Small Bowel Enteroscopy/Therapeutics in Pediatric Endoscopy

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery and the President of Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm very pleased to have Dr. Jessica Berry, who is a Pediatric Gastroenterologist in the Department of Gastroenterology, Hepatology, and Nutrition here at Cleveland Clinic Children's. Dr. Barry, thanks so much for joining us on Butts & Guts.

Dr. Jessica Berry: Thank you so much for having me.

Dr. Scott Steele: Today, we're going to talk about something I don't think we've ever talked about before, and that is small bowel enteroscopy in the pediatric setting. But before we jump into that, we always like to get to know our guests. And so, Dr. Barry, if you can give us a little bit about your background for the listeners.

Dr. Jessica Berry: I'm a pediatric gastroenterologist, as you said. I'm actually from Vermont. I came here in 2011 and did all my training here at The Clinic. I did pathology for a couple of years and then I switched over to peds, so I did my pediatrics residency, and then did my gastroenterology fellowship, and have been here as staff since that time. I actually came with my husband, who's an adult gastroenterologist. So, we came and did all our training, and now we have two little ones. And our family's here and settled in Cleveland, and we love it.

Dr. Scott Steele: Well, that's fantastic, and we sure are glad that you're here. As I said today, we're going to talk about small bowel enteroscopy in the pediatric setting. But before we get there, what is small bowel enteroscopy?

Dr. Jessica Berry: Yeah, so good question. Small bowel enteroscopy is essentially an endoscopic mechanism to look at the extensive component from the small intestine to be able to have a full visualization of the small bowel. Whereas, typically, endoscopy from above only goes to about the second to sometimes the third portion of the small intestine, which is the first aspect (which is the duodenum). Then colonoscopy typically just goes a little bit further into the terminal ileum (which is the last portion of the small bowel), and then looks at the remainder of the colon. This endoscopic mechanism, or process, allows us to look at the full entirety of the small bowel through either an anterograde or a retrograde manner.

Dr. Scott Steele: I think a lot of listeners may have heard this in the past for adults, but when did this enter the pediatric setting?

Dr. Jessica Berry: Enteroscopy single balloon and double balloon came about in the early 2000s. First was 2000, and then about 2008 for the second mechanism. For a pediatric standpoint, shortly after, I would say 2012 or 2010 or so, providers started doing it on younger and younger gastroenterology patients. Within The Clinic here, I am the only provider that does pediatric enteroscopy as a pediatric gastroenterologist, and then there are providers in the adult group where I was fortunate enough to train with to be able to perform those techniques in children. But, it's a relatively less common procedure to be able to be performed because there are not many pediatric gastroenterologists or adult gastroenterologists who feel comfortable completing the procedure.

Dr. Scott Steele: Take us a little bit more into the procedure itself. Who would you do this procedure on, and then how does it work?

Dr. Jessica Berry: Sure. This procedure is really reserved for patients that we need to really take a look at the small bowel in further evaluation. Certain patients that this may be considered on are those with small bowel Crohn's disease. If we have imaging and no biopsies from other aspects of the intestinal tract, as I mentioned, via a standard endoscopy or colonoscopy, we weren't able to make the diagnosis, there were concerning findings on labs or imaging making us wonder or concerned about or maybe capsule endoscopy that there may be findings in the small bowel so that we'd be able to get tissue biopsies for a confirmatory diagnosis.

Additionally, this procedure is utilized for concerns of small bowel bleeding or unknown GI bleeding, be it that there, again, wasn't found initially in a standard endoscopy or in colonoscopy, they're having hematochezia, melena or hematemesis - looking for that underlying cause. Then also, sometimes,I have been questioned where or asked to perform the procedure in patients that were initially bleeding and then there was a question of possibility of metastasis into the small bowel or tumor, polyps, so other masses that often present with hypoalbuminemia or GI bleeding, to further help make that diagnosis.

Dr. Scott Steele: So “truth or myth?” Truth or myth: a small bowel enteroscopy can provide a more thorough evaluation of pediatric patients and actually potentially reduces the need for more invasive procedures?

Dr. Jessica Berry: I would say it's a little bit of both. In most cases, that's the hope; that I'm able to either find the source, say it's a GI bleed and we're unsure based on other studies have been negative - maybe imaging techniques or standard endoscopy, colonoscopy – and weren't able to find the source, sometimes then I go and do enteroscopy. The hope is that I may be able to find the source, perhaps it's a polyp, a vascular malformation, and that I'd be able to... or say maybe somebody who's undergone prior procedures and has anastomotic ulcers, I'd be able to treat that source of bleeding to stop further episodes and diagnose where the source was, what is that underlying etiology. But, in some cases, it's not always the answer and I may not find the cause and it may still be that the patient needs to undergo further evaluation, which may include surgical procedures, such as laparoscopy or exploratory surgeries, where sometimes I then also include it to help assist to evaluate the bowel from intraluminal while there is an extraluminal evaluation happening.

Dr. Scott Steele: Give us a look behind the curtain. What does a normal small bowel look like, and what are you actually looking for when you perform a small bowel enteroscopy?

Dr. Jessica Berry: Yeah, sure. I always say and describe it most of the small bowel looks like kind of a healthy shag carpet appearance. It should be nice and pink, normal villi. We shouldn't see any erosions, flattening, ulcerations or polypoid or other extraneous masses. A nice healthy, small bowel wouldn't show me any evidence of current or recent bleeding, like stigmata, so sometimes I might see fresh blood or I might see older blood or areas of ulcer that now no longer have visible vessels or active bleeding occurring. But the hope is that it looks nice and healthy, but if it doesn't that I'm able to identify it so that I can treat it.

Dr. Scott Steele: I got to be honest with you, if I told my daughter that she was getting a small bowel enteroscopy, she might be pretty intimidated no matter what her age has been or what it is right now. How do you help a child through this entire process?

Dr. Jessica Berry: Yeah, it's a good question. Similarly to how we are able to help our patients when they're undergoing endoscopy and colonoscopy, we're really fortunate to have a wonderful team of pediatric directed endoscopy nurses, anesthesiologists, our Child Life. No procedure is easy for any patient, child, parent, any adult, and we help them to be as comfortable as possible. They're under general anesthesia for the entire procedure. So, with medications, their memory or recall of the event is fairly limited and I keep them as comfortable as possible. I use CO2 insufflation, so they have minimal gas and that discomfort after the procedure is decreased. And just making sure I explain to them as best as possible in their terms of what's going to happen. I like to describe it as kind of pulling a sock over a limb or onto your foot and that I use a balloon to help me move through to hold onto the bowel so that I can really move my way through in a safe but efficient manner so I can see all aspects and be able to try to help them.

Dr. Scott Steele: Are there any advancements on the horizon when it comes to this procedure, small bowel enteroscopy in the pediatric setting?

Dr. Jessica Berry: I think there's always new things coming down the pipe. Right now, there is no new development that I'm aware of other than the double balloon and the single balloon devices and the equipment that's available. There are some studies in adult populations looking at different techniques and different scopes that are able to move through the bowel in a similar but a little bit different fashion. But right now, that's not being looked at in pediatrics. Oftentimes I'm using balloon enteroscopy in coordination with video capsule endoscopy if it may have been done prior or after if I'm still not able to get all the way to where I need to. But, otherwise, no other new equipment right now.

Dr. Scott Steele: Two final questions. Number one, how long does it take, and can you get through the entire small bowel?

Dr. Jessica Berry: Yeah. I say, in typical, that the procedure itself if I'm doing a colonoscopy as well as a balloon enteroscopy and in some patients, especially for polyposis disorders in evaluation, which is a typical reason why I might be doing the procedure in both combined, that can be a little bit of a longer procedure. I typically say about two hours just because I have to do an upper endoscopy, a colonoscopy, and then make sure that I can really look through the entire small bowel with an anterograde enteroscopy. Now, in a patient that maybe is not having a colonoscopy and we're just doing an anterograde enteroscopy with a single balloon, it's about an hour, sometimes a little more, a little less. In most cases, I am able to, depending on the size of the child, the prep, what I'm looking for, and what are the reasons for the procedure, there's better success overall for patients undergoing anterograde endoscopy to be able to visualize the entire small bowel. Retrograde sometimes is a little bit lower, and sometimes we do have to go from both aspects to be able to try to look at everything. But I think most of the time I'm able to get a really good look.

The nice component is if I feel like I did not reach to my full extent or reach my area of concern to assist with my surgical colleagues, I'm able to apply a tattoo or a clipping device mechanism that then they are able to help in utilization if they do have to go for laparoscopic evaluation or open evaluation to try to be able to identify my markings, which is really important. Especially, I utilize this procedural a lot in patients who perhaps have undergone multiple prior intestinal resections, they have short gut, their anatomy is a little bit more complicated, a lot of adhesions, to really help them to find. And that's something I've done frequently and have actually utilized for cases where there's maybe metastatic disease, unfortunately.

Dr. Scott Steele: Well, now it's time for our quick hitters as we get to know you just a little bit better. First of all, if I was to turn on your favorite music device, what type of music would I be listening to?

Dr. Jessica Berry: Oh, I listen to everything, really. Nothing is very specific. The only thing I'm not a big fan of - I don't listen to a lot of country music.

Dr. Scott Steele: Sounds good. So, Taylor Swift. Second of all, what is your first car?

Dr. Jessica Berry: Oh, I had a Honda Civic.

Dr. Scott Steele: Third, tell me about a trip that you either want to go on or that you have already gone on that you would recommend to our listeners.

Dr. Jessica Berry: Oh, as a family we go to Grand Cayman every year and we stay at the Kimpton, which is really fun. It's a great family resort, and it's beautiful, so I highly recommend it. We're going in May.

Dr. Scott Steele: Fantastic. Then finally, tell us something that you like about living here in Northeast Ohio.

Dr. Jessica Berry: I really love the seasonal changes. It reminds me a lot of - I'm from Vermont, so it kind of keeps me feeling like home. It's really beautiful and there's lots to do outdoors, which is very familiar to me.

Dr. Scott Steele: Fantastic. What's a final take-home message for our listeners regarding this?

Dr. Jessica Berry: I think it's really important to recognize that this procedure is an option for patients and we're able to provide it in a pediatric setting (and if needed in assistance with our adult colleagues). And to know what's available. I get a lot of patients that are coming from all over for polyposis disorder evaluations or questions about prior diagnoses of small bowel Crohn's. And I think it's important to note we are able to get tissue and evaluate to help solidify diagnoses when needed.

Dr. Scott Steele: Well, that's fantastic. To learn more about the Department of Gastroenterology, Hepatology, and Nutrition here at Cleveland Clinic Children's, please visit clevelandclinicchildrens.org/gi. Again, that's clevelandclinicchildrens.org/gi. You can also call us at 216.444.5437. That's 216.444.5437. Dr. Barry, thanks so much for joining us on Butts & Guts.

Dr. Jessica Berry: Thanks for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.