DBE is carried out.

The DBE will either be inserted through the patient’s mouth or anus, depending on which part of his or her bowel needs to be accessed. The procedure takes 2-3 hours as the intestine is lengthy. It is like a regular endoscopy procedure only that the duration is longer, due to the twists in the intestine.

The intestinal tract needs to be clear for the DBE to be able to view the small intestine. If it is being inserted through the mouth then the patient will probably need to fast for around six hours before. If it is being inserted through the anus then the patient will probably be given a bowel preparation to take the day before. This causes diarrhoea so that the bowel is cleared out. Preparing the bowel for the examination can be unpleasant and time-consuming; however, it is necessary to ensure the intestinal lining can be viewed clearly.

The small intestine is around 20 feet and is a difficult area to navigate as regular endoscopy and colonoscopy cannot access it. In the past, doctors had to resort to surgery to tackle any problem in the small intestine as there was no other option. With this procedure, the small intestine can be visualised; problems like ulcers, tumours known as polyp, gastrointestinal bleeding and cancer in the small intestine can be identified and treated without surgery.

It is often seen that patients with longstanding abdomen pain and diarrhoea may have normal reports from regular endoscopy and colonoscopy. In some cases, further investigation such as a CT scan of the abdomen or capsule endoscopy may indicate a problem in the small intestine. Using this procedure, bleeding and tumours in the small intestine can be controlled by laser APC and clips, all while avoiding surgery.

Presently, there are two instruments that may be used to treat problems with the small intestine: DBE and Capsule Endoscopy. While capsule endoscopy can identify the problem and its location, it cannot help in carrying out a biopsy or endoscopic surgery.

Fewer complications

There are many advantages to employing DBE in case of previously undiagnosed conditions. To begin with, cost is comparatively lesser than surgery. A patient would only need to spare a day or at most an overnight stay to complete the procedure and return home. There are no complications except for throat pain and bloatedness. Previously, patients had to undergo surgery for a small intestine biopsy, which is now avoided through this method.

For instance, a 55-year-old man was in his office when he suddenly felt dizzy. He ended up passing black stools. He attributed it to a stomach upset from the previous night’s food. After two hours, he continued to feel dizzy, had stomach cramps and passed one more bout of black stools. He also began vomiting blood and collapsed. He was rushed to a hospital, where they evaluated that his haemoglobin dropped to 6 gm percent. They diagnosed that he had internal bleeding. He was stabilised after a round of blood transfusion.

Following this, an endoscopy showed that there were no ulcers in his stomach while a colonoscopy showed that there were no abnormalities in the large intestine. The black stool appeared to be coming from the small intestine, which indicated that the bleeding originated there. Using DBE, bleeding was identified in the upper intestine jejunum. The ulcer was clipped and Laser APC was done to stop further bleeding. A simple procedure in place of a major surgery, and the patient was home in two days.

In general, DBE has been shown to be a safe, feasible and effective procedure with a relatively high diagnostic yield.

(The writer is Chief of Medical Gastroenterology, BGS Gleneagles Global Hospitals, Bengaluru)