Double balloon enteroscopy is a new method allowing the exploration of the whole intestine by the oral or anal route,1 with the possibility of endoscopic intervention. We describe here the first case of enduring paralytic ileus following this technique.
Case report
A 47 old woman was referred to our unit for chronic and obscure undiagnosed gastrointestinal bleeding. Unremarkable conventional upper and lower endoscopies were performed twice. Small bowel follow through studies, abdominal computed tomography (CT), and pushed enteroscopy were also normal. A capsule enteroscopy was performed showing three angiodysplasias in the distal jejunum, all measuring 2–3 mm. To reach them, we performed a double balloon enteroscopy which showed two of the three lesions. Electrocoagulation with an argon plasma coagulator (50 W, 1.5 l/min) was performed on both lesions. Twelve uneventful hours followed the procedure, after which nausea and vomiting occurred. Abdominal examination showed abdominal meteorism with diffuse moderate pain and no focal tenderness. No fever or other clinical signs apart from those of intestinal occlusion were observed. An abdominal CT showed localised and moderate dilation of a few intestinal loops with normal proximal and distal ileum (fig 1 ▶). No complications such as pneumoperitoneum, abscess, intestinal haematoma, or intussusceptions were observed. Oral intake was stopped and intravenous fluids given. The clinical state remained stable but transit remained totally interrupted without passage of stool or flatus, and 2–3 litres of gastric aspirate was obtained per day. As the intestinal occlusion had not resolved by day 7, erythromycin 3 mg/kg/day was given intravenously in two doses, of 30 minutes each, with disappearance of signs of occlusion within 48 hours. Total recovery was observed after four days, allowing discharge with no further events over the following five months.
Figure 1.
Abdominal computed tomography: dilated (white arrows) small bowel loops.
Discussion
Double balloon enteroscopy was first reported by Yamamoto et al in 2001 in a series of four patients, with insertion of the endoscope as far as 30–50 cm distal to the ligament of Treitz in three cases and to the ileocaecal valve in one, without any complications.2 Since then, two larger series of 1231 and 62 patients3 have been reported, with two and no complications recorded, respectively. In the former,1 a total of 178 procedures were performed. The first complication was multiple perforations in a patient with intestinal lymphoma thought to be due to chemotherapy whereas the second complication was of spontaneously resolving postoperative fever and abdominal pain in a patient with Crohn’s disease. Elsewhere, a total of eight papers4,5,6,7,8,9,10,11 reported 20 patients having DBE with only one recorded complication (post polypectomy sepsis).10 Two large series of 62 and 125 patients, respectively, have been published in abstract form,12,13 with no complications in the former and two in the latter. The two reported complications were intra-abdominal abscess and mild pancreatitis thought to be due to balloon inflation near the ampulla of Vater.
Two aspects are of interest in this case. Firstly, this is, to our knowledge, the first case of small bowel ileus following double balloon enteroscopy. This is of interest because the ileus appeared without the diagnosis of perforation, abscess, gastrointestinal haemorrhage, or haematoma following the procedure, indicating isolated motility impairment. Indeed, plasma argon coagulation is not known to induce an ileus lasting seven days without other complications.14 Therefore, it could be that the ileus was caused by the double balloon technique itself due to the pronounced stretching of the small bowel and possibly the mesentery.1 Secondly, it should be emphasised that conservative medical management should be tried first, and that treatment may include prokinetic agents such as erythromycin which improve motility impairment disorders.15
Conflict of interest: None declared.
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