The small bowel distal to the duodenum was once thought to be an unreachable area for an endoscope.
However, the recent development of double and single balloon enteroscopy now allows exploration of the small bowel. Balloon enteroscopy involves sequen- tially infl ating and defl ating the balloon or balloons, which allows the endoscope to be advanced using a device called an overtube. The enteroscope can be advanced by pulling or pleating the small bowel, like an accordion, onto the instrument. Indications for enteroscopy are both therapeutic and diagnostic.
Hemostasis for small bowel bleeding, small bowel polypectomy, and balloon dilation are possible thera- pies that can be performed with this procedure.
Complications of enteroscopy include bleeding, per- foration, and pancreatitis.
Wireless video capsule endoscopy has emerged in the last 5 years as a non-invasive technology that can also provide diagnostic imaging of the small intestine.9
FIGURE 10–11 ■ (a) ERCP in patient with primary sclerosing cholangitis; (b) endoscopic ultrasound.
a b
Small bowel capsules are commercially available from Given Imaging (PillCam SB) and Olympus (EndoCap- sule). Both capsules take two video images per second, which are transmitted wirelessly to a recorder, which can acquire up to 55,000 images over approximately 8 hours. The patient wears an eight-lead sensor array that picks up the signal and also provides information about capsule location within the abdomen. The array is connected to a recording device, which is worn on a belt (Figure 10–12a). The video capsules from both companies currently measure 11 ⫻ 26 mm ( Figure 10–12b).
Preparation for capsule endoscopy is variable, and at our institution involves a regular diet until noon on the day before the procedure. Non-red clear liquids can be taken up to 3 hours prior to the procedure. A mild bowel prep consisting of 17 g of PEG-3350 in the afternoon and again at bedtime is administered in order
to minimize the amount of dark bile and secretions.
Capsules are swallowed with water. A clear liquid diet can be resumed after 2 hours; food and medication can be ingested 4 hours after the video capsule is swallowed.
Indications for capsule endoscopy include look- ing for an obscure source of gastrointestinal bleeding, suspected Crohn’s disease, celiac disease, and polyps in patients with hereditary polyposis syndromes. Capsule endoscopy is FDA approved for children 10 years of age and older; however, capsule studies have been done in patients as young as 2.5 years, with one case report of successful capsule in an 18 month old. Young patients who cannot swallow the capsule can have it placed endoscopically using a delivery device. The main risk associated with capsule endoscopy is capsule retention, which is clinically significant in less than 1% of patients.
FIGURE 10–12 ■ Wireless capsule endoscopy (a) Antenna array (b) antenna placement diagram (c) closeup view of capsule endo- scope, with clear optical dome and LED lights on the right side.
a b
c
Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116:1736–1754.
6. Cotton PB, Williams CB. Upper endoscopy: diagnostic techniques. In: Cotton PB, Williams CB, eds. Practical Gas- trointestinal Endoscopy: The Fundamentals. Singapore:
Markono Print Media Pte Ltd; 2008:37–58.
7. Gershman G, Ament M. Pediatric colonoscopy. In: Gersh- man G, Ament M, eds. Practical Pediatric Gastrointestinal Endoscopy. Malden, MA: Blackwell Publishing Inc.;
2007:132–168.
8. Fox V. Pediatric endoscopy. In: Classen M, Tytgat G, Light- dale CJ, eds. Gastroenterological Endoscopy. New York: Thi- eme; 2002:720–748.
9. Lee KK, Anderson MA, Baron TH, et al. Modifi cations in endoscopic practice for pediatric patients. Gastrointest Endosc. 2008;67:1–9.
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1. Hirschowitz BI, Modlin IM. History of endoscopy: the American perspective. In: Classen M, Tytgat GNJ, Lightdale CJ, eds. Gastroenterological Endoscopy. Stuttgart, Germany:
Thieme; 2002:2–16.
2. Gilger MA. Gastroenterologic endoscopy in children: past, present, and future. Curr Opin Pediatr. 2001;13:429–434.
3. Heard L. Taking care of the little things: preparation of the pediatric endoscopy patient. Gastroenterol Nurs.
2008;31:108–112.
4. Fredette ME, Lightdale JR. Endoscopic sedation in pediat- ric practice. Gastrointest Endosc Clin N Am. 2008;18:
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INTRODUCTION
Gastroesophageal refl ux (GER), defi ned as the passage of gastric contents into the esophagus, occurs on a daily basis as a normal process in infants, children, and adults.
Most episodes of physiologic reflux are transient, asymptomatic, and reach only the distal esophagus.
Gastroesophageal reflux disease (GERD) is distin- guished by refl ux into the esophagus resulting in well- defi ned symptoms or medical problems (see Chapter 12).
When children present with atypical complaints or extraesophageal symptoms, testing may be necessary to document the presence or absence of pathologic refl ux, or the association between refl ux events and specifi c symptoms.1
While endoscopy can be helpful in documenting acid damage to the esophageal mucosa in the form of erosions or ulcers, the majority of patients with symp- toms of GERD do not have endoscopic or pathologic evidence of esophagitis.2 Tests designed to detect the presence of GER have been developed.
The fi rst test utilized was esophageal pH monitor- ing, in which an electrode designed to detect changes in pH is used to assess the frequency and duration of acidic refl ux present in the distal esophagus. Over the years the advantages, disadvantages, and limitations of tradi- tional, catheter-based esophageal pH monitoring have become better defi ned, with a subsequent evolution of newer diagnostic techniques. Wireless methods to detect acidic contents in the esophagus have now become available (Bravo capsule). Additionally, we have seen the development of the technical possibility of measuring both acidic and non-acidic refl ux with multichannel intraluminal impedance (MII). In the present chapter we will review the current techniques that are being used for the dynamic detection of refl ux episodes.