Version October 2024
INTRODUCTION — Evaluation of the small bowel is difficult due to its length, intraperitoneal location, and contractility. Methods for evaluating the small bowel include video capsule endoscopy, push enteroscopy, and intraoperative enteroscopy. These techniques all have advantages and limitations:
●Video capsule endoscopy is capable of examining the entire small bowel but lacks therapeutic capacity.
●Push enteroscopy has both diagnostic and therapeutic capabilities but typically only examines that part of the small bowel that is 50 to 150 cm distal to the ligament of Treitz.
●Intraoperative enteroscopy permits examination of the entire small bowel and therapeutic interventions but is much more invasive.
Alternative endoscopic approaches have been developed to overcome these limitations. This topic will review options and techniques for performing small bowel enteroscopy. Wireless video capsule endoscopy is discussed elsewhere. (See "Wireless video capsule endoscopy".)
GENERAL PRINCIPLES — Approaches to deep small bowel enteroscopy can be categorized into two general types:
Balloon-assisted enteroscopy (see 'Balloon-assisted enteroscopy' below):
●Double balloon enteroscopy (DBE)
●Single balloon enteroscopy (SBE)
●Balloon catheter-guided enteroscopy (using a catheter with a balloon attached at the tip)
Rotatable overtube-assisted enteroscopy (see 'Rotatable overtube-assisted enteroscopy' below):
●Spiral enteroscopy, using a manually rotatable overtube
●Motorized enteroscopy, using an electric motor rotatable overtube
DBE, SBE, spiral enteroscopy, and motorized enteroscopy facilitate examination of the small bowel by using insertion techniques that pleat the small bowel onto an overtube. During balloon catheter-guided enteroscopy, a catheter is introduced through the working channel that facilitates the examination by pleating the small bowel onto the endoscope.
The techniques for deep small bowel enteroscopy reduce stretching of the small bowel (as occurs with push enteroscopy) and permit better transmission of maneuvers that advance the instrument, position the tip of the enteroscope, and stabilize the enteroscope. As a result, these maneuvers facilitate therapeutic interventions.
Each of the systems can theoretically be used with an anterograde or retrograde approach, although most of the published reports on spiral enteroscopy describe an anterograde approach.
The availability of these systems varies by geographic region. As an example, DBE, SBE, and spiral endoscopy (ie, manually rotatable overtube) are widely available, whereas motorized enteroscopy and balloon catheter-guided enteroscopy are not available in the United States. Selecting a system for deep small bowel enteroscopy is also based on hospital resources and clinician preference.
INDICATIONS — Deep small bowel enteroscopy has multiple diagnostic and therapeutic applications, the most common being the evaluation of suspected small bowel bleeding [1]. (See "Evaluation of suspected small bowel bleeding (formerly obscure gastrointestinal bleeding)".)
Wireless capsule endoscopy is preferred as an initial diagnostic test because it is noninvasive, well tolerated, and can view the entire small bowel [2]. Furthermore, wireless capsule endoscopy can often locate the bleeding source or other abnormality, and these details are helpful for planning deep small bowel enteroscopy with therapeutic intervention. Alternatively, deep small bowel enteroscopy may be performed to evaluate gastrointestinal (GI) bleeding when wireless capsule endoscopy is nondiagnostic. Deep small bowel enteroscopy may also be preferred in patients with suspected small bowel stricture because wireless capsule endoscopy is associated with an increased risk of capsule retention. (See "Wireless video capsule endoscopy", section on 'Capsule retention'.)
Diagnostic applications — Diagnostic applications for deep small bowel enteroscopy include:
●Evaluation of suspected small bowel bleeding [2,3]
●Evaluation and tattooing of suspected small bowel malignancies (eg, adenocarcinoma, lymphoma, GI stromal tumors, metastatic tumors) or abnormal findings on other imaging studies [4,5]
●Evaluation of suspected nonsteroidal anti-inflammatory drug-induced small bowel injury
●Evaluation of suspected or established small bowel Crohn disease
●Evaluation of refractory celiac disease [6,7]
●Detection of polyps in patients with polyposis syndromes such as familial adenomatous polyposis or Peutz-Jeghers syndrome [8]
●Examination of the gastric remnant in patients who have undergone Roux-en-Y gastric bypass [9]
Therapeutic applications — An advantage of deep small bowel enteroscopy compared with capsule endoscopy and radiologic methods to visualize the small bowel is the ability to perform therapeutic interventions:
●Treatment of GI bleeding (eg, angiodysplasia)
●Small bowel polypectomy [8]
●Stricture dilation [10]
●Stenting of small bowel obstruction
●Foreign body retrieval (eg, retained video capsule) [11,12]
●Endoscopic mucosal resection [13]
Advanced techniques — Approaches involving balloon-assisted enteroscopy continue to be developed. These include a modified double balloon enteroscopy (DBE) technique to access the proximal side of a stricture in the distal colon (anterograde colonoscopy) by using a long transnasal decompression tube as a guide [14].
CONTRAINDICATIONS — In general, patients deemed fit to undergo endoscopic procedures are candidates for deep small bowel enteroscopy. Surgically altered gastrointestinal (GI) anatomy (eg, an ileoanal or ileocolonic anastomosis or an ileostomy) is a relative contraindication to deep small bowel enteroscopy because of a higher perforation rate [15] (see 'Adverse events' below). For an anterograde approach using an overtube, esophageal stenosis and active eosinophilic esophagitis are also relative contraindications.
For patients with surgically altered GI anatomy who require deep small bowel enteroscopy, we suggest that the examination be carried out cautiously by an experienced advanced endoscopist because of the increased risk of perforation. For patients with Roux-en-Y gastric bypass who undergo endoscopic retrograde cholangiopancreatography (ERCP), expertise in both small bowel enteroscopy and biliary endoscopy is required. (See "ERCP in patients with Roux-en-Y anatomy".)
In addition, the balloons used for double balloon enteroscopy (DBE) (although not for single balloon enteroscopy [SBE]) are made of latex and should not be used in patients with latex allergy. In some countries, silicone balloons for DBE are available, but such balloons are not available in the United States. (See "Latex allergy: Epidemiology, clinical manifestations, and diagnosis".)
BALLOON-ASSISTED ENTEROSCOPY — Balloon-assisted enteroscopy using an overtube includes DBE and SBE. While similar, the systems vary with regard to whether a balloon is attached only to the overtube (SBE) or also to the tip of the enteroscope (DBE), resulting in differences in the techniques used to perform the procedures. Limited data suggest that the systems have similar overall efficacy. (See 'Efficacy' below and 'Single balloon enteroscopy' below.)
Systems are also available to permit balloon-assisted enteroscopy using a balloon catheter that is passed through the channel of a standard colonoscope [16]. (See 'Balloon catheter-guided enteroscopy' below.)
Double balloon enteroscopy — The DBE system includes an endoscope with a 200 cm working length (Fujifilm EN-580XP and EN-580T), a 145 cm soft overtube, and a specially designed pump (picture 1). After the overtube is backloaded onto the scope, a soft latex balloon is attached to the tip of the enteroscope. Nonlatex balloons are available in some countries but are not available in the United States. (See 'Contraindications' above.)
The balloon can be inflated and deflated using a pump through the air channel in the enteroscope. The flexible overtube also has a latex balloon at its tip that can be inflated and deflated. The pressure in both balloons is monitored and regulated at 5.6 kPa.
Some enteroscope models (ie, Fujifilm EN-580T) have a larger outer diameter (9.4 mm) and can accommodate a larger channel (3.2 mm in diameter) for therapeutic use. A shorter double balloon endoscope with a working length of 155 cm is also available (Fujifilm EI-580T). This endoscope is compatible with accessories that are designed for use during endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopy, and this endoscope is primarily used for cases of incomplete colonoscopy and for ERCP in patients with surgically altered anatomy.
Preprocedure preparation — Patients should fast after midnight the evening prior to the examination to allow time for food residue to clear the small bowel. In addition, patients undergoing retrograde examinations are given a bowel preparation to cleanse the colon. (See "Bowel preparation before colonoscopy in adults".)
For patients undergoing advanced endoscopic procedures including deep small bowel enteroscopy, most centers use monitored anesthesia care or general anesthesia, while a few centers use intravenous moderate sedation. Anesthesia for gastrointestinal (GI) procedures is discussed separately. (See "Anesthesia for gastrointestinal endoscopy in adults".)
Technique — DBE can be performed by inserting the enteroscope into the mouth (anterograde approach) or the anus (retrograde approach). Selecting an insertion route is guided by the estimated location of the suspected lesion(s).
With an antegrade examination, the enteroscope is advanced using repetitive cycles of balloon inflation/deflation and scope advancement (figure 1). During one cycle of the procedure, the scope is advanced until no further forward progress is made. The balloon on the tip of the scope is then inflated, anchoring the small bowel. Once the small bowel is anchored by the enteroscope balloon, the balloon on the overtube is deflated (having been inflated during the prior cycle) and advanced until it reaches the inflated balloon on the scope. The balloon at the end of the overtube is then inflated, and with both balloons inflated, the scope and overtube are gently withdrawn to remove loops and pleat the small bowel onto the overtube. The balloon on the scope is then deflated, and the cycle is repeated until the scope can no longer be advanced or the lesion of interest is reached. The procedure is carried out in reverse during withdrawal of the scope. Abdominal pressure is often helpful for advancing the enteroscope with fluoroscopic guidance. Another technical tip is not to inflate the balloon until the enteroscope is past the papilla to minimize the possibility of pancreatitis after the procedure.
The procedural technique is the same for retrograde examinations, except that the cycles of scope advancement and withdrawal are carried out in the colon, as well as in the small bowel, to ensure that there is no colonic looping prior to intubation of the terminal ileum. A tip for intubating the terminal ileum is to open the valve by advancing the tip of the enteroscope just beyond the ileocecal valve and manipulating the angle of the enteroscope's tip while pulling back.
A tattoo is often placed at the point of maximal enteroscope insertion by injecting carbon black ink into the submucosal space of the small bowel, so that the site can be identified on subsequent examinations (eg, capsule endoscopy, subsequent deep small bowel enteroscopy, or surgery). The maximal depth of insertion may be limited in patients with postsurgical or postinflammatory abdominal adhesions. Technical aspects of tattoo placement are discussed separately. (See "Tattooing and other methods for localizing gastrointestinal lesions".)
Fluoroscopic guidance may be useful for patients with suspected adhesions or with retained foreign bodies. Fluoroscopy may also be used by endoscopists who are learning balloon-assisted enteroscopy techniques to observe advancing and reducing the enteroscope and to identify looping (image 1) [15]. It has been estimated that the learning curve for anterograde examination is approximately 10 cases, compared with 20 to 30 cases for retrograde examinations [15,17]. However, some endoscopists require more than 100 to 150 cases to develop expertise [18].
Efficacy — For most patients without a history of major abdominal surgery who undergo an antegrade examination, the mid to distal jejunum or proximal ileum can be reached within 40 to 80 minutes of examination time (not including the time to set up for the examination, which can be significant) [19].
Retrograde examinations are more difficult, even in expert hands [19,20]. Even if the terminal ileum is intubated, adhesions may limit subsequent advancement to only 10 to 15 cm within the small bowel.
The reported rates of complete enteroscopy (ie, visualization of the entire small bowel, often through a combination of an anterograde and retrograde approach performed) range from 14 to 86 percent, with a large meta-analysis suggesting 44 percent [3,21]. Typically, the antegrade and retrograde examinations are performed during two separate sessions. Lower rates of complete enteroscopy have been noted in patients with obesity, previous abdominal surgery, and excess visceral fat [22] and for less experienced endoscopists.
Diagnostic and therapeutic yields — The diagnostic yield of DBE ranges from 40 to 80 percent, with therapy being performed in 15 to 55 percent of patients [18-20,23]. A meta-analysis of 11 studies that compared DBE with capsule endoscopy estimated that the overall yield for clinically pertinent small bowel findings was similar with the two examinations (60 and 57 percent) [24]. The yield was also similar when comparing specific types of findings such as vascular malformations (picture 2) (24 percent with both), tumors (picture 3) (11 percent with both), polyps (picture 4) (11 percent with both), and inflammatory lesions (18 and 16 percent).
A few studies have compared DBE with push enteroscopy and have found better diagnostic yields with DBE [25,26]. The better diagnostic yields with DBE were in part related to higher rates of complete visualization of the small bowel (ie, total enteroscopy).
A study of 2245 DBE examinations in 1765 patients found that the diagnostic yield varied with the indication [27]:
●Peutz-Jeghers syndrome: 82 percent
●Suspected small bowel bleeding: 53 percent
●Crohn disease: 47 percent
●Abdominal pain: 19 percent
●Diarrhea: 16 percent
In patients with small bowel bleeding due to angiodysplasia, DBE allows for effective treatment with argon plasma coagulation (APC), although recurrent bleeding is common [28,29]. In a study of 50 patients with small bowel lesions, 44 patients (88 percent) were treated with APC for angiodysplasia [28]. After a mean follow-up of 55 months, hemoglobin levels increased from a mean of 7.6 g/dL prior to treatment to 11 g/dL following treatment. In addition, there was a significant decrease in the number of patients requiring blood transfusions, from 30 patients prior to treatment to 8 patients following treatment. However, small bowel bleeding recurred in 21 of the patients (48 percent) treated with APC.
In a second study that included 98 patients with small bowel vascular lesions who were followed after DBE-guided treatment (primarily with APC), rebleeding occurred in 45 (46 percent) at 36 months [29]. Factors that increased the risk of bleeding included the total number of observed lesions and the presence of valvular and/or arrhythmic cardiac disease.
Adverse events — The overall rate for adverse events related to DBE in large series has ranged from 1.2 to 1.6 percent [27,30,31]. A meta-analysis found that minor adverse events occurred in 9.1 percent of procedures, whereas major adverse events were reported in 0.7 percent. Specific events include pancreatitis, perforation, bleeding, and aspiration pneumonia [27,30-34]. The rate of adverse events may be higher for patients undergoing therapeutic procedures compared with those undergoing diagnostic procedures (eg, 4.3 versus 0.8 percent in a series of 2362 procedures) [30].
Pancreatitis — Pancreatitis is the most common significant complication of DBE. The rate of pancreatitis following DBE is approximately 0.3 percent based upon data from three series with a total of 8734 procedures [30,31,33]. The cause of pancreatitis is uncertain but may be related to physical trauma to the pancreas. It is important to distinguish clinical pancreatitis from hyperamylasemia alone, which occurs in approximately 50 percent of patients, especially following long procedures [35,36]. There are no proven methods to reduce the incidence of pancreatitis.
Perforation — The rate of perforation is 0.1 to 0.4 percent [30,31,33,37]. The cause of perforation is likely to be multifactorial. In a study that included more than 29,000 patients who underwent balloon-assisted enteroscopy, there were 32 perforations (0.1 percent) [37]. Factors associated with an increased risk of perforation included inflammatory bowel disease being treated with glucocorticoids (odds ratio [OR] 8.6) and use of glucocorticoids for other reasons (OR 3.3).
Therapeutic interventions also increase the risk of perforation. In one series, 3.4 percent of polypectomies were complicated by perforation [31]. The risk is also increased if stricture dilation is carried out in the setting of active ulceration. Balloon dilation in these cases should be postponed until the ulcer has healed [38].
Surgically altered anatomy is another risk factor for perforation. In one series, the rate of perforation in 219 examinations in patients with surgically altered anatomy was 3 percent [33]. Patients who may be at particularly increased risk include those with an ileoanal or ileocolonic anastomosis and those having their examination performed through a stoma. Altered surgical GI anatomy is a relative contraindication to balloon-assisted enteroscopy. (See 'Contraindications' above.)
Given these risk factors for perforation, we suggest that further insertion of the enteroscope across the lesion be avoided when fragile lesions such as active ulceration are encountered in the small intestine. In addition, DBE should be performed with caution in patients with a history of GI tract surgery.
Bleeding — Bleeding has been reported in approximately 0.2 percent of procedures [31,33]. Polypectomy and biopsy appear to be risk factors for bleeding.
Others — Additional reported complications include two cases of aspiration pneumonia in a series of 265 procedures [32], one cecal volvulus in a series of 2478 procedures [33], and a case report that described severe esophageal trauma from the overtube in a patient with eosinophilic esophagitis, a condition known to predispose to mucosal tearing [39]. (See "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)".)
Single balloon enteroscopy — The SBE system uses a 200 cm high-resolution enteroscope (Olympus SIF-Q180) with a 2.8 mm working channel. Another SBE system (Olympus SIF-Q190) is equipped with a 3.2 mm working channel. The overtube is 140 cm long. The overtube is equipped with a silicone balloon at its tip, which can be inflated and deflated with a pressure setting range of -6.0 to +5.4 kPa.
The technique for SBE is similar to that used for DBE (see 'Technique' above). Like DBE, SBE uses an overtube with a distal balloon to aid with scope advancement through the small bowel. However, SBE uses the scope's flexible tip to anchor the scope, rather than a second balloon on the tip of the enteroscope as with DBE (figure 2). Anchoring stabilizes the scope, permitting advancement of the overtube. The overtube balloon is then inflated, and the tip of the enteroscope is straightened. With the overtube balloon inflated, the scope and overtube can be withdrawn, pleating the small bowel onto the overtube. The enteroscope is then advanced. Like DBE, the cycle of advancement and withdrawal is repeated until the scope can no longer be advanced or the lesion of interest is reached. As with DBE, the point of maximal insertion is frequently marked with a tattoo. (See 'Double balloon enteroscopy' above.)
Experience with SBE suggests that its efficacy is similar to that of DBE. Diagnostic yields have ranged from 41 to 65 percent, and therapeutic yields have ranged from 7 to 50 percent [40-48]. However, the rate of total enteroscopy may be lower than with DBE at 0 to 24 percent [40-42,47,49-51]. In our experience, this is largely due to more difficult intubation of the terminal ileum with SBE compared with DBE. With DBE, the balloon on the tip of the enteroscope can anchor the scope in the small bowel while the overtube is advanced. This is not an option with SBE, so it is harder to maintain position of the enteroscope within the small bowel during overtube advancement. (See 'Diagnostic and therapeutic yields' above.)
Most data on complications of balloon-assisted enteroscopy come from studies of DBE. Complications that have been reported with SBE include abdominal pain, fever, pancreatitis (following ERCP), mucosal tears, and perforation [40-43,46,52,53]. (See 'Adverse events' above.)
Balloon catheter-guided enteroscopy — Balloon catheter-guided enteroscopy (commercially available as the NaviAid Advancing Balloon [AB] system) consists of a "through-the-scope" balloon catheter that is placed through the endoscope's accessory channel and that contains an inflatable balloon at the catheter's tip [54]. The NaviAid AB system can be used with an endoscope with a 3.7 mm accessory channel. The balloon catheter functions as an anchoring device within the small bowel lumen [55]. Preliminary studies using balloon catheter-guided endoscopy reported a mean depth of maximal insertion of 120 cm for antegrade enteroscopy and 110 cm for retrograde enteroscopy, with mean procedure times ranging from 24 to 31 minutes [56].
ROTATABLE OVERTUBE-ASSISTED ENTEROSCOPY
Spiral enteroscopy — Spiral enteroscopy is an alternative to balloon-assisted enteroscopy mainly for antegrade evaluation of the small bowel. Spiral enteroscopy uses an overtube with a soft raised helix at its distal end (eg, Endo-Ease Discovery SB) (picture 5).
Similar to balloon-assisted enteroscopy, spiral enteroscopy can be performed using moderate sedation or general anesthesia. However, if the patient is endotracheally intubated, the anesthesiologist should be asked to deflate the cuff on the endotracheal tube until the spiral is completely within the stomach to prevent esophageal trauma that may be induced by the raised helical spirals on the overtube. (See "Gastrointestinal endoscopy in adults: Procedural sedation administered by endoscopists".)
The 118 cm overtube is compatible with enteroscopes that are 200 cm long and between 9.1 and 9.5 mm in diameter (ie, the enteroscopes used for double balloon or single balloon enteroscopy, but not standard enteroscopes). The spirals on the overtube are either 4.5 mm (low profile) or 5.5 mm (standard profile) high. The overtube has a coupling device that affixes it to the scope while permitting rotation of the overtube. By rotating the overtube clockwise, the small bowel is pleated onto the overtube and the enteroscope is advanced.
Data on spiral enteroscopy are limited. Initial reports suggested decreased procedure times and similar depths of insertion compared with balloon-assisted enteroscopy as well as low complication rates [46,57-62]. However, other reports suggested lower rates of complete small bowel enteroscopy with spiral enteroscopy compared with balloon-assisted enteroscopy. This, however, is not surprising since spiral enteroscopy is performed from an antegrade approach, whereas balloon-assisted enteroscopy can be performed both antegrade and retrograde, increasing the chances for complete enteroscopy. In one study, the rate of complete small bowel enteroscopy was much lower for spiral enteroscopy compared with balloon-assisted enteroscopy (8 versus 92 percent), though the rate of complete small bowel enteroscopy with balloon-assisted enteroscopy was higher than that reported in many studies [63]. (See 'Efficacy' above.)
In addition, the reported yield of spiral enteroscopy has been lower than that seen with balloon-assisted enteroscopy and has varied by indication [57-59,61]. In a study of 95 patients who underwent spiral enteroscopy, the mean procedure time was 34 minutes and the mean depth of insertion was 267 cm [58]. In another series of 61 patients who had spiral enteroscopy, the procedure was successfully completed in 56 patients (92 percent) [59]. Positive findings were present in 36 patients (59 percent) and therapeutic maneuvers were carried out in 30 patients (49 percent).
The reported rate of serious adverse events associated with spiral endoscopy is low. In a study including 1750 patients who had spiral enteroscopy, serious adverse events were reported in seven procedures (0.4 percent) [61]. Six of the events were perforations and all occurred as the enteroscope was being pushed through an overtube.
The yield of spiral enteroscopy in patients with positive findings on capsule endoscopy has also been examined. One study included 56 spiral enteroscopy procedures [64]. Findings on capsule endoscopy included angiodysplasia (26 patients), masses (eight patients), ulcers (four patients), polyps (four patients), abnormal mucosa (six patients), fresh blood (six patients), and stricture (one patient). The findings on capsule endoscopy were reproduced with spiral enteroscopy in 30 patients (54 percent). The type of finding on capsule endoscopy was associated with reproducibility on spiral enteroscopy. Blood was reproducible in 86 percent of patients, angiodysplasia in 69 percent, abnormal mucosa in 50 percent, masses in 38 percent, polyps in 33 percent, and ulcers and strictures in 0 percent.
Motorized spiral enteroscopy — A motorized version of the spiral endoscopy system has been developed, and it consists of a 168 cm long flexible endoscope with 3.2 mm accessory channel and a separate irrigation channel [65-67]. The system incorporates an electric motor to rotate the spiral tube. Tissue resistance is continuously measured to reduce the risk of bowel damage when pleating the small bowel onto the enteroscope.
Studies have suggested that motorized spiral enteroscopy often achieves complete examination of the small bowel with good diagnostic yield for detecting small bowel disorders [68-71]. In a trial comparing motorized spiral enteroscopy with single balloon enteroscopy in 110 adults with suspected small bowel disorders, rates of complete small bowel examination were higher in patients who underwent motorized spiral enteroscopy (71 versus 11 percent) [68]. Motorized spiral enteroscopy also resulted in higher yield for diagnosing small bowel disease (80 versus 62 percent) and shorter mean procedure times (58 versus 114 minutes). No major adverse events occurred in either group. These data show promise, but further studies on safety are needed before performing motorized spiral enteroscopy routinely in clinical practice. In addition, its use may be limited by equipment availability and endoscopic expertise.
SUMMARY AND RECOMMENDATIONS
●General principles – Deep small bowel enteroscopy permits visualization and interventional therapy throughout the small bowel. Available options for deep small bowel enteroscopy include double balloon enteroscopy (DBE), single balloon enteroscopy (SBE), balloon catheter-guided endoscopy, spiral enteroscopy, and motorized enteroscopy. (See 'Introduction' above.)
Balloon-assisted enteroscopy (eg, DBE, SBE) can be performed orally or per rectum, whereas spiral enteroscopy can only be performed orally. (See 'Balloon-assisted enteroscopy' above and 'Spiral enteroscopy' above.)
●Indications – Indications for deep small bowel enteroscopy include (see 'Indications' above):
•Small bowel lesions that were found on video capsule endoscopy or radiographic imaging but are beyond the reach of a standard endoscope (eg, evaluation of suspected small bowel bleeding or Crohn disease).
•Suspected small bowel lesion(s) despite a negative capsule study.
•Suspected impaction of a video capsule proximal to a small bowel stricture.
Therapeutic applications for deep small bowel enteroscopy include the treatment of gastrointestinal bleeding from the small bowel, small bowel polypectomy, and small bowel stricture dilation.
●Adverse events – Deep small bowel enteroscopy is generally well tolerated but has been associated with many of the adverse events seen with other forms of advanced endoscopy. The two most common serious adverse events are perforation and pancreatitis. (See 'Adverse events' above.)
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