Single and double balloon enteroscopy are advanced endoscopic techniques that use balloon‑assisted technology to examine the small intestine. They help diagnose and treat GI bleeding, strictures, tumors, and inflammatory bowel disease, offering improved reach and therapeutic capability.
Introduction
Enteroscopy has revolutionised the evaluation and management of small bowel disorders, providing endoscopists with direct access to regions previously considered unreachable. Among the most significant advancements in this field are Single Balloon Enteroscopy (SBE) and Double Balloon Enteroscopy (DBE), both of which have established themselves as indispensable tools in diagnostic and therapeutic gastroenterology.
Historical Background and Importance
The small intestine has historically been a challenging region to access due to its length and convoluted anatomy. Conventional endoscopic techniques, such as push enteroscopy, were limited by poor reach and incomplete visualisation. The introduction of balloon-assisted enteroscopy in the early 2000s marked a significant milestone. Double Balloon Enteroscopy, developed by Yamamoto et al. in 2001, was soon followed by Single Balloon Enteroscopy, offering alternative approaches to deep small bowel exploration. These innovations have improved diagnostic yield, expanded therapeutic options, and transformed small bowel endoscopy into a routine clinical practice.
Principles of Balloon Enteroscopy
Mechanism of Action
Balloon enteroscopy operates on the principle of sequential advancement and pleating of the small intestine over the endoscope using inflatable balloons. By alternately inflating and deflating balloons on the scope and overtube, the endoscopist can anchor and shorten sections of the bowel, allowing for progressive insertion and detailed examination.
Equipment Overview
- Single Balloon Enteroscopy (SBE): Utilises a specialised enteroscope and an overtube equipped with a single balloon at the distal tip. The balloon is controlled by an external pump, facilitating advancement and withdrawal.
- Double Balloon Enteroscopy (DBE): Employs an enteroscope and overtube, each with a separate balloon. The coordinated inflation and deflation of both balloons enable greater control and deeper insertion into the small bowel.
- Accessories: Standard endoscopic instruments, including biopsy forceps, snares, injection needles, and therapeutic devices, can be used through the enteroscope channel.
Indications
Diagnostic Indications
- Obscure gastrointestinal bleeding (OGIB) not explained by upper or lower endoscopy
- Suspected small bowel tumours or masses
- Unexplained iron deficiency anaemia
- Chronic diarrhoea with suspected small bowel involvement
- Evaluation of abnormal imaging findings (e.g., capsule endoscopy, CT/MR enterography)
- Suspected Crohn’s disease or other inflammatory bowel diseases affecting the small intestine
Therapeutic Indications
- Polypectomy for small bowel polyps (e.g., Peutz-Jeghers syndrome)
- Dilation of small bowel strictures
- Foreign body removal
- Control of bleeding via injection, cautery, or clipping
- Stent placement in selected cases
Patient Preparation
Pre-Procedure Assessment
Comprehensive pre-procedure assessment is vital to ensure patient safety and optimise outcomes. Key steps include:
- Detailed medical history and physical examination
- Review of previous imaging and endoscopy results
- Assessment for contraindications such as severe cardiopulmonary disease, coagulopathy, or suspected bowel perforation
- Laboratory investigations: haemoglobin, coagulation profile, renal and hepatic function
Consent and Preparation Steps
- Informed consent should cover potential risks, benefits, and alternatives, including the possibility of therapeutic interventions.
- Patients are typically advised to fast for at least 6–8 hours prior to the procedure.
- Laxatives or bowel preparation may be considered, especially for antegrade (oral) enteroscopy.
- Prophylactic antibiotics are not routinely required but may be considered in high-risk individuals.
- Venous access should be established for sedation and possible fluid administration.
- Monitoring equipment for pulse, blood pressure, and oxygen saturation must be in place.
Technique
Single Balloon Enteroscopy (SBE)
- Insertion: The enteroscope is introduced via the mouth (antegrade) or anus (retrograde), depending on clinical indication.
- Balloon Inflation: The overtube balloon is inflated to anchor the bowel, while gentle advancement of the scope is performed.
- Pleating: The bowel is pleated over the overtube, allowing deeper progression.
- Sequential Advancement: The process of inflating the balloon, advancing the scope, and pleating is repeated until the desired segment is reached.
- Inspection and Intervention: Visualisation of the mucosa is performed, with biopsies or therapeutic interventions as indicated.
- Withdrawal: Careful withdrawal with continued observation is essential to avoid mucosal injury.
Double Balloon Enteroscopy (DBE)
- Insertion: The enteroscope and overtube are advanced together via the oral or anal route.
- Balloon Coordination: The distal balloon on the scope is inflated to anchor the bowel; the overtube is then advanced.
- Overtube Balloon Inflation: The overtube balloon is inflated, securing the bowel and allowing the scope to advance further.
- Alternating Inflation/Deflation: By alternately inflating and deflating the two balloons, the bowel is systematically pleated and shortened, permitting deep insertion.
- Mucosal Examination and Intervention: The enteroscope channel allows for diagnostic and therapeutic procedures, including biopsies, polypectomy, and haemostasis.
- Withdrawal: Slow withdrawal with continued examination is performed, with care to avoid complications.
Advantages
Diagnostic Yield and Reach
Both SBE and DBE offer superior diagnostic yield compared to traditional push enteroscopy, with the ability to visualise and access extensive lengths of the small intestine. DBE, owing to its dual balloon system, generally achieves greater depth of insertion and higher rates of complete small bowel examination. SBE, while slightly less extensive, provides comparable diagnostic utility with a simplified setup.
Therapeutic Potential
Balloon enteroscopy facilitates a wide range of therapeutic interventions, including polypectomy, stricture dilation, haemostasis, and foreign body retrieval. This versatility allows for comprehensive management of small bowel pathology during a single procedure.
Safety Profile
When performed by experienced endoscopists, both procedures have favourable safety profiles and are well tolerated by most patients. Sedation requirements are similar to those for colonoscopy, and the risk of serious adverse events is low.
Limitations
Technical Challenges
Balloon enteroscopy is technically demanding and requires specialised training. The procedure is time-consuming, often lasting 1–2 hours, and may require fluoroscopic guidance in complex cases. Incomplete visualisation can occur, particularly in patients with altered anatomy or adhesions.
Patient Factors
Obesity, prior abdominal surgery, and anatomical variations can limit the reach and effectiveness of balloon enteroscopy. Patient tolerance may be reduced in those with significant comorbidities.
Incomplete Visualisation
Despite advances, complete examination of the small bowel is not always possible. Factors such as looping, angulation, and strictures may impede progress, necessitating alternative diagnostic modalities.
Complications
Common Complications
- Abdominal pain: Mild to moderate discomfort is common post-procedure and usually self-limited.
- Nausea and vomiting: Related to sedation or bowel manipulation.
- Minor mucosal injury: Small erosions or superficial bleeding may occur.
Rare Complications
- Perforation: Occurs in less than 1% of cases, typically in patients with pre-existing pathology.
- Pancreatitis: Particularly after retrograde DBE, due to manipulation near the ampulla of Vater.
- Significant bleeding: Usually associated with therapeutic interventions.
- Cardiopulmonary events: Related to sedation, especially in high-risk patients.
Management Strategies
Most complications are managed conservatively with observation and supportive care. Perforation or severe bleeding may necessitate surgical intervention. Timely recognition and multidisciplinary management are essential for optimal outcomes.
Nursing Care for Patients Undergoing Single and Double Balloon Enteroscopy
Crohn’s disease evaluation, and retrieval of foreign bodies. The complexity and invasiveness of these procedures demand meticulous nursing care to ensure patient safety, comfort, and optimal outcomes.
Pre-Procedure Nursing Care
Effective nursing care begins well before the procedure itself, focusing on comprehensive patient assessment, preparation, and education. Nurses play a pivotal role in coordinating multidisciplinary care, preparing the patient physically and psychologically, and minimizing the risk of complications.
1. Patient Assessment:
A thorough review of the patient’s medical history is essential. Nurses should assess for comorbidities such as cardiovascular disease, respiratory disorders, coagulopathies, and previous adverse reactions to anesthesia or sedation. Baseline vital signs, laboratory results (including renal function and coagulation profile), and allergies must be documented. Special attention should be paid to medications that may affect bleeding risk, such as anticoagulants or antiplatelet agents.
2. Informed Consent:
Nurses must verify that the patient has received and understood information about the procedure, including its risks, benefits, and alternatives. Ensuring that the consent form is properly signed and witnessed is a crucial legal and ethical responsibility.
3. Preparation Instructions:
Patients are typically required to fast for 6–8 hours prior to the procedure to reduce the risk of aspiration. Bowel preparation may be necessary, depending on the procedural route (oral or anal), and nurses should provide clear, written and verbal instructions regarding the timing and method of bowel cleansing. Monitoring for adherence is important, as inadequate preparation can compromise the procedure’s success.
4. Allergy Checks:
Confirming allergies to medications (e.g., sedatives, contrast agents, antibiotics), latex, and adhesives is vital. Any concerns should be communicated to the endoscopy team immediately.
5. Psychological Support:
Anxiety is common prior to enteroscopy, given its invasive nature. Nurses should address patient concerns, provide reassurance, and offer information about what to expect before, during, and after the procedure. Establishing a trusting relationship can improve cooperation and reduce pre-procedure stress.
Intra-Procedure Nursing Responsibilities
During balloon enteroscopy, nurses are instrumental in maintaining patient safety, supporting the endoscopist, and ensuring procedural efficiency. Key responsibilities include:
- Vital Signs Monitoring: Continuous monitoring of heart rate, blood pressure, respiratory rate, oxygen saturation, and level of consciousness is mandatory. Any deviations from baseline should be promptly reported to the medical team.
- Assisting the Endoscopist: Nurses assist with equipment setup, balloon inflation/deflation, and provide necessary instruments or supplies. They should anticipate the needs of the endoscopist and facilitate smooth workflow.
- Sedation Management: Sedation is commonly used to minimize discomfort and facilitate cooperation. Nurses are responsible for administering sedatives as prescribed, monitoring for adverse reactions, and ensuring airway patency. They should be prepared to initiate emergency protocols if complications such as respiratory depression occur.
- Patient Positioning: Proper positioning (usually left lateral or supine) is necessary for optimal access and visualization. Nurses must ensure patient comfort and prevent pressure injuries by using appropriate padding and repositioning as needed.
- Infection Control: Strict adherence to aseptic techniques is required throughout the procedure. This includes hand hygiene, use of personal protective equipment (PPE), and proper handling and disposal of contaminated materials.
Post-Procedure Nursing Care
The post-procedure phase focuses on monitoring for complications, managing discomfort, and facilitating recovery. Nursing interventions should be tailored to the specific needs of each patient.
Recovery Monitoring: Patients are transferred to a recovery area for observation until sedation wears off. Nurses should monitor vital signs closely, assess for airway patency, and evaluate the patient’s level of consciousness. Early detection of adverse events is essential.
- Pain Management: Mild abdominal discomfort, bloating, or sore throat may occur post-procedure. Nurses should assess pain levels using standardized scales and provide analgesia as prescribed. Non-pharmacological measures, such as reassurance and positioning, may also be beneficial.
- Observation for Complications: Bleeding, perforation, infection, and pancreatitis are serious risks associated with balloon enteroscopy. Nurses should observe for signs such as persistent abdominal pain, tachycardia, hypotension, fever, or hematemesis/melena. Prompt reporting and intervention are critical.
- Documentation: Accurate and timely documentation of the procedure, patient’s response, medications administered, and any complications is essential for continuity of care and legal compliance.
Patient Education
Patient education is a cornerstone of nursing care for balloon enteroscopy. Clear communication helps patients understand the procedure, anticipate normal and abnormal findings, and recognize when to seek medical attention.
- Pre-Procedure Instructions: Nurses should review fasting and bowel preparation protocols, explain the need for medication adjustments, and answer questions regarding the procedure’s duration and expected sensations.
- Post-Procedure Instructions: Patients must be informed about expected recovery timelines, activity restrictions, dietary recommendations, and warning signs of complications. Written instructions are recommended to reinforce verbal guidance.
- Signs of Complications: Education should focus on recognizing symptoms such as severe abdominal pain, persistent vomiting, fever, rectal bleeding, or difficulty breathing. Patients should be instructed to contact their healthcare provider immediately if these occur.
- Follow-Up Care: Nurses should emphasize the importance of attending scheduled follow-up appointments, completing laboratory tests as ordered, and reporting any new or worsening symptoms.
Complications and Nursing Interventions
While balloon enteroscopy is generally safe, complications can arise. Early detection and prompt intervention are essential for minimizing morbidity.
- Bleeding: May result from biopsy, polypectomy, or mucosal trauma. Nurses should monitor for signs of hemorrhage and initiate protocols for fluid resuscitation, blood transfusion, and surgical consultation if needed.
- Perforation: Presents as sudden, severe abdominal pain with signs of peritonitis. Immediate notification of the medical team, nil-by-mouth status, and preparation for possible surgical intervention are critical.
- Infection: Fever, chills, and localized pain may indicate infection. Nurses should obtain cultures as ordered, administer antibiotics, and monitor for sepsis.
- Pancreatitis: Rare but serious, more common with DBE. Symptoms include epigastric pain and elevated enzymes. Supportive care and specialist referral are required.
- Adverse Reaction to Sedation: Hypotension, hypoxia, or paradoxical agitation may occur. Nurses must be prepared to provide airway support, administer reversal agents, and summon emergency assistance.
Best Practices
Nursing care for balloon enteroscopy patients is multifaceted, requiring clinical expertise, vigilance, and compassionate communication. Best practices include:
- Comprehensive pre-procedure assessment and preparation.
- Continuous monitoring and rapid response to intra- and post-procedure complications.
- Clear and empathetic patient education.
- Meticulous documentation and infection control.
- Collaboration with the multidisciplinary team to ensure seamless care.
- Commitment to patient-centered care and safety.
REFERENCES
- American Society for Gastrointestinal Endoscopy. Media Backgrounder Balloon Assisted or “Deep” Enteroscopy https://www.asge.org/home/about-asge/newsroom/media-backgrounders-detail/balloon-assisted-enteroscopy.
- ASGE Technology Committee; Chauhan SS, Manfredi MA, et al. Enteroscopy. https://pubmed.ncbi.nlm.nih.gov/26388546/. Gastrointest Endosc. 2015 Dec;82(6):975-90.
- Lo SK, Paski S, Liu Q. Tips for successful deep enteroscopy . https://pubmed.ncbi.nlm.nih.gov/34265795/. Curr Opin Gastroenterol. 2021 Sep 1;37(5):434-440.
- Nehme F, Goyal H, Perisetti A, et al. The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy. https://pubmed.ncbi.nlm.nih.gov/35004760/. Front Med (Lausanne). 2021 Dec 23;8:792668.
- Skinner M, Velázquez-Aviña J, Mönkemüller K. Using balloon-overtube-assisted enteroscopy for postoperative endoscopic retrograde cholangiopancreatography. Therap Adv Gastroenterol. 2014 Nov;7(6):269-79. doi: 10.1177/1756283X14544154. PMID: 25364385; PMCID: PMC4212471.
- Koh JTE, Kim Wei L, Francisco CP, Ravi R, Chan W, Khor C, Asokkumar R. Double balloon enteroscopy versus single balloon enteroscopy: A comparative study. Medicine (Baltimore). 2024 May 17;103(20):e38119. doi: 10.1097/MD.0000000000038119. PMID: 38758917; PMCID: PMC11098199.
- Schneider M, Höllerich J, Beyna T. Device-assisted enteroscopy: A review of available techniques and upcoming new technologies. https://pubmed.ncbi.nlm.nih.gov/31367155/). World J Gastroenterol. 2019 Jul 21;25(27):3538-3545.
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