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Enteroscopy

Enteroscopy is a nonsurgical endoscopic procedure that enables direct visualization of the small intestine (small bowel) using a specialized, flexible endoscope, allowing for diagnosis and treatment of conditions in this often inaccessible part of the gastrointestinal tract.^[1] The small intestine, measuring approximately 20 feet (6 meters) in length and about 1 inch (2.5 cm) in diameter, connects the stomach to the large intestine and is crucial for nutrient absorption, but its coiled structure historically limited examination to indirect methods like X-rays or capsule imaging.^[2] Developed to address these challenges, enteroscopy has evolved from basic push techniques in the 1970s to advanced device-assisted methods that can reach the entire small bowel.^[3] The primary purposes of enteroscopy include investigating obscure gastrointestinal bleeding and other small bowel disorders, such as tumors, polyps, strictures, and malabsorption syndromes, often when other tests like colonoscopy or upper endoscopy are inconclusive.^[4] During the procedure, healthcare providers can perform biopsies, remove polyps or foreign objects, control bleeding, and dilate strictures.^[1] Several types of enteroscopy exist, including push enteroscopy for the proximal small intestine, balloon-assisted enteroscopy (double- and single-balloon variants) for deeper access via antegrade or retrograde routes, and spiral enteroscopy (including the motorized version introduced in 2015) for rapid advancement.^[2]^[5] These techniques are performed under sedation or general anesthesia by gastroenterologists and have advanced to improve accessibility and efficacy in managing small bowel disorders.^[6]

Overview

Definition and Purpose

Enteroscopy is an endoscopic procedure designed to visualize and potentially intervene in the small intestine, also known as the small bowel, which is a coiled tubular structure approximately 20 feet (6 meters) long in adults and connects the stomach to the large intestine.^[7]^[8] This procedure employs specialized endoscopes that can navigate beyond the reach of standard upper or lower gastrointestinal endoscopes, targeting the jejunum and ileum sections of the small bowel where access is challenging due to the organ's length and tortuosity.^[1]^[9] The primary purpose of enteroscopy is to enable direct inspection of the small bowel mucosa for diagnostic evaluation, particularly in cases of obscure gastrointestinal bleeding, tumors, inflammatory conditions such as Crohn's disease, or malabsorption syndromes.^[9] Therapeutically, it facilitates interventions including tissue biopsies for histopathological analysis, removal of polyps or lesions, dilation of strictures, and control of bleeding sources through cauterization or clipping.^[1] These capabilities make enteroscopy essential for managing small bowel disorders that are difficult to assess noninvasively.^[9] Unlike broader endoscopic techniques such as esophagogastroduodenoscopy (EGD), which examines the esophagus, stomach, and only the proximal duodenum, or colonoscopy, which reaches the terminal ileum from the distal end, enteroscopy specifically focuses on the mid-to-distal small bowel regions inaccessible by these methods.^[9] It overcomes the limitations of radiological imaging modalities like CT enterography by providing real-time, high-resolution mucosal visualization and the ability to obtain targeted tissue samples or perform immediate treatments, rather than relying solely on indirect anatomic depictions.^[1]^[9]

Anatomy and Physiology Involved

The small intestine, the primary site visualized during enteroscopy, is a coiled tubular organ approximately 6 to 7 meters in length in adults, extending from the pylorus of the stomach to the ileocecal valve where it connects to the large intestine.^[10] It is divided into three distinct regions: the duodenum, a short C-shaped segment about 25-30 cm long that receives chyme from the stomach and secretions from the pancreas and liver; the jejunum, comprising the proximal two-fifths and characterized by prominent circular folds (plicae circulares) that enhance surface area for absorption; and the ileum, the distal three-fifths ending in the terminal ileum, which features the ileocecal valve to prevent reflux from the colon.^[11] This segmentation reflects a gradient of function, with the duodenum focused on initial digestion, the jejunum on primary nutrient uptake, and the ileum on final absorption and transit regulation.^[12] The mucosa of the small intestine is highly specialized for digestion and absorption, featuring villi—finger-like projections covered in epithelial cells with microvilli that form a brush border to maximize surface area, estimated at 200-300 square meters overall.^[12] Physiological processes include enzymatic breakdown of carbohydrates, proteins, and fats by brush border enzymes and pancreatic secretions, followed by active and passive transport of nutrients such as glucose, amino acids, and fatty acids via enterocytes.^[12] The jejunum primarily absorbs water-soluble vitamins, minerals, and most calories, while the ileum specializes in bile salts, vitamin B12, and remaining fats, facilitated by specific transporters like the intrinsic factor-B12 complex.^[12] Additionally, the ileum contains Peyer's patches, aggregates of lymphoid tissue that contribute to immune surveillance by sampling luminal antigens and initiating mucosal immunity against pathogens.^[12] Peristaltic contractions propel contents distally, coordinated by the enteric nervous system, while the organ's tortuous, looped anatomy within the peritoneal cavity poses challenges for complete endoscopic intubation.^[3] Pathophysiologically, the small intestine's structure predisposes certain segments to specific disorders; for instance, the ileum is prone to transmural inflammation as in Crohn's disease, the jejunum to villous atrophy in celiac disease triggered by gluten exposure, and various sites to vascular malformations such as arteriovenous malformations that can lead to obscure gastrointestinal bleeding.^[13]^[14]^[15] These vulnerabilities arise from the organ's extensive vascular supply and immune-rich environment, which can amplify inflammatory or hemorrhagic responses. The small intestine's length and dynamic peristalsis further complicate full visualization, often requiring specialized enteroscopes measuring 200-250 cm to navigate beyond the reach of standard endoscopes.^[3]

History

Early Developments

The development of enteroscopy began in the early 1970s with the introduction of sonde-type enteroscopes, which relied on passive advancement through the small intestine via natural peristalsis. The first successful total enteroscopy was reported in 1971 using a combination of ropeway and sonde methods, involving a thin, 5-mm forward-viewing fibroscope inserted nasally and propelled without active control by the endoscopist.^[16] These devices, clinically evaluated by Tada et al. in 1977, were limited to diagnostic viewing of the small bowel mucosa, with no capability for tissue sampling or therapeutic interventions, and often required 6-8 hours for the procedure.^[17] By the mid-1970s, push enteroscopy emerged as an advancement, utilizing longer fiberoptic scopes—up to 150-200 cm in length—developed by companies such as Olympus (e.g., the SIF-10 model with a 168 cm shaft). This technique enabled active advancement by the endoscopist into the proximal jejunum, facilitating evaluation of obscure gastrointestinal bleeding beyond the reach of standard upper endoscopy.^[18] Early push enteroscopes addressed the partial inaccessibility of the small bowel but were constrained by incomplete visualization, typically limited to 50-100 cm depth due to looping and stretching of the intestine, as well as significant patient discomfort in the absence of adequate sedation.^[16] Key milestones included the emergence of therapeutic applications of push enteroscopy in the mid-1970s for hemostasis in small bowel bleeding lesions, marking a shift from purely diagnostic to interventional capabilities.^[16] By the 1980s, push enteroscopy gained widespread adoption in clinical practice for investigating obscure gastrointestinal bleeding, becoming the standard method for proximal small bowel examination despite its limitations in depth and tolerability.^[19]

Modern Advancements

The introduction of double-balloon enteroscopy (DBE) in 2001 by Hironori Yamamoto marked a significant advancement in small bowel visualization, utilizing two balloons—one at the endoscope tip and one on the overtube—to facilitate pleating of the intestinal wall and enable bidirectional access for pan-enteric examination. This technique overcame the limitations of earlier push enteroscopy methods, which were restricted to the proximal small bowel, by allowing deeper intubation and complete evaluation of the small intestine in a single procedure when combined with oral and anal approaches.^[20] Subsequent innovations simplified DBE's setup while maintaining efficacy. Single-balloon enteroscopy (SBE), introduced in 2007, employs a single balloon on the overtube with a sliding endoscope, reducing procedural complexity and time compared to DBE without compromising insertion depth. Spiral enteroscopy, introduced in 2007, further streamlined advancement by incorporating a manually rotatable overtube with a helical sheath to pleat the small bowel onto the endoscope, achieving faster intubation rates—often exceeding 200 cm in the jejunum—in less than 30 minutes for many cases.^[21] A key evolution came in 2015 with the introduction of motorized spiral enteroscopy (MSE), which automates the rotation using a powered overtube, enabling even quicker and deeper small bowel examination with insertion depths up to 400 cm antegrade in under 30 minutes and high diagnostic yields of 65-80%. As of 2025, MSE has become a preferred technique for its efficiency and reduced operator fatigue.^[22] These methods integrated with fluoroscopic imaging for real-time guidance, enhancing navigation accuracy during complex interventions.^[23] Therapeutic capabilities expanded accordingly, enabling procedures such as foreign body retrieval and balloon-assisted stricture dilation directly within the small bowel, which were previously challenging or impossible with non-invasive imaging alone.^[24] Post-2010 adoption surged following American Society for Gastrointestinal Endoscopy (ASGE) guidelines endorsing device-assisted enteroscopy for obscure gastrointestinal bleeding and small bowel disorders, reflecting its established safety and utility.^[23] Diagnostic yields improved markedly, rising from approximately 30% with early push techniques to 60-80% using balloon- and spiral-assisted methods, primarily due to greater small bowel coverage and tissue sampling opportunities.^[20]

Indications

Diagnostic Applications

Enteroscopy serves as a key diagnostic tool for evaluating obscure gastrointestinal bleeding (OGIB), defined as persistent or recurrent bleeding of unknown origin following negative upper endoscopy and colonoscopy, encompassing both occult forms (manifesting as iron deficiency anemia without visible blood loss) and overt forms (with visible hemorrhage).^[25] This procedure enables direct visualization of the small bowel, facilitating the identification of underlying pathologies that contribute to approximately 5% of all gastrointestinal bleeding cases in the United States, equating to around 50,000 annual evaluations given the roughly 1 million total GI bleeding presentations each year.^[26]^[27] Common diagnostic findings include vascular abnormalities such as angiodysplasias and Dieulafoy's lesions, which are frequent causes of OGIB, as well as neoplastic lesions like small bowel adenocarcinomas and lymphomas.^[28] Inflammatory conditions, including Crohn's disease with its characteristic ulcers and strictures,^[29] and nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy featuring mucosal erosions and diaphragms,^[30] are also effectively detected through mucosal inspection. The procedure is particularly indicated after inconclusive esophagogastroduodenoscopy (EGD) and colonoscopy or when capsule endoscopy reveals suggestive small bowel abnormalities, with a diagnostic yield of 60-80% for pinpointing bleeding sources in OGIB patients.^[31]^[25] Beyond visualization, enteroscopy supports targeted tissue sampling via biopsy, which is essential for histopathological confirmation of various small bowel disorders. For instance, it aids in diagnosing celiac disease by obtaining distal duodenal or jejunal samples to verify villous atrophy in cases where proximal biopsies are equivocal, and it enables detection of infectious agents like Giardia through mucosal examination and sampling in suspected parasitic enteritis.^[32]^[33] Similarly, biopsies during enteroscopy can reveal amyloid deposits in the lamina propria, confirming gastrointestinal amyloidosis when systemic involvement is suspected.^[34] Overall, enteroscopy influences clinical management in 40-60% of OGIB cases by providing actionable diagnostic insights that guide subsequent therapies, such as targeted medical treatments or further interventions.^[35]

Therapeutic Applications

Enteroscopy enables direct therapeutic interventions in the small bowel, extending beyond diagnostic visualization to treat various pathologies such as bleeding lesions, polyps, strictures, and obstructions. Device-assisted enteroscopy techniques, including double-balloon, single-balloon, and spiral methods, facilitate the delivery of endoscopic tools to deep small bowel segments, allowing for procedures like hemostasis, polypectomy, and dilation with high technical feasibility. These interventions have revolutionized management by offering minimally invasive alternatives to surgery, particularly for obscure gastrointestinal bleeding and inflammatory conditions.^[36] Hemostasis is a primary therapeutic application, targeting small bowel bleeding sources such as angiodysplasias, ulcers, or tumors. Techniques include mechanical clipping, injection of epinephrine or sclerosants, and thermal ablation via argon plasma coagulation (APC), which can be applied through the enteroscope channel. Initial hemostasis success rates range from 80% to 90% when performed early, especially in overt bleeding cases, with therapeutic yields reported up to 77.8% overall and higher (up to 90%) within 24 hours of presentation. These methods effectively control bleeding in most patients, reducing transfusion requirements and hospitalization duration.^[36]^[37] Polypectomy and tumor resection represent key interventions for neoplastic or polypoid lesions, such as those in Peutz-Jeghers syndrome or small bowel adenomas. Snares, either hot or cold, are used to excise polyps, often under saline immersion or cap assistance for larger lesions (>10-15 mm). Complete resection rates reach 76% in polyposis syndromes, with procedures demonstrating high efficacy and safety, including no major complications in dedicated series. Compared to surgical resection, enteroscopic polypectomy lowers 1-year costs (approximately €8,438 vs. €13,402) while avoiding risks like short bowel syndrome.^[36]^[38]^[37] Stricture management, particularly in Crohn's disease, involves through-the-scope balloon dilation to alleviate obstructive narrowing. Balloons are inflated progressively to 12-20 mm diameters, achieving technical success in 94.8%-94.9% of cases and short-term clinical improvement in 82.3%-83.3% of patients. This approach postpones surgery, with 1-year surgery-free rates of 87.3% and overall surgical intervention needed in only 22%-27.4% over follow-up, though symptom recurrence may necessitate repeat dilations in up to 48%. Foreign body removal, such as ingested batteries or retained capsules, is also feasible using grasping forceps or nets, with high success rates such as 86% reported in series for small bowel retrieval when identified endoscopically.^[36]^[39]^[37]^[40] Advanced therapies include enteral stent placement for malignant or refractory obstructions, using self-expanding metal stents deployed via the enteroscope to restore luminal patency. This palliative option achieves technical success in over 90% of proximal small bowel cases, improving quality of life by avoiding emergent surgery. Tattooing with India ink or sterile carbon facilitates surgical localization of lesions, enabling precise intraoperative identification and minimally invasive resection, with visibility retained in 90%-100% of marked sites during follow-up laparoscopy. Overall, therapeutic enteroscopy reduces the need for surgery in approximately 50% of cases by enabling targeted interventions and strategy revisions.^[36]^[37]

Types of Enteroscopy

Push Enteroscopy

Push enteroscopy is a traditional endoscopic technique that utilizes a long, flexible endoscope, typically measuring 140 to 200 cm in length, inserted orally to examine the proximal small bowel. The procedure involves advancing the endoscope through the esophagus, stomach, and duodenum into the proximal jejunum using a straightforward pushing method, achieving insertion depths of up to 100 to 150 cm beyond the ligament of Treitz. This forward-viewing approach allows for direct visualization, biopsy sampling, and therapeutic interventions in the reachable segments of the small intestine.^[20]^[41]^[42] One key advantage of push enteroscopy is its simplicity and accessibility, as it can be performed using standard equipment like a colonoscope or dedicated enteroscope without requiring specialized training or additional devices. The procedure is generally faster, lasting 30 to 60 minutes, and is well-suited for outpatient settings with moderate sedation, contributing to lower overall costs compared to more advanced enteroscopy methods. Additionally, it offers both diagnostic and immediate therapeutic capabilities, such as hemostasis or polyp removal, in the proximal small bowel.^[43]^[20]^[44] Despite these benefits, push enteroscopy has notable limitations, primarily due to the tendency for the endoscope to loop within the stomach or duodenum, which restricts advancement and prevents complete examination of the mid or distal small bowel. This incomplete reach often necessitates complementary imaging or alternative procedures for deeper evaluation. Furthermore, while generally safe, the use of an overtube to mitigate looping can increase patient discomfort and the risk of minor complications like mucosal injury.^[43]^[20] In clinical practice, push enteroscopy serves as a first-line option for investigating proximal small bowel lesions, particularly in cases of obscure gastrointestinal bleeding, where it demonstrates a diagnostic yield of approximately 40%. It is especially valuable for identifying vascular malformations, ulcers, or tumors in the proximal jejunum and enables therapeutic interventions like clipping or injection for hemostasis in accessible bleeding sites. This method's role has evolved alongside the development of balloon-assisted techniques, which address its depth limitations for more comprehensive small bowel assessment.^[44]^[20]^[43]

Balloon-Assisted Enteroscopy

Balloon-assisted enteroscopy (BAE) encompasses advanced endoscopic techniques designed to achieve deeper intubation of the small bowel compared to traditional push enteroscopy, which is limited to the proximal segments. These methods utilize inflatable balloons to facilitate pleating and advancement through the bowel loops, enabling comprehensive examination of the entire small intestine via anterograde (oral) or retrograde (anal) approaches. Developed as a response to the limitations of earlier enteroscopy methods, BAE has become a cornerstone for evaluating obscure gastrointestinal bleeding, tumors, and inflammatory conditions in the mid-to-distal small bowel.^[3] Double-balloon enteroscopy (DBE), first introduced by Yamamoto et al. in 2001, employs two balloons—one attached to the distal tip of the enteroscope and another to the overtube—to alternately inflate and deflate, thereby anchoring the bowel and shortening loops for stepwise advancement. This push-and-pull mechanism allows for controlled progression, with the overtube providing stability while the enteroscope advances, followed by deflation and repositioning to pleat the intestine onto the overtube. DBE supports both oral insertion for proximal-to-mid bowel visualization and anal insertion for distal access, often requiring combined approaches to achieve total enteroscopy. The technique typically demands two operators: one to maneuver the enteroscope and the other to manage the overtube and balloons. Procedures generally last 60 to 120 minutes, with total enteroscopy rates reaching 80% to 90% when bidirectional routes are used.^[45]^[46]^[20]^[47] Single-balloon enteroscopy (SBE), developed in 2007 as a simplified alternative to DBE, features a single balloon on the overtube tip combined with a flexible enteroscope that has an angled distal tip for hook-and-advance control. By inflating the overtube balloon to fix the bowel position and then advancing the enteroscope while hooking the mucosa, SBE achieves similar insertion depths to DBE—often up to 250-400 cm from the mouth or 100-200 cm proximal to the ileocecal valve—but with easier setup and reduced need for balloon deflation cycles. Like DBE, SBE facilitates anterograde and retrograde examinations and is performed by two operators, with procedure durations of 60 to 120 minutes and total enteroscopy rates of approximately 20% to 70%, depending on the approach. SBE's design minimizes complexity, making it more accessible in settings with limited resources.^[48]^[49]^[50] Clinical outcomes of BAE demonstrate diagnostic yields of 60% to 70% for identifying small bowel pathologies, particularly in cases of obscure gastrointestinal bleeding, where it excels at reaching distal lesions inaccessible by push enteroscopy. Therapeutically, BAE enables interventions such as polypectomy, dilation of strictures, and hemostasis in mid-to-distal sites, with success rates comparable between DBE and SBE. By the 2020s, BAE has been established as the standard for device-assisted small bowel endoscopy in international guidelines, reflecting its safety, efficacy, and broad applicability.^[51]^[52]^[53]

Other Specialized Techniques

Spiral enteroscopy employs a specialized overtube equipped with a raised helical ridge that facilitates advancement of the endoscope through rotational pleating of the small bowel, enabling deeper intubation primarily in an antegrade direction.^[49] This technique, introduced in the early 2000s, allows for diagnostic evaluation and therapeutic interventions such as polypectomy or hemostasis in the mid-to-distal small bowel, with median depths of maximal insertion reaching approximately 330 cm antegrade.^[49] Procedure times are notably shorter, often around 45 minutes, compared to balloon-assisted methods, making it suitable for rapid diagnostics in patients with obscure gastrointestinal bleeding or suspected tumors.^[54] However, it offers limited retrograde access and typically requires a second operator to assist with rotation, with diagnostic yields comparable to double-balloon enteroscopy at 40-80%.^[49]^[16] Intraoperative enteroscopy integrates endoscopic visualization with surgical intervention, such as laparotomy or laparoscopy, to directly manipulate and exteriorize segments of the small bowel for comprehensive examination.^[16] Reserved for cases where non-surgical device-assisted enteroscopy fails, such as complex strictures, tumors, or extensive polyposis, it permits full small bowel traversal and therapeutic actions like resection or dilation under direct vision.^[55] This approach achieves complete enteroscopy but carries higher risks, including morbidity rates up to 17% and mortality around 5%, due to the invasive surgical component.^[16] It remains a valuable adjunct for definitive management in obscure bleeding or Crohn's disease complications when less invasive options are inadequate, with yields similar to device-assisted techniques but greater procedural complexity.^[55] Emerging refinements include motorized spiral enteroscopy, which automates the rotation via a foot-pedal-controlled overtube, enhancing efficiency for deep small bowel access up to 450-490 cm antegrade in 25-40 minutes, with total enteroscopy rates of 60-70% and diagnostic yields of 65-80%.^[16] This variant supports applications in altered anatomy, such as post-Roux-en-Y gastric bypass, for interventions like foreign body retrieval or biopsy, though long-term safety data remain preliminary.^[49] Niche developments, such as hybrid systems combining magnetic guidance with capsule-like navigation, are under investigation to improve non-endoscope-based small bowel exploration, but clinical adoption is limited to research settings.^[56]

Procedure

Patient Preparation

Patient preparation for enteroscopy begins with fasting requirements tailored to the approach. For the oral (antegrade) route, patients must fast for 8 to 12 hours prior to the procedure to ensure an empty stomach and minimize aspiration risk during sedation.^[57]^[47] Clear liquids may be permitted up to 2 to 4 hours before in some protocols, but nothing by mouth (NPO) status is standard from midnight the night before.^[58] Bowel preparation varies by route to optimize visualization of the small intestine. The oral approach typically requires no purgative, though some centers recommend a clear liquid diet the day prior or optional low-volume polyethylene glycol (PEG) solution to clear proximal debris.^[20] For the anal (retrograde) route, a full colonoscopy-style preparation is essential, involving split-dose laxatives such as 2 to 4 liters of PEG-electrolyte solution the day before to evacuate the colon and distal small bowel.^[20]^[47]^[59] Antibiotics are not routinely administered but may be considered if there is a high risk of perforation, such as in patients with suspected strictures.^[58] Pre-procedure assessment ensures patient safety, particularly for sedation. Blood tests, including a coagulation profile, are recommended to evaluate bleeding risk, especially in patients with liver disease or on antithrombotics.^[60]^[58] Cardiac evaluation, such as auscultation or ECG, is advised for patients with cardiopulmonary comorbidities, advanced age, or those undergoing prolonged procedures under deep sedation.^[58] Informed consent is obtained, discussing procedure-specific risks like perforation, bleeding, and sedation complications.00324-0/fulltext)^[61] Medication adjustments focus on antithrombotics to balance thrombotic and bleeding risks. Diagnostic enteroscopy is low-risk for bleeding, allowing continuation of anticoagulants like warfarin or direct oral anticoagulants (DOACs).^[62] Therapeutic enteroscopy, however, is high-risk, requiring discontinuation of warfarin 5 days prior, DOACs 1 to 6 days based on renal function, and thienopyridines 5 to 7 days prior while continuing aspirin if indicated; bridging with heparin may be needed for high thrombotic risk patients.^[62]^[63] Other medications, such as insulin or oral hypoglycemics, are held or adjusted per endocrine guidelines.^[58] Preparations are route-specific, with oral approaches emphasizing upper GI clearance and anal approaches prioritizing colonic evacuation.^[47]

Performance Techniques

Enteroscopy procedures are performed in a controlled endoscopic suite, with the patient positioned in the left lateral decubitus for anterograde approaches or supine for retrograde routes. Route selection depends on the suspected location of pathology, typically determined from prior imaging such as capsule endoscopy or cross-sectional studies; an oral (anterograde) route is chosen for proximal or mid-small bowel lesions, allowing access up to the distal jejunum or ileum, while an anal (retrograde) route targets distal ileal abnormalities, and a combined approach may be used for total enteroscopy to visualize the entire small bowel.^[49]^[64] Sedation is administered to ensure patient comfort and safety during scope insertion, which begins after confirming fasting status to minimize aspiration risk. Moderate conscious sedation with agents like midazolam and opioids (e.g., pethidine) is common for shorter push enteroscopy, while device-assisted techniques often require deeper sedation with propofol or general anesthesia due to procedural complexity and duration. Fluoroscopy may guide insertion in balloon-assisted or spiral methods to monitor loop formation and advancement, particularly when overtubes or balloons are deployed.^[20]^[64] The endoscope is advanced through the mouth or anus into the small bowel, with maneuvers tailored to the technique to overcome looping and achieve deep intubation. For push enteroscopy, the scope is inserted orally past the ligament of Treitz, using torque, withdrawal, and external abdominal pressure to reduce loops and extend reach up to 80-100 cm; air or carbon dioxide insufflation distends the lumen for visualization, and tools like biopsy forceps or clips are passed through the working channel for sampling or hemostasis. In double-balloon enteroscopy, the enteroscope and overtube with distal balloon are advanced together, followed by balloon inflation to anchor the small bowel, withdrawal of the overtube to pleat the intestine onto the scope, and deflation-reinflation cycles to progress in 40 cm increments; single-balloon variants employ suction and scope angulation for similar pleating. Spiral enteroscopy involves clockwise rotation of a spiraled overtube to gather bowel loops over the scope, facilitating rapid advancement. Depth of insertion is tracked using markers on the scope or overtube, estimating progress by counting pleats or measuring from anatomical landmarks like the ligament of Treitz.^[20]^[49]^[64] Throughout the procedure, continuous monitoring of vital signs—including heart rate, blood pressure, oxygen saturation, and capnography—is essential to detect sedation-related issues or procedural complications. Procedure duration varies by type and indication, typically lasting 30 minutes for push enteroscopy, 30-40 minutes for spiral methods, and 70-120 minutes for balloon-assisted enteroscopy, with therapeutic interventions extending time as needed. Carbon dioxide insufflation is preferred over air to reduce post-procedural discomfort and enable deeper insertion.^[20]^[64]

Post-Procedure Care

After enteroscopy, patients are transferred to a recovery area for observation lasting 1 to 2 hours, during which vital signs are monitored continuously, and assessments for pain, sedation recovery, and immediate complications are performed. This period allows the effects of sedation or anesthesia to dissipate, with common sensations including grogginess, mild bloating, gas, cramping, or sore throat resolving within a few hours.^[65]^[2]^[20] Dietary resumption begins with clear liquids once the patient is alert and nausea-free, progressing to light solid foods as tolerated later in the day, though full normal intake may be delayed if therapeutic interventions occurred. Patients are instructed to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) for at least one week to minimize bleeding risk, particularly following biopsies or hemostasis procedures. For retrograde (anal) enteroscopy, additional stool softeners or laxatives may be recommended to ease bowel movements and alleviate potential discomfort lasting a few days.^[66]^[67]^[20] In the 24 to 48 hours post-procedure, patients should monitor for symptoms including fever, severe abdominal pain, vomiting, or signs of bleeding such as black stools, contacting their provider immediately if these arise. A follow-up clinic visit is typically scheduled within 1 to 2 weeks to discuss biopsy results and further management. Therapeutic enteroscopy cases warrant extended initial monitoring, up to several hours, to detect rare complications like perforation. Patients must arrange for a responsible adult to drive them home and are advised to refrain from driving, operating machinery, or making important decisions for 24 hours due to residual sedation effects.^[68]^[65]^[20]

Risks and Complications

Common Adverse Events

Enteroscopy procedures, including push, balloon-assisted, and other device-assisted techniques, are generally safe with an overall adverse event rate of approximately 1% for diagnostic cases. Minor adverse events occur more frequently, reported in up to 9-14% of cases depending on the technique, but most are self-limited without long-term consequences.^[20]^[69] Sedation-related adverse events are among the most common, typically mild and occurring in 1-5% of procedures, including transient drowsiness, nausea, and respiratory depression such as hypoxemia. These are often managed with supportive measures or reversal agents like flumazenil for benzodiazepine-induced effects.^[20]^[70] Gastrointestinal adverse events frequently include bloating and transient abdominal pain due to air insufflation and bowel manipulation, which usually resolve within hours to days. Minor bleeding following biopsies is uncommon, affecting less than 1% of cases, and resolves spontaneously in the vast majority (over 90%) without intervention.^[20]^[71]^[72] Mild pancreatitis, characterized by self-limiting inflammation often from duodenal manipulation in oral approaches, has an incidence of about 1% in device-assisted enteroscopy. It is typically managed conservatively and does not lead to chronic issues in most patients.^[73]

Rare and Serious Complications

While enteroscopy is generally safe, rare and serious complications can occur, with an overall major adverse event rate of approximately 0.3% to 1.6% across device-assisted techniques such as double- and single-balloon enteroscopy.^[20] These events, though infrequent, carry high morbidity and often require urgent intervention, including surgical repair or hemodynamic support. Risk factors include therapeutic interventions like polypectomy or dilation, prior abdominal surgery, and patient comorbidities such as altered anatomy.^[74] Perforation of the bowel wall is one of the most feared complications, occurring at a rate of 0.3% to 0.4% in balloon-assisted enteroscopy, with higher incidence (up to 1%) during therapeutic procedures. This tear can lead to peritonitis, presenting with severe abdominal pain, fever, and hemodynamic instability shortly after the procedure.^[20] Management typically involves immediate surgical intervention, as conservative approaches are rarely sufficient in small bowel perforations.^[3] Major bleeding affects 0.2% to 1.3% of cases, most commonly following polypectomy, biopsy, or stricture dilation. It may manifest as overt gastrointestinal hemorrhage requiring transfusion, endoscopic hemostasis, or, in severe instances, angiographic embolization.^[75] The risk is notably lower (0.1%) in purely diagnostic procedures.^[76] Infection, including bacteremia or abscess formation, is exceedingly rare (<0.1%) in enteroscopy but can occur due to translocation of gut flora during manipulation.^[20] Antibiotic prophylaxis is recommended for high-risk patients, such as those with valvular heart disease or immunosuppression, to mitigate endocarditis or systemic spread.^[3] Other serious events include aspiration pneumonia from sedation-related airway compromise and cardiovascular incidents like arrhythmias or myocardial infarction, often linked to anesthesia in frail patients.^[20] Procedure-related mortality remains very low at less than 0.05%, primarily from unmanaged perforation or bleeding in comorbid individuals. These complications underscore the need for vigilant monitoring, particularly in therapeutic settings where minor symptoms like abdominal discomfort may precede escalation.^[20]

Diagnostic Findings and Outcomes

Typical Results

Enteroscopy typically reveals a normal small bowel mucosa characterized by an intact lining with preserved villous architecture, a clearly visible submucosal vascular pattern, and absence of erosions, ulcers, or friable tissue.^[77] These findings indicate healthy small bowel tissue without evidence of inflammation, bleeding sources, or structural abnormalities.^[78] Abnormal findings vary by underlying condition but commonly include vascular ectasias, such as angiodysplasias, which represent the most frequent etiology of obscure gastrointestinal bleeding identified during the procedure.^[47] In inflammatory disorders like Crohn's disease, enteroscopy often detects ulcers ranging from aphthous erosions to deep longitudinal fissures, along with mucosal edema and cobblestoning.^[55] Neoplastic lesions appear as submucosal masses or polyps, including gastrointestinal stromal tumors (GISTs) with smooth, bulging contours and carcinoid tumors typically presenting as small, firm intraluminal nodules in the distal ileum.^[79] For malabsorptive conditions such as celiac disease, characteristic features include scalloped folds, a mosaic mucosal pattern, and reduced or absent villi indicative of atrophy, confirmed histologically.^[80] The diagnostic yield of enteroscopy in cases of obscure gastrointestinal bleeding ranges from 60% to 80%, with balloon-assisted techniques achieving higher rates due to improved visualization of the entire small bowel and reduced false negatives compared to partial examinations.^[81] Total enteroscopy further minimizes missed lesions by enabling bidirectional access, enhancing detection in up to 70% of double-balloon enteroscopy cases.^[47] Findings are documented through high-resolution photographs and video recordings of key areas, such as lesions or normal segments, which are integrated into procedural reports for correlation with patient symptoms like bleeding or abdominal pain.^[82] Biopsies obtained from suspicious sites provide histopathological confirmation, with samples processed for analysis of inflammation, neoplasia, or atrophy, ensuring comprehensive evaluation.^[83] If vascular ectasias or accessible lesions are identified, therapeutic interventions like clipping or ablation may be performed during the same procedure.^[47]

Interpretation and Follow-Up

Interpretation of enteroscopic findings involves detailed analysis by pathologists who review obtained biopsies to assess histological features, such as grading the degree of inflammation, villous atrophy, or neoplastic changes in conditions like inflammatory bowel disease (IBD) or small bowel tumors.^[53] These histological evaluations are integrated with laboratory markers, including fecal calprotectin levels, which correlate strongly with endoscopic severity of small bowel Crohn's disease, aiding in confirming active inflammation and monitoring disease activity.^[84] For instance, elevated calprotectin alongside endoscopic evidence of mucosal ulceration supports the diagnosis of active IBD. Clinical correlation requires matching enteroscopic visuals, such as ileal ulcers or strictures, to patient symptoms like abdominal pain or diarrhea, thereby confirming conditions like Crohn's disease.^[53] In cases of suspected small bowel malignancies, multidisciplinary input from gastroenterologists, oncologists, and surgeons is essential to integrate findings with imaging and guide management decisions, such as surgical resection or chemotherapy.^[85] This approach ensures that enteroscopy results inform precise therapeutic strategies, including initiation of biologics for IBD when active lesions are identified. Follow-up protocols are tailored to the underlying pathology; for example, surveillance enteroscopy is recommended every 1-3 years in Peutz-Jeghers syndrome to monitor and resect polyps greater than 10-15 mm, preventing complications like intussusception.^[86] Repeat enteroscopy may be indicated if the initial procedure is incomplete or if symptoms recur, such as in Crohn's strictures post-dilation, where up to 50% require re-intervention by 5 years.^[87] Enteroscopy outcomes demonstrate high clinical impact, with diagnostic yields of 22-80% in suspected Crohn's disease and the potential to change the initial diagnosis in up to 12% of cases, particularly through biopsy confirmation.^[53] These findings guide targeted therapies, such as biologic agents for IBD or endoscopic interventions for vascular lesions, improving patient management and reducing rebleeding risks.^[88]

Versus Standard Upper Endoscopy

Enteroscopy and esophagogastroduodenoscopy (EGD), also known as standard upper endoscopy, differ primarily in the anatomical regions they examine within the gastrointestinal tract. EGD utilizes a flexible endoscope to visualize the esophagus, stomach, and proximal duodenum, typically reaching up to approximately 40 cm from the incisors, including the area up to the ligament of Treitz.^[43] In contrast, enteroscopy extends visualization deeper into the small bowel, beyond the ligament of Treitz, to examine the jejunum and, depending on the technique (such as push enteroscopy or device-assisted methods like double-balloon or spiral enteroscopy), portions of the ileum, with reach ranging from 45-80 cm for push enteroscopy to over 200 cm for antegrade device-assisted approaches.^[43]^[1] The utility of these procedures aligns with their respective scopes, with EGD serving as the primary tool for evaluating proximal gastrointestinal issues such as peptic ulcers, esophageal varices, and gastritis.^[89] Enteroscopy, however, is specifically indicated for disorders of the small bowel distal to the duodenum, including obscure gastrointestinal bleeding, Crohn's disease involvement in the jejunum or ileum, small bowel polyps, and tumors.^[43]^[1] While EGD provides high-resolution imaging and biopsy capabilities for upper tract pathologies, enteroscopy enables therapeutic interventions like polypectomy or hemostasis in the mid-small bowel, which are often inaccessible via standard EGD.^[43] These procedures complement each other in clinical practice, with EGD typically performed as the first-line investigation for upper gastrointestinal symptoms; if findings are negative or symptoms suggest small bowel involvement, enteroscopy follows for targeted evaluation.^[43] In some cases, both can be conducted in the same session, starting with EGD and advancing to enteroscopy using specialized overtubes or balloons to facilitate deeper intubation.^[1] This sequential approach enhances diagnostic yield without necessitating separate procedures. Compared to enteroscopy, EGD offers advantages in terms of brevity and reduced invasiveness, with procedure times averaging 15-30 minutes and lower overall risk profiles, including rare complications like perforation (less than 0.1%).^[43]^[89] Enteroscopy, while providing critical access to the deeper small bowel for comprehensive assessment, is more time-intensive (30-120 minutes or longer) and invasive, often requiring sedation, specialized equipment, and carrying a higher adverse event rate of about 1%, including risks of perforation (0.3-0.4%) and pancreatitis.^[43]^[1] These trade-offs make EGD preferable for routine upper tract evaluations, reserving enteroscopy for cases where small bowel pathology is suspected.^[43]

Versus Capsule Endoscopy

Enteroscopy and capsule endoscopy both enable visualization of the small bowel but differ fundamentally in their approaches and capabilities. Capsule endoscopy involves swallowing a small, wireless camera that passively transits through the gastrointestinal tract, capturing images over approximately 8 to 12 hours to provide a panoramic view of the small bowel mucosa.^[90] In contrast, enteroscopy employs an actively advanced endoscope, often assisted by balloons or overtubes (such as double-balloon or single-balloon techniques), allowing controlled navigation and deeper intubation into the small bowel for targeted examination.^[91] This active method enables real-time manipulation, whereas the capsule relies on natural peristalsis for progression.^[92] Capsule endoscopy serves primarily as a non-invasive screening tool for small bowel evaluation, particularly in suspected small-bowel bleeding (SSBB) or obscure gastrointestinal bleeding (OGIB), with completion rates of 68% to 95% and diagnostic yields ranging from 46% to 67% for identifying mucosal lesions like angioectasias or ulcers.^[90] It excels in detecting superficial abnormalities but cannot perform interventions, and it misses approximately 11% of solitary small bowel lesions, including up to 19% of tumors, due to limitations in resolution for flat or submucosal pathologies.^[93] Enteroscopy, however, is indicated for therapeutic purposes following a positive capsule study, allowing biopsies, polypectomies, hemostasis, or stricture dilation, with therapeutic success rates of 67% to 76% in such cases; its diagnostic yield can reach 75% to 84% when guided by prior capsule findings, though total enteroscopy is achieved in only 58% to 70% of procedures.^[92]^[90] The advantages of capsule endoscopy include its patient-friendly, sedation-free nature and low risk profile, with retention occurring in 1.2% to 8.2% of cases (mitigated by patency capsules in high-risk patients), making it ideal for initial broad screening.^[91] Drawbacks encompass the inability to intervene and potential for incomplete visualization in 5% to 32% of cases due to delayed transit. Enteroscopy offers superior utility for confirmation and treatment but is more invasive, requiring sedation and carrying risks such as perforation (0.3% to 1.3%), bleeding (up to 1.5%), or pancreatitis (0.3% to 1%), with overall major adverse events in 1.5% to 15% of procedures.^[90]^[91] According to European Society of Gastrointestinal Endoscopy (ESGE) guidelines, capsule endoscopy is the first-line investigation for OGIB and SSBB, recommended within 48 hours for overt bleeding to identify potential therapeutic targets, while enteroscopy follows as a second-line procedure for lesion confirmation, biopsy, or therapy within 72 hours if capsule results are positive.^[90] This sequential pathway optimizes diagnostic accuracy and minimizes procedural risks, with enteroscopy reserved for cases necessitating intervention, such as after detecting vascular malformations or polyps on capsule imaging.^[92]

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