Jonathan A. Leighton and Shabana F. Pasha Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA The small bowel is a tortuous tubular organ, 600–800 cm in length. Anatomically, it lies between the pylorus and ileocecal valve. It comprises three segments: the duodenum, jejunum, and ileum. The duodenum is the most proximal and shortest segment of the small bowel, with a mean length of 25 cm. It is shaped like a C‐loop. This is the only segment located in the retroperitoneal space and is therefore relatively fixed. It includes the duodenal bulb, and the second, third and fourth portions, and it extends up to the ligament of Treitz. The ampulla of Vater lies in the second portion of the duodenum. The remainder of the small bowel is suspended in the peritoneal cavity by a broad‐based mesentery, and is freely mobile. The proximal 40% of this portion is the jejunum and the remaining distal 60% is the ileum. The luminal surface of the small bowel has numerous folds called the plicae circulares. The plicae are most prominent in the proximal small bowel, and decrease in number distally. The length and mobility of the small bowel have posed challenges to its evaluation in the past. The introduction of capsule endoscopy and deep enteroscopy has led to a significant improvement in endoscopic evaluation and management of small bowel disorders, including obscure gastrointestinal bleeding, Crohn’s disease, and small bowel tumors. (Figures 76.1–76.3). The entire small bowel can be visualized in a noninvasive manner using capsule endoscopy. The patency capsule is useful to confirm the patency of the gastrointestinal tract prior to administration of the capsule in patients with a suspected obstruction or stricture (Figure 76.4). Therapeutic management of small bowel lesions is now possible with deep enteroscopy techniques, including balloon‐assisted enteroscopy and spiral enteroscopy. Each of these devices has unique advantages and disadvantages that should be taken into consideration during selection of the appropriate modality. Capsule endoscopy and deep enteroscopy techniques are often considered as complementary tests, and utilized together in the evaluation of suspected small bowel disorders. The images in this chapter illustrate the clinical usefulness of small bowel endoscopic modalities in the evaluation of patients with vascular lesions (Videos 76.1–76.3), inflammatory lesions (Figures 76.5 and 76.11), celiac sprue (Figure 76.6), polyps (Figures 76.7, 76.8, 76.10), and tumors (Figure 76.9). Figure 76.1 Algorithm for evaluation and management of patients with obscure gastrointestinal bleeding. Source: Kuo J, Pasha SF, Leighton JA. The Clinician’s Guide to Suspected Small Bowel Bleeding. Am J Gastroenterol 2019; 114(4): 591598. Reproduced with permission of Wolters Kluwer Health. Figure 76.2 Algorithm for evaluation of patients with suspected Crohn’s disease. Source: Mergener K, Ponchon T, Gralnek I, et al. Literature review and recommendations for clinical application of small‐bowel capsule endoscopy, based on a panel discussion by international experts: consensus statements for small bowel capsule endoscopy, 2006/2007. Endoscopy 2007;39:895. Erratum in: Endoscopy 2007;39:1105. Reproduced with permission of Thieme Publishing Group. Figure 76.3 Algorithm for evaluation and management of patients with suspected small bowel tumor. Source: Adapted from Leighton JA. The role of endoscopic imaging of the small bowel in clinical practice. Am J Gastroenterol 2011;106:27. Reproduced with permission of Wolters Kluwer Health. Figure 76.4 Patency capsule. The Agile© Patency Capsule System (Medtronic Imaging Ltd, Yoqneam, Israel) contains a radiofrequency identification tag covered with a dissolvable body of lactose and barium with a timer plug on either side. Image reproduced with permission. Figure 76.5 Capsule endoscopy showing mucosal ulcerations in the distal ileum. This 45‐year‐old male presented with abdominal pain and diarrhea. Ileocolonoscopy and computed tomography enterography were both negative. The diagnosis of Crohn’s disease was confirmed with retrograde double‐balloon enteroscopy and biopsies. Figure 76.6 Capsule endoscopy showing mucosal nodularity and fissuring in the proximal small bowel. This 54‐year‐old female had iron deficiency anemia and an elevated immunoglobulin A tissue transglutaminase antibody titer of 75 U/mL. The diagnosis of celiac disease was confirmed with small bowel biopsies. Figure 76.7 Capsule endoscopy view of a hamartomatous polyp in the small bowel of a 25‐year‐old female with Peutz–Jeghers syndrome. Figure 76.8 (a) Capsule endoscopy showing a polypoid lesion with active bleeding in the midjejunum. This 61‐year‐old patient presented with hematochezia. (b) Double‐balloon enteroscopy (DBE) showing polypoid hemangioma. Figure 76.9 Capsule endoscopy showing a small bowel tumor in the proximal‐mid jejunum. The capsule was retained proximal to the tumor. Surgical resection of the tumor was performed. Pathology was consistent with a melanoma. Figure 76.10 Large hamartomatous polyp in the ileum diagnosed on retrograde double‐balloon enteroscopy. This 72‐year‐old male had intermittent hematochezia. Two capsule endoscopies performed prior to DBE were negative. Figure 76.11 (a,b) Ulcerated stricture seen on CE and retrograde DBE in a patient with history of NSAID use. There were multiple distal ileal strictures with interposed normal mucosa.
CHAPTER 76
Capsule and small bowel endoscopy
![](https://freepngimg.com/download/social_media/63059-media-icons-telegram-twitter-blog-computer-social.png)
Stay updated, free articles. Join our Telegram channel
![](https://clinicalpub.com/wp-content/uploads/2023/09/256.png)
Full access? Get Clinical Tree
![](https://videdental.com/wp-content/uploads/2023/09/appstore.png)
![](https://videdental.com/wp-content/uploads/2023/09/google-play.png)