Not achieving adequate mucosal visualisation
Inadequate mucosal visualisation may increase the risk of missing a culprit lesion and every effort should be made to optimise the views obtained. In the context of SBCE, although the subject is still contentious, the latest ESGE technical review on small bowel endoscopy recommends the use of purgatives and an antifoaming agent, as well as fasting prior to SBCE to enhance mucosal visualisation and potentially reduce the risk of missed pathology.15
In the context of DAE, particularly in the setting of active bleeding, adequate mucosal visualisation can be challenging. In our practice, and as recommended by the ESGE technical review,15 we perform the following: active mucosal washing with saline (using a motorised jet pump), selective application of antifoaming agents (such as simethicone, used judiciously, since this may also cloud the visual field) and selective administration of intravenous hyoscine-N-butylbromide to reduce peristaltic activity (unless contraindicated).
Careful inspection of the small bowel mucosa should be achieved both on insertion and withdrawal—in the case of double-balloon enteroscopy (DBE), the maintenance of gentle scope-balloon inflation on enteroscope withdrawal may help to straighten mucosal folds to further enhance visualisation. The use of a very short, soft, distal attachment is also recommended.17 In our own practice, we also prefer to substitute gaseous insufflation with saline-immersion since this may further improve visualisation of an active bleeding point.18 The placement of an endoclip just proximal to a lesion, at the time it is identified, acts as a reliable reference point particularly during active bleeding, when adequate views may be difficult to reachieve or maintain. The endoclip may also serve as a reference point for interventional radiology, should this be required. For retrograde DAE procedures, optimal bowel preparation with purgatives is essential.
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