Endoscopic Intervention in Inflammatory Bowel Disease

Fig. 20.1

Algorithm for small-bowel examination for OGIB

For vascular lesions, an endoscopic classification of small intestinal vascular lesions (Yano–Yamamoto classification, Table 20.1) [4] is useful for selecting the hemostatic procedure. In general, the coagulation method is adopted for types Ia, Ib, and IIa. Clipping is indicated for types Iia, Iib, and III. Some type III cases, which are relatively large pulsating protrusions, require angiography or surgery. For type IV, which are large hemangiomas and other vascular lesions that are difficult to treat with endoscopic hemostasis, endoscopic tattooing, or clipping would be effective for creating landmarks for surgical treatment. As for small-bowel tumors, gastrointestinal stromal tumor (GIST) is often observed as the source of bleeding. In most cases, a GIST has ulceration and bleeding that is caused from a vascular lesion within the ulceration. APC or electronic coagulation is useful for temporary hemostasis. However, considering its potential for malignancy, surgical resection is needed for small bowel GIST to prevent re-bleeding, increase in size, and metastasis. Other tumors, such as adenomas, adenocarcinomas, malignant lymphomas, and carcinoid tumors, have the potential risk of bleeding. However, active bleeding from these lesions is not frequently seen when performing DBE.

Table 20.1

Endoscopic classification of small intestinal vascular lesions (Yano-Yamamoto classification) [5]

Type	Lesion
Type 1a	Punctuate erythema (less than 1 mm) with or without oozing
Type 1b	Patchy erythema (a few mm) with or without oozing
Type 2a	Punctuate erythema (less than 1 mm) with pulsatile bleeding
Type 2b	Pulsatile red protrusion without surrounding venous dilatation
Type 3	Pulsatile red protrusion with surrounding venous dilatation
Type 4	Other lesions not classified into any of the above categories

In IBDs, small-bowel ulcerative lesions are most commonly observed endoscopically, and they have a potential risk of bleeding (Fig. 20.2). However, massive bleeding is infrequent in patients with IBDs. Patients with Crohn’s disease sometimes have massive bleeding that requires transfusion. However, we usually cannot detect the bleeding point because of the widespread small-bowel lesions, even with BAE or CE. Therefore, angiography or surgery is required in such cases [5]. Thus, endoscopic small-bowel hemostasis is performed for the few cases in which the bleeding point can be detected with BAE (Fig. 20.3).

Fig. 20.2

Endoscopic findings of DBE show multiple open ulcers in the ileum (a, b)

Fig. 20.3

A vessel with active bleeding is seen in the ileal longitudinal ulcer (a). Hemostasis using a heater probe is performed to the vessel (b). a, b Reprinted with permission from Hirai F, et al. Small-bowel bleeding in Crohn’s disease (in Japanese). Stomach and Intestine 2010; 45: 379–387. Copyright 2009 by IGAKU-SHOIN Ltd

20.2.2 Endoscopic Mucosal Resection

Endoscopic mucosal resection (EMR) is indicated for small-bowel tumors, such as early cancers, adenomas, and other benign tumors. However, early cancers and adenomas are quite rare in the small bowel compared to the esophagus, stomach, and colon. In benign tumors, Peutz-Jeghers syndrome (PJS) usually shows multiple sessile polyps in the small intestine. These sessile polyps often cause small-bowel intussusception and require surgical intervention. When considering the benefit of preventing surgery, EMR is useful for the small-bowel polyps of PJS. Therefore, these polyps, which are large in some cases, are a good indication for EMR [6]. Since almost all small-bowel tumors of PJS are pedunculated polyps, EMR is not very difficult. However, careful snaring and cutting are important to avoid perforation because of the narrow working space in the small intestine.

In patients with IBDs, there are relatively rare cases that need EMR. Although IBD patients often have inflammatory polyps, EMR is indicated for lesions with obvious bleeding.

20.2.3 Endoscopic Balloon Dilation

Strictures of the gastrointestinal tract occur for various reasons, including inflammation, malignant tumors, and adhesions. They often cause obstructive symptoms or ileus. EBD for strictures of the esophagus, stomach, duodenum, and large intestine has been established as an effective and safe procedure [7–11]. However, EBD for strictures of the small intestine has been used only in those locations where colonoscopy or push enteroscopy can be inserted. BAE, which was recently used for small-bowel disorders, enables EBD to be performed even for deeply situated strictures of the small intestine. Endoscopic balloon dilation is indicated for small bowel tumors and inflammatory diseases such as Crohn’s disease (CD), NSAID-induced enteropathy (Fig. 20.4), intestinal tuberculosis, and chronic non-specific multiple ulcers of small intestine (Fig. 20.5). As for patients with IBDs, we consider that this procedure is a therapeutic modality that should be attempted before surgical therapy. In particular, small-bowel strictures of CD are a good indication for EBD because severe strictures of the small intestine are the major cause of surgery. When considering the relapsing nature of this disease, it is important to avoid frequent surgical therapy and short-bowel syndrome. The indication for EBD is symptomatic small-bowel stricture or a severe stricture through which an endoscope cannot be passed [7]. Basically, this endoscopic intervention is not indicated for small-bowel strictures with a deep ulcer, fistula, abscess, or severe deformity [7, 11].