The small bowel is approximately 20 feet in length and, historically was an inaccessible part of the gastrointestinal tract due to its length. Single balloon enteroscopy (otherwise called balloon-assisted enteroscopy) uses endoscopes equipped with balloons that inflate and deflate to pinch together the walls of the GI tract. By compressing the walls, the gastroenterologist can reach and treat less accessible areas like deeper parts of the small intestine.

How is SBE performed?

Single balloon endoscopy utilizes a 200 cm long flexible, fiberoptic, camera (the endoscope) fitted with an equally long overtube that slides the full length of the endoscope. On the tip of the overtube is a balloon that can be inflated and deflated. The balloon is blown up to anchor the overtube within the intestine. While the overtube is anchored, the endoscope can be advanced further into the small intestine. By withdrawing the overtube the small intestine can be shortened and straightened to make the passage of the inner endoscope easier. This cycle is then repeated multiple times until the area of interest is reached or the scope cannot be advanced any further.

The endoscope allows the intestine to be inflated with gas, rinsed with water, or used to guide biopsy or other procedural instruments.

SBE is a longer procedure and can take anywhere from 1 to 3 hours. It can be performed through the mouth (anterograde) or through the rectum (retrograde), depending on the location your doctor needs to access. Enteroscopy may be done as an inpatient or outpatient procedure.

Why do I need a balloon assisted enteroscopy (SBE)?

Usually, SBE’s are requested to access abnormalities spotted on other forms of imaging including a small bowel capsule endoscopy (VCE), a CT or MRI scans or for failed colonoscopies using standard colonoscopes.

Balloon-assisted enteroscopy may allow the gastroenterologist to:

-Identify and treat the source of GI bleeding.

-Take tissue samples to examine for a laboratory diagnosis (biopsy).

-Remove small bowel polyps or a foreign object.

-Enlarge a narrowed pathway (stricture) in the upper or lower GI tract.

Not all gastroenterologists do this procedure and you will need to be referred to a GI doctor with advanced endoscopy training (like Dr. Siddique) for these procedures.

What do I have to do to prepare for the SBE procedure?

For an upper SBE (otherwise called anterograde SBE - through the mouth):

Your stomach should be empty to allow an effective and safe examination. You should not eat or drink anything, including water, for about 8 hours prior to your endoscopy (we will usually ask that you fast from midnight onwards on the day of your procedure).

Most medications can be continued prior to the exam but some medications such as aspirin or blood thinners may need to be stopped and we will give you instructions based on your individual circumstance. We encourage you to ask the physician specifically about these medications.

If you are diabetic, you will need to monitor your blood glucose carefully on the day prior to your procedure.  We will give you specific instructions, if you are on insulin or take oral hypoglycemic agents like Glyburide or any of the newer drugs. We will try and schedule your procedure(s) early in the morning on the planned date.

Occasionally, we may ask you to get clearance from your cardiologist or another specialist for the procedure, usually from an anesthesia perspective.

For a lower SBE (otherwise called as retrograde SBE - performed through the rectum):

Similar to a colonoscopy, the success of SBE dependent on whether the gastroenterologist can adequately visualize (see) the inner lining of the colon and access the small through a clean colon , and this is critically dependent on the bowel preparation being adequate (good enough prep to clear out the stools). Therefore, it is critical that you follow the instructions given to you.

As a rule:

7 days prior to your procedure:

1. Avoid fruits or vegetables with skin or peels on them.
2. Stop any multi-vitamins or iron supplements.
3. If you suffer from constipation or are taking any narcotic pain medications (like Tylenol 3, Norco, Percocet, Morphine, Oxycodone etc), we will usually prescribe a daily laxative (usually Miralax or a generic equivalent) to be taken daily, starting 5-7 days prior to your procedure and you may have to take an additional dose on the morning prior to your procedure.

5 days prior to your procedure:

1. If you are on blood thinners like Plavix (Clopidogrel), Brilinta (Ticagrelor) or Effient (Prasugrel), we will ask you to stop them for 5 days prior to the procedure. If you are on Coumadin (Warfarin), Eliquis (Apixaban) or Xarelto (Rivaroxoban), we will usually ask you to stop them 3-5 days prior to your scheduled procedure date.

Please note – we will give you specific instructions based on your individual circumstances or conditions and we will usually get clearance from your prescribing physician prior to stopping any of these medications. DO NOT STOP THESE MEDICATIONS WITHOUT DISCUSSING WITH US AND/OR TALKING TO YOUR PRESCRIBING PHYSICIAN.

1 day prior to your procedure:

1. You should stay only on clear liquids (any liquid that you can see through) including tea or coffee without creamer, clear juices without bits or pieces, broth and water. Drink plenty of fluids to keep you hydrated.
2. If you suffer from chronic constipation or take narcotic medications, we will ask you to take an additional dose of bowel prep or Miralax in the morning.
3. If you are diabetic, you will need to monitor your blood glucose carefully.  We will give you specific instructions, if you are on insulin or take oral hypoglycemic agents like Glyburide or any of the newer drugs. We will try and schedule your procedure(s) early in the morning on the planned date.

4. The regular/routine prep is usually split into two parts – one taken early in the evening and the other part taken between 10pm and midnight (for morning procedures) or between 3am and 5am for late morning or afternoon procedures. We will give you instructions based on the type of preparation (laxative) prescribed for you and the timing of your procedure.

What happens on the day of my procedure?

We will ask you to come an hour prior to your scheduled time to register and be admitted to our endoscopy unit (we do procedures at the hospital or at the ambulatory surgical center). The nursing staff will help you change into a comfortable gown and place you on a stretcher. An IV line will be placed to help us give you fluids and medications for the procedure. You will be asked to complete a health questionnaire, confirm your consent for the procedure and may meet a member of the anesthesia staff. Once the documentation and safety checks have been completed, you will be taken to the procedure room. You will then be given anesthesia or moderate sedation and go off to sleep. Once the procedure is completed, you will wake up and usually experience no pain or discomfort. Occasionally, people may complain of a sore throat or more significantly, abdominal pain. If this happens, we may admit you for observation and/or treatment, as indicated.

You will be taken to the recovery area and be monitored for about 30-60 mins prior to being discharged home.

You will need to have a driver pick you up from the unit and drive you home. Ideally, there should be someone with you at home to supervise your recovery as you may experience some drowsiness or groggy feeling as the sedative/anesthetic agent works its way out of your body.

Important:

1. We strongly urge you to not drive on the day of your procedure as your reflexes may be slower that you anticipate.

2. For safety reasons, you cannot use a taxi or public transportation to go home.

3. We strongly urge you to defer planning or making any legal decisions for up to 24 hours after the procedure, to ensure that your mind is clear and unaffected from the residual effects of anesthesia or moderate sedation.

4. We recommend not making any travel plans for up to a week after your procedure. This varies greatly – please discuss any planned or upcoming travel with Dr. Siddique at the time of scheduling.

5.If we need to admit you for observation due to concerns about a possible complication, we will speak to you in recovery. If you develop any symptoms later in the day, please contact the on-call doctor (usually Dr. Siddique) or return to the ER at the same hospital, where you had your procedure.  We apologize in advance for any inconvenience due to this - our primary priority is your safety and well-being.

How will I feel after my procedure/aftercare?

You may feel bloated or gassy for a few hours until any excess air is released from the colon. If any polyps are removed, you may notice a small amount of blood in the next bowel movement.

You will be told when to restart your blood thinners after your procedure.

If you notice more a lot of blood in your stools or notice severe abdominal discomfort, then please call us or go to the nearest ER for evaluation as this is unusual and should be investigated.

The results of the biopsies will be sent in the mail to you, usually, within two weeks along with any recommendations.

How safe is SBE? What are the potential common complications?

Balloon assisted colonoscopy is an extremely safe procedure and may pose few risks, being quoted at only 0.6% from literature.

Complications may include but are not limited to:

• Adverse reaction to the sedative or anesthetic used during the exam (up to 0.9%).
• Bleeding from the site where a tissue sample (biopsy) was taken or a polyp or other abnormal tissue was removed (up to 0.6%).
• A tear in the intestinal wall (perforation) – approximately 0.3% risk.
• Inflammation of the pancreas (called pancreatitis - very rare).
• Infections – very rare.
• Risk of death – very rare – 1/100,000.

All complications are rare and infrequent, and we will try to ensure you have the safest experience we can provide, each time, every time.

We encourage you to talk to Dr. Siddique about any specific concerns that you may have