i k d i t o r l a l
S i t u a t i o n a c t u e l l e d e I ' e n t 6 r o s c o p i e
K. KAWAI, M. TADA, F. M I S A K I
D e p a r t m e n t o f P r e v e n t i v e M e d i c i n e , K y o t o P r e f e c t u r a l U n i v e r s i t y o f M e d i c i n e K a w a r a m a c h i - H i r o k o f i , K a m i k y o - K u , K y o t o ( J a p a n )
Present status of enteroscopy
L e s e x p l o r a t i o n s r a d i o l o g i q u e s et e n d o s c o p i q u e s e n p a t h o l o g i e g a s t r o - i n t e s t i n a l e d u c61on s o n t entr6es d a n s la r o u t i n e e n r a i s o n des progr~s a c c o m p l i s d a n s ces d e u x d o m a i n e s t e c h n i q u e s . N 6 a n m o i n s , e n pra- t i q u e c o u r a n t e , le d i a g n o s t i c p r 6 o p 6 r a t o i r e d ' u n e a f f e c t i o n de l ' i n t e s t i n gr61e d e m e u r e n o n r6solu. A u c o u r s des 10 a n n 6 e s 6coul6es, n o u s a v o n s p r a t i q u 6 d a n s n o t r e c e n t r e h o s p i t a l i e r , u n n o m b r e t o t a l d ' e x a - m e n s c o m p o r t a n t 82 0 0 0 e n d o s c o p i e s d u t r a c t u s digestif s u p 6 r i e u r , 5 0 0 0 E R C P et plus de 6 0 0 0 co- loscopies.
P o u r t a n t , a u c o u r s de la m ~ m e p6riode, n o u s n e d 6 n o m b r o n s q u e 187 e n t 6 r o s c o p i e s . O n p e u t s ' i n t e r - roger h p r o p o s d ' u n n o m b r e si r 6 d u i t d ' e n t 6 r o s c o p i e s . Les r a i s o n s de cette s i t u a t i o n s o n t m u l t i p l e s : en p r e m i e r lieu, la faible f r 6 q u e n c e des m a l a d i e s de l ' i n t e s t i n gr~le et d ' a u t r e part, les difficult6s tech- n i q u e s p r o p r e s h l ' e n t 6 r o s c o p i e . R 6 c e m m e n t , des essais s y s t 6 m a t i q u e s d ' a m 6 1 i o r a t i o n de l ' e n d o s c o p i e o n t 6t6 a c c o m p l i s e n v u e d u d i a g n o s t i c des m a l a d i e s de l ' i n t e s t i n gr6le. N o u s r a p p o r t o n s c i - d e s s o u s la s i t u a t i o n a c t u e l l e et les p e r s p e c t i v e s f u t u r e s de l ' e x p l o r a t i o n e n d o s c o p i q u e de l ' i n t e s t i n gr61e.
I N D I C A T I O N D E L ' E M P L O I D E C H A O U E T Y P E D ' E N T E R O S C O P E
Ires e n d o s c o p e s destin6s h l ' e x p l o r a t i o n de l ' i n - testin gr61e o n t 6t6 m i s au p o i n t s e l o n trois m o d e s de c o n c e p t i o n d i f f 6 r e n t s :
9 u n f i b r o s c o p e d u type << ~. p o u s s e r >>, e n fait u n d u o d 6 n o s c o p e l o n g i n t r o d u i t d i r e c t e m e n t p a r vole orale d a n s le j 6 j u n u m s u p 6 r i e u r ;
9 u n f i b r o s c o p e h <~ill-guide >> qui est e n fait tir6 le long d u t r a c t u s i n t e s t i n a l p a r voie basse aprbs
i n t r o d u c t i o n p r 6 a l a b l e d ' u n fil a y a n t t r a v e r s 6 la t o t a - lit6 d u t r a c t u s digestif ;
9 f i b r o s c o p e d e type <~ s o n d e >>, s e m b l a b l e a u x s o n d e s de M i l l e r - A b b o t t o u de C a n t o r et d o n t le m o d e d ' i n t r o d u c t i o n est c o m p a r a b l e h l ' e m p l o i de ces d e r n i b r e s (figure i , t a b l e a u I).
TABLEAU I CARACTI~RISTIQUES
DES TROIS TYPES D'ENTI~ROSCOPES
Syst~me optique Direction et obscr.
vation . . . Angle de vision . Syst~me de localisa-
tion . . . Limites de la pro-
fondeur de champ Caract~ristiqu es du tube
Diam6tre ext6rieur Limites
de b~quillage Haut et bas . . . Droite ~t gauche . Canal biopMque Diam&re int6rieur Longueur utile . . . Longueur totale
Type << h pousser >>
(SIF-B)
Axioscope 74 ~ fixe 5-45 mm
10 mm
150 ~ , 120 ~ 90 ~ , 90 ~
2,8 mm 1 620 mm 1 770 mm
Type
~ fil-guide >>
(SIF-2 C)
Axioscope 100 ~ fixe 5-60 mm
11 mm
180 ~ , 120 ~ 120 ~ , 120 ~
2,8 mm, 2,0 mm 1 700 mm 1 900 mm
Type
<~ sonde >>
(SSIF-V)
Axioscope 65 ~ fixe 5-60 mm
%8 mm
90 ~ , 90 ~ 90 ~ , 90 ~
2,0 mm 2 730 mm 3 020 mm
Tir6s h part : K. KAWAI, Department of Preventive Medicine, Kyoto Prefectural University of Medicine, Kawa- ramachi-Hirokoji, Kamikyo-Ku, Kyoto (Japan).
Mots-clFs : enteroscopie, indications, intestin gr~,le, nou- veaux instruments.
Key-words : enteroscopy, new instruments, indications, snrall intestine.
Acta Endoscopica Volume 12 - N ~ 4 - 1982 2 8 3
Figure 1
Trois types d'ent~roscopes
(A : type ,, & pousser ,,, B : type - f i l - g u i d e . , C . type ,, sonde ,,) Three types of enteroscope
( A : push type, B : rope-way type, C : sonde type)
L a technique de l'endoscopie sur << ill-guide ~> n6- cessite l'introduction pr6alable par voie orale d'un tube de teflon mince, traversant la totalit6 du tractus digestif au cours des 2 h 5 jours pr6c6dant l'explo- ration endoscopique. L'avantage du fibroscope sur ill-guide est de pouvoir explorer t o u s l e s niveaux de l'intestin gr61e (figure 3). Malheureusement, lorsque les 16sions st6nosantes interrompent la progression du ill-guide, ce mode d'exploration est compromis.
D'autre part, le risque d'abrasion ou de perforation intestinale par la portion rigide du ill-guide doit 6tre prise en consid6ration.
Le fibroscope de type << ~ pousser >> (SIF-B) peut
~,tre introduit dans le j6junum proximal dans un temps relativement court et procure une image excel- lcnte. Des biopsies guid6es peuvent 6tre pr61ev6es la pince ou encore par une sonde pour biopsie-aspi- ration-section qui peut 8tre introduite dans le canal biopsique. Le principal d6savantage de cet instru- ment est de limiter l'exploration au j6junum proxi- mal et de ne pouvoir au m a x i m u m d6passer 90 cm de l'angle de Treitz (figure 2).
Figure 2
Cliche rad=ologique montrant la progression du fibroscope type ,, & p o u s s e r - clans plusieurs anses intestinales X-ray picture of the insert=on loops of the push type fiberscope
Figure 3
Progression dans les anses intestinales de I'ent6roscope type ,, fil-guide ,,
Insertion loops of the rope-way type fiberscope
Le ilbroscope de type sonde est un endoscope long et mince : sa longueur utile est d'environ 280 cm.
I1 est lest6 par un ballon rempli de mercure situ6 ~t l'extr6mit6 de l'appareil et facilitant sa progression plus rapide vers les portions distales de l'intestin.
Nous avons ~ notre disposition 5 mod61es d'endo- scopes type sonde. Les quatre premiers prototypes (type I, II, II1 et IV) 6taient d6pourvus de canal biopsique et de m6canisme de b6quillage afin de maintenir la minceur du fibroscope. Un module plus r6cent, le type V, a subi des am61iorations destin6es permettre la biopsie et des manoeuvres de b6quil- lage. Ces avantages ont entrain6 en contrepartie un accroissement du diam6tre externe, soit 7,8 mm,
284 V o l u m e 1 2 - N ~ 4 - 1 9 8 2 A c t a E n d o s c o p i c a
calibre sup6rieur au prEc6dent prototype. Apr.Ss anesthEsie pharyng~e "~ la xylocaine, le patient avale lui-m~me l ' e n d o s c o p e c o m m e un tube duodenal. L a ht;ure 4 m o n t r e une image radiologique des anses intestinales explorEes p a r l'endoscope. L'extrEmitE de ce dernier atteint h a b i t u e l l e m e n t l'ilEon terminal en 2 h 3 heures, sans inconvenient p o u r les patients.
Les lesions intestinales c o m p o r t a n t des r~trEcisse- ments ou des stEnoses e m p a c h a n t le passage du m o - dule <~ ~t pousser ~> ou de l'endoscope sur ill-guide, peuvent bEnEficier de ce type d'exploration p a r fibroscope de type <~ sonde >>.
Figure 4
Progression dans I'intestin grOle de I'ent~roscope type ,, s o n d e ~, p o r t e u r de son b a l l o n n e t ~ mercure
Insertion loops of the s o n d e type fiberscope
C a s n ~ 1 ; une patiente figEe de 58 ans, admise
dans notre service hospitalier p o u r plaintes doulou- reuses abdominales et amaigrissement. L ' e m p l o i d ' u n fibroscope type ~ ~t p o u s s e r ~> a permis la visualisa- tion d'une stricture annulaire couverte d'Erosions et de nodules irr6guliers. Les biopsies ont rEvilE un ad6nocarcinome d u j e j u n u m . Dans de telles condi- tions, une entEroscopie p e u t 6tre pratiqu~e aussi aisdment q u ' e n g a s t r o d u o d 6 n o s c o p i e (figure 5).
C a s n ~ 2 ; un p a t i e n t figE de 49 ans, admis p o u r douleurs a b d o m i n a l e s basses. L ' e x p l o r a t i o n radio- logique rEvble une large t u m e u r ulcErEe proche de
l'ilEon terminal. L ' e n d o s c o p e <~ a pousser ,~, l ' e n d o - scope de type <~ sonde ,> et la coloscopie n ' o n t p a s permis d'atteindre la 16sion. L'entEroscopie a 6tE effectuEe sur ill-guide et a dEmontrE une large tu- m e u r avec excavation centrale au niveau il6al (figure 6). L ' e x a m e n histologique a permis d'6tablir le diagnostic de l y m p h o m e malin. Ainsi, l ' e n d o s c o p i e sur ill-guide p e r m e t la visualisation et la biopsie dirig~e m~me en cas de l~sion du gr~le distal.
C a s n ~ 3 ; un h o m m e gtg6 de 48 ans est hospita- lisE p o u r sensation de plenitude et lourdeurs 6pi- gastriques avec d o u l e u r p6riombilicale 6voluant depuis trois mois. L a r a d i o g r a p h i e baryt6e m o n t r e des anomalies au niveau de l'eesophage, de l ' e s t o m a c et du d u o d e n u m ainsi que des st6noses EtagEes m u l - tiples et une rEtrodilatation au niveau de l'il6on.
L ' e n d o s c o p e type << sonde >> (type I I D a permis d ' a t - teindre r a p i d e m e n t le niveau 1Esionnel. Une i m p o r - tante quantitE de liquide de stase remplissait la lumi~re intestinale dilat6e. Apr6s aspiration du liquide, une stEnose annulaire avec ulceration circu- laire ainsi que des Erosions irrEgulibres multiples avec plis convergents ont EtE visualisEs et l'ensemble des donn6es endoscopiques a p e r m i s d'orienter f e r m e - m e n t le diagnostic vers celui de tuberculose il6ale confirmEe par l'histologie. D a n s un cas semblable, l'endoscope type << "h p o u s s e r >> ne p e r m e t p a s d ' a t - teindre le niveau IEsionnel et d ' a u t r e part, le ill- guide ne peut franchir la stEnose.
Ainsi, seul un e n d o s c o p e de type <~ sonde ~> p e u t 6tre utilisE en cas de lesions stEnosantes.
C a s n ~ 4 ; un h o m m e ftg6 de 68 ans est admis
dans le service p o u r m616na r6cidivant. Plusieurs explorations radiologiques et endoscopiques a v a i e n t 6t6 accomplies sans p e r m e t t r e la mise en 6vidence du site des h6morragies. A la suite d ' u n m616na massif, une ent6roscopie au m o y e n d ' u n e n d o s c o p e de type <~ sonde >> a 6tE mise en route en urgence et a permis de r e c o n n a i t r e une lesion blanchgtre Emergeant dans un lac sanguin au niveau j6junal.
A l'intervention, cette t u m e u r de diam~tre 3 x 2 c m s'est rEvE1Ee ~tre un 1Eiomyome du jejunum supE- rieur. E n pareil cas, un e n d o s c o p e de type <~ sonde >>
peut 6tre utilis6 sans risque et ce m o d e d ' e x p l o r a t i o n s'av~re tr~s utile en urgence dans la mise au point d'hEmorragies intestinales massives.
L a tableau I I r6sume les avantages et inconv6- nients des diffdrents types d ' e n d o s c o p e s . C h a q u e type d ' a p p a r e i l a des m6rites et des d6savantages et le choix c o m m e le m o n t r e le t a b l e a u I I I , doit ~tre accompli en fonction de la configuration et de la localisation des 16sions au niveau de l'intestin gr~le.
Les endoscopes de type <~ ~t p o u s s e r >> c o n v i e n n e n t dans les 16sions du j6junum p r o x i m a l o u en vue de la biopsie de 16sions ?~ extension diffuse. Les e n d o - scopes de type ~ ill-guide >> d o i v e n t ~tre utilis6s en cas d ' e x p l o r a t i o n de la totalit6 de l'intestin gr~le.
D ' a u t r e part, l ' e n d o s c o p e de type ~ sonde ~> est re- c o m m a n d 6 p o u r l ' e x a m e n en urgence dans les h6morragies gastro-intestinales, dans l'exploration des patients en m a u v a i s 6tat g6n6ral, dans le diag-
A c t a E n d o s c o p i c a V o l u m e 1 2 - N ~ 4 - 1 9 8 2 285
nostic des 16sions st6nosantes localis6es h la portion distale de l'intestin gr~le, lh off ne p e u v e n t parvenir les endoscopes du type <~ h pousser ~> ou du type
<~ ~t fil-guide >>. E n r6alit6, ~t quelque niveau que surviennent les 16sions de l'intestin gr61e, nous de- vons 6tre en m e s u r e de les explorer suffisamment avec un appareil ad6quat.
TABLEAU II
AVANTAGES ET DI~SAVANTAGES DES TROIS TYPES D'ENTI~ROSCOPES
Avantages
D6savantages
Type r ~ pousser ~>
Temps d'examen court (20-40 min.)
Observation limit6e au j6junum proximal
Type
~r fil-guide >>
Observation de
l'ensemble de l'intestin gr&le Temps de progression long du fil transintes- tinal Mauvaise tol6rance par les pa- tients ( + + )
Type
~ sonde ~>
Temps d'examen court (2-3 heures) Tol6rance par les patients (___)
Impossibilit6 d'examen de l'il6on terminal
D E V E L O P P E M E N T F U T U R D E L ' E N T E R O S C O P I E
M o d k l e d ' u n e n t d r o s c o p e p l u s ~ c o n o m i q u e
Ainsi que nous l ' a v o n s mentionn6 plus haut, au- curt des trois types d'ent6roscope ne p e r m e t un exa- m e n satisfaisant et chacun m6rite des perfectionne- ments en v u e d ' u n e ent6roscopie correcte. I1 est toutefois difficile d ' i m p o s e r h un h6pital l'acquisition des trois types d'appareils. U n n o u v e a u modble d'en- t6roscope, S I F - R P O l y m p u s , associe les caract6- ristiques des deux mod6les <~ h pousser >> et ~ ill- guide ~.
Cet i n s t r u m e n t a une longueur utile de 1 425 m m , un diam6tre ext6rieur de 11 m m et est p o u r v u d ' u n e section b6quillable.
Le diam~tre interne du canal biopsique est de 2,8 m m . L e syst~me optique p r o c u r e une image ronde avec un angle de vue de 100 ~ Le syst6me de b6quillage est quadri-directionnel : 180 ~ le sens h a u t - b a s et 160 ~ dans le sens droite-gauche.
Utilis6 selon la m 6 t h o d e du <~ ill-guide ~>, l ' e n d o - scope traverse la totalit6 de l'intestin gr61e selon le proc6d6 conventionnel. D ' a u t r e part, le j6junum proximal p e u t 6tre examin6 selon le proc6d6 d ' e n d o - scopie <~ ~ pousser ~>, dans le p r o l o n g e m e n t des tech- niques usuelles d ' e n d o s c o p i e du tractus digestif sup&
rieur. Ces caract6ristiques font de l ' e n d o s c o p e S I F - R P un appareil c o m b i n 6 <~ ~t pousser >> et sur <~ ill- guide >>, n e t t e m e n t plus 6conomique.
TABLEAU III
INDICATIONS DE L'ENTI~ROSCOPIE
Type ~ ?t pousser ~>
L6sions du j6junum proximal
Biopsies de 16sions muqueuses diffuses
Type ~ sur ]il-guide ~>
Observation de la totalit6 de l'intestin gr~le Utilisation d'optiques grossissantes
Type ~ sonde ~>
Emploi en urgence pour h6morragie gastrointestinale Utilisation p6diatrique
Examen de patients en mauvais 6tat g6n6ral L6sions st6nosantes.
E n d o s c o p i e p ( d i a t r i q u e
Le. d 6 v e l o p p e m e n t des endoscopes, de f i n calibre et grand angu[aire, a p e r m i s l'exploration d ' u n e lu- mi6re gastrointestinale 6troite chez l'enfant et l ' a d o - lescent. C e p e n d a n t l'exp6rience de l'ent6roscopie chez l'enfant d e m e u r e restreinte en raison de l ' a b - sence d'appareils ad6quats ainsi que des difficult6s soulev6es p a r l'ent6roscopie dans cette cat6gorie de patients. Les appareils ordinaires pr6vus p o u r l'adulte ne sont ni adapt6s ni stirs et l'ent6roscopie p6diatri- que n6cessite des appareils sp6ciaux.
L ' e n t 6 r o s c o p e de t y p e <~ sonde >> qui ne c o m p o r t e pas autant de risques a 6t6 am61ior6 en vue de l'usage p6diatrique. Un n o u v e a u mod61e SSIF type V I (Olympus) a 6t6 modifi6 en vue de p e r m e t t r e la biopsie mais n o n p o u r v u de syst~me de b6quillage et se pr6sente c o m m e un appareil plus fin que le prototype type V. L a l o n g u e u r utile du type S S I F - V I est de 2 864 m m , suit p r a t i q u e m e n t la m~me que les types I-V. Le diam6tre ext6rieur est de 6,8 m m , ce qui est sup6rieur a u x types I - I V mais m o i n d r e que le type V. Le syst6me optique du type V I est prati- q u e m e n t le m ~ m e que celui du SSIF ant6rieur. L ' a n - gle de vision est de 65 ~ avec locale fixe.
Au cours de l'ann6e 6coul6e, trois cas p6diatriques furent explor6s dans notre service au m o y e n de l'en- doscope SSIF type VI. U n jeune garqon fig6 de 11 ans souffrant d'6pisodes r6p6t6s de douleur abdo- minale d'6tiologie inconnue, une lille gtg6e de 12 ans ant6rieurement op6r6e de j6junectomie partielle p o u r invagination due ~ u n s y n d r o m e de Peutz-Jeghers et un garcon de 13 ans atteint de colite granulomateuse et suspect6 de 16sion au niveau de l'intestin gr~le.
Apr6s anesth6sie pharyng6e ~ la xilocaine, l'endo- scope a 6t6 d6gluti de fagon active c o m m e une sonde duod6nale. L ' e n t 6 r o s c o p e a 6t6 introduit jusqu'h la portion distale de l'intestin gr~le (110-140 cm de l'angle de Treitz, r6gion consid6r6e radiologique- ment c o m m e l'il6on sup6rieur) dans un d61ai de 50 60 minutes (tableau IV). Le temps total d ' e x a m e n a 6t6 de 70 minutes dans les cas 1 et 3, et 75 minutes dans le cas 2, ce qui est consid6r6 c o m m e supporta- ble chez un enfant (figure 7).
286 V o l u m e 12 - N ~ 4 - 1982 Acta Endoscopica
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9 ~ , ,-:';':':v"
9 ~ . "*,~176 % - ,
, . , , , , . , , . ' , ' g
". ,,, ','.'.;.;~,;.:.:.'.%:. '.% . ' , , ,
o . .
4~
9 " i - ":~i".-,... .,~
Figure 5
Cancer du jejunum observe & travers un enteroscope type ,, & pousser ~
Cancer in the jejunum seen by the push type fiberscope
Figure 6
Lymphome malin de I'il6on observ~ ~ travers un enteroscope type ,, fil-guide ,,
Malignant lymphoma in the ileum observed by the rope-way type scope
Figure 7
Polype de I'il~on dans un syndrome de Peutz-Jeghers (fillette
~gee de 12 ans) observ~ ~ travers un enteroscope type ,, sonde ,,
Polyp in the deum of Peutz-Jeghers' syndrome (a 12-year- old girl) seen by the sonde type fiberscope
Figure 9
Vue agrandie des villosit~s & travers un ent6roscope & optique g rossissante
Magnifying view of the villi by the magnifying enteroscope
A c t a E n d o s c o p i c a V o l u m e 1 2 - N " 4 - 1 9 8 2 287
TABLEAU IV
R~SULTATS DE L'ENT~ROSCOPIE AVEC L'APPAREIL SSIF- TYPE VI Cas observ6s
(~ge, sexe) 1. !1, garqon . . . 2. 12, fille . . . 3. 13, garqon . . .
Segment intestinal explor6 (*)
110 cm 120 cm 140 cm
Dur6e de la mise en place
50 min.
50 min.
60 min.
Dur6e totale de l'exploration
70 min.
75 min.
70 min.
Observations endoscopiques
Normal Polypose
Normal
(*) Distance h partir de l'angle de Treaz.
L'ent6roscopie sur << fil-guide >> est consid6r6e c o m m e trop angoissante chez l'enfant, c o m m e d'ail- leurs chez certains a d u l t e s ; nous ne l ' a v o n s pas pratiqu6e dans cette cat6gorie d'ftge.
En g6n6ral, les enfants ne c o m p r e n n e n t pas la motivation de l'examen, et leur coop6ration ne peut
~tre obtenue.
E n pareil cas, l ' e x a m e n peut 6tre envisag6 sous anesth6sie g6n6rale. N6anmoins l'anesth6sie pharyn- g6e est suffisante lors de l'exploration avec un endo- scope SSIF type V I chez un enfant plus ~g6.
E n fait, les enfants c o m m e les adultes doivent 6tre examin6s avec un m i n i m u m de risques.
E n fait, une technique ad6quate et une exp6rience plus grande des endoscopistes doivent permettre l'utilisation d ' u n ent6roscope type V I en exploration p6diatrique de routine.
Ce d 6 v e l o p p e m e n t de l'ent6roscope devrait per- mettre chez les enfants d ' a p p o r t e r plus d ' i n f o r m a t i o n s physiopathologiques relatives aux m a l a d e s de l'in- testin gr61e.
E n t ~ r o s c o p i e
e n p r a t i q u e e n d o s c o p i q u e c h i r u r g i c a l e Les m6thodes d'61ectro-coagulation-section h l'anse d i a t h e r m i q u e ont permis un d 6 v e l o p p e m e n t de la p o l y p e c t o m i e endoscopique ~t diff6rents niveaux du tractus gastrointestinal. Ces manipulations au niveau de l'~esophage, de l'estomac, du duod6num, du c61on et du r e c t u m sont effectu6es avec facilit6 et s6curit6 mais n6anmoins au niveau de l'intestin gr61e, elles ne sont jamais ex6cut6es en raison des diffi- cult6s techniques de m a n i p u l a t i o n d ' e n d o s c o p e . L a mise au point d ' u n ent6roscope ~ double canal type S I F - 2 C (Olympus) a r6solu ce p r o b l ~ m e c o m m e le d6montre le cas suivant :
C a s n ~ 5 ; une jeune patiente de 22 ans pr6sentant une p i g m e n t a t i o n au niveau des 16vres, a u t o u r de la cavit6 buccale, sur la m u q u e u s e de la b o u c h e et au niveau des extr6mit6s, a 6t6 hospitalis6e dans notre service en raison de c r a m p e s a b d o m i n a l e s avec vo- missements. U n e il6ostomie partielle fut ex6cut6e p o u r investigation due ~ deux v o l u m i n e u x polypes.
L ' e x a m e n microscopique a r6v616 des h a m a r t o m e s
p e r m e t t a n t d'6tablir le diagnostic de s y n d r o m e de Peutz-Jeghers. Les radiographies baryt6es apr6s inter- vention ont r6v616 de multiples polypes du j6junum et de l'il6on. Des p o l y p e c t o m i e s endoscopiques ont 6t6 effectu6es au niveau de l'intestin gr61e en utili- sant le fibroscope type << ill-guide >>, S I F - 2 C. L ' a p - pareil SIF-2 C c o m p o r t e deux canaux de diam6tre int6rieur r e s p e c t i v e m e n t de 2,8 m m et 2,0 m m . Le SIF-2 C a 6t6 introduit dans l'intestin selon la m6- thode classique du << ill-guide >>. Apr~s passage travers le tractus gastrointestinal, le fil a 6t6 pass6
travers l ' u n des canaux biopsiques de l'ent6roscope.
Le SIF-2 C rut d o u c e m e n t introduit dans l'intestin gr61e du sujet p a r voie orale et sous anesth6sie g6n6- rale. Apr~s introduction de l'appareil dans l'il6on terminal, l ' e n d o s c o p e fut attir6 d o u c e m e n t vers le bas sans retrait du ill-guide laiss6 en place dans un des canaux. P a r traction du ill, il est possible h la fois d ' e m p 6 c h e r l'ent6roscope de glisser vers l'aval.
Une anse d i a t h e r m i q u e a 6t6 introduite dans l ' a u t r e canal (figure 8). Des polypes v o l u m i n e u x de dia- m ' t r e sup6rieur ~t 1 c m furent retir6s tandis que de petits p o l y p e s ont 6t6 laiss6s en place. Ainsi p a r attraction de l'ent6roscope hors de l'intestin gr61e proximal, les p o l y p e s ont 6t6 r6s6qu6s un ~ un et en tout, trois p o l y p e s ont 6t6 r6s6qu6s au niveau de l'il6on et un au niveau du j6junum. T o u s les p o l y p e s ont 6t6 r6s6qu6s sans h6morragie ni p e r f o r a t i o n mais leur r6cup6ration n ' a pas 6t6 complete en raison du n o m b r e de p o l y p e s r6s6qu6s au cours d ' u n e seule maneeuvre.
Malgr6 le calibre 6troit de la lumi6re intestinale, l'anse d i a t h e r m i q u e et un cath6ter de type D o r m i a peuvent ~tre introduits. L ' u n des avantages techni- ques de ce proc6d6 de p o l y p e c t o m i e endoscopique est de p e r m e t t r e que le ill-guide reste en place sans toucher l'anse, autorisant la r6alisation des p o l y p e c - tomies de faqon sfire et ais6e. Les p e r f e c t i o n n e m e n t s du SIF-2 C r e n d e n t l'ent6roscopie sur ill-guide m i e u x praticable, ce qui 61argit les c h a m p s d ' a p p l i c a t i o n de l'ent6roscopie th6rapeutique et diagnostique.
V i s i o n d e s v i l l o s i M s a v e c o p t i q u e g r o s s i s s a n t e
A u cours des derni~res ann6es, les optiques gros- sissantes ont 6t6 plus l a r g e m e n t utilis6es dans l'ob-
288 V o l u m e 12 - N o 4 - 1982 A c t a E n d o s c o p i c a
i' ,,I ,.,,, ,'
Figure 8
Clich~ radiologique montrant I'extr6mit6 de I'ent6roscope type - i l l - g u i d e . & 2 canaux (type SIF-2C Olympus) X-ray picture of the tip of two channel rope-way type
fiberscope, type SIF-2C (Olympus)
servation des muqueuses gastrointestinales. I1 n'est pas n6cessaire d'en souligner les avantages dans la d6tection pr6coce des petits cancers superficiels et des polypes et dans la compr6hension des aspects physiopathologiques des muqueuses gastrointestinales.
N6anmoins l'observation de la muqueuse intestinale n'a pas toujours 6t6 ais6e en raison de la difficult6 d'introduire ces endoscopes h optique grossissante dans l'intestin gr61e, que ce soit par voie orale ou par voie anale. A u cours des trois derni6res ann6es, un nouvel ent6roscope h optique grossissante type SIF-M (Olympus) et un coloscope h optique gros- sissante type C F - H M (Olympus) ont 6t6 commercia- lis6s et utilis6s dans notre clinique. Le SIF-M a une longueur utile de 1 860 mm. Son diambtre ext6rieur cst de 10 mm. L e calibre interne du canal biopsique est de 2,8 mm. Le syst6me optique comporte un angle de vue de 65 ~ L'observation par contact per-
met d'agrandir la muqueuse jusqu'h dix fois et fournit ainsi une vision nette des structures villo- sitaires. Employ6 selon le syst~me << ill-guide >>, le SIF-M ou le C F - H M sont introduits dans l'intestin gr~le par voie anale. Le SIF-M est utilis6 p o u r l'ob- servation de toutes les portions de l'intestin gr~le et le C F - H M est r6serv6 ~ l'il6on. Apr~s une explo- ration classique de la muqueuse de l'intestin gr61e, 10 ml d ' u n e solution de bleu de m6thyl~ne ~ 0 , 1 % sont instill6s au contact de la muqueuse p a r un cath6ter spray. Ensuite, la mise au point de la focale de l'optique grossissante permet une observation d6- taill6e de l'aspect et de la disposition des villosit6s.
Ceiles-ci sont rapidement color6es et inspect6es p a r optique grossissante (figure 9). Les structures villo- sitaires normales se pr6sentent comme des digitations ou des feuilles larges avec parfois des pontages.
L'aspect, la dimension et la disposition sont r6guliers dans les structures de la muqueuse normale. D ' a u t r e part, elles se pr6sentent sous une forme irr6guli~re ou partiellement d6truite dans les maladies infiam- matoires. De telles anomalies des villosit6s intesti- nales ont 6t6 observ6es dans les maladies inflamma- toires mais 6galement chez des patients gastrecto- mis6s souffrant de malabsorption. L ' e x p l o r a t i o n par optique grossissante contribue non seulement h l'ana- lyse des structures morphologiques villositaires mais 6galement ~t une meilleure compr6hension des trou- bles de l'absorption. C'est pourquoi l'exploration avec optique grossissante constitue un progr6s dans ',la compr6hension des m6canismes physiopatholo- giques des processus diffus des parois de l'intestin gr6le.
P R O B L E M E S F U T U R S P O S E S P A R L ' E N T E R O S C O P I E
Les bases correctes d'une exploration de l'intestin gr6le par ent6roscopie laissent apparaitre la possi- bilit6 d ' e m p l o y e r cette m6thode dans l'6tude de la physiopathologie des maladies intestinales. L a m6- thode des optiques grossissantes type S I F - M est la mieux adapt6e ~ ce type d'exploration.
La technique de l'ent6roscopie reste plus difficile que les autres m6thodes endoscopiques gastrointesti- nales et vraisemblablement un n o m b r e ffmit6 d ' e n d o - scopistes est appel6 ~ en acqu6rir la pratique. L e probl6me futur reste donc la possibilit6 de rendre cette technique plus facile. Nous esp6rons que les am61iorations techniques des ent6roscopes contri- bueront ~ la diffusion de ce m o d e d'exploration et ainsi contribueront ~t un diagnostic plus pr6cis et une approche physiopathologique plus claire de la pathologie de l'intestin gr~le.
A c t a E n d o s c o p i c a V o l u m e 12 - N o 4 - 1982 289
Radiological and endoscopic examination for upper gastrointestinal and colon diseases has become routine according to recent advances in radiology and fiberoptic instrumentation. However, a current preoperative diagnosis of the small intestine remains still unsolved. During the last 10 years, total exami- nations for upper gastrointestinal endoscopy num- bered 82 000 times, E R C P , over 5 000 times, colo- noscopy over 6 000 times in our clinic: However, enteroscopy numbered only 187 times. W h y is the number of examination of enteroscopy so small ? There are several reasons. One of them is a low incidence o/ the diseases of the small intestine and another is the technical difficulties of enteroscopy.
In recent years, systemic studies from the endoscopic point of view have been tried to manifest the diseases of the small intestine. In this paper, we'll discuss about the present status and further problems of enteroscopy.
I N D I C A T I O N O F E A C H T Y P E O F E N T E R O S C O P E
Up to date, small intestinal endoscopy has been developed along three main lines :
9 a push type fiberscope which is actually a long duodenoscope and is inserted perorally directly into the upper jejunum ;
9 a rope-way type fiberscope which is pulled through the gastrointestinal tract from below with the aid of a previously passed transintestinal string, and
9 a sonde type fiberscope which resembles a Miller-Abbott or Cantor tube and is introduced in the same manner (figure 1, table I).
T A B L E I S P E C I F I C A T I O N S
O F T H R E E T Y P E S O F E N T E R O S C O P E
Optical system
D i r e c t i o n o f o b s e r - v a t i o n . . . A n g l e o f v i e w f i e l d F o c u s s i n g s y s t e m . . R a n g e o f o b s e r v a -
t i o n . . .
Insertion tube
O u t e r d i a m e t e r . . .
Angle mechanism
U p a n d d o w n . . . R i g h t a n d l e f t . . .
Biopsy channel
I n n e r d i a m e t e r . . W o r k i n g l e n g t h . . W h o l e l e n g t h . . . .
P u s h t y p e
(SIF-B)
f o r w a r d 7 4 ~ f i x e d 5 - 4 5 m m
1 0 m m
1 5 0 ~ , 1 2 0 ~ 9 0 ~ , 9 0 ~
2 . 8 m m 1 6 2 0 m m 1 7 7 0 m m
R o p e - w a y t y p e ( S I F - 2 C )
f o r w a r d 1 0 0 ~ f i x e d 5 - 6 0 m m
1 1 m m
1 8 0 ~ , 1 2 0 ~ 1 2 0 ~ , 1 2 0 ~
2 . 8 m m , 2 . 0 m m 1 7 0 0 m m 1 9 0 0 m m
S o n d e t y p e ( S S I F - V )
f o r w a r d 6 5 ~ f i x e d 5 - 6 0 m m
7 . 8 m m
9 0 ~ , 9 0 ~ 9 0 ~ , 9 0 ~
2 . 0 m m 2 7 3 0 m m 3 0 2 0 m m
The push type scope ( S I F - B ) can be easily inserted into the proximal jejunum within a short time and provides an excellent image. Target biopsy is possible with forceps or a suction tube passed through its channel. A disadvantage is that only the proximal jejunum (at most 90 cm from Treitz' ligamenO can be visualized (figure 2).
The rope-way technique of small intestine endo- scopy is accomplished by means of a slender teflon tube (intestinal string) that is previously swallowed and passed through the gastrointestinal tract 2 to 5 days before the examination. Indeed, rope-way type fiberscope can be inserted into all parts of the small intestine (figure 3). Unfortunately, the presence of stenotic lesions through which the intestinal string cannot pass precludes the use of this method. Also, the risk of intestinal abrasion or perforation by the taut string must be considered.
Sonde type fiberscope is a slender, long scope. Its working length is about 280 cm. I t has a balloon cuff, as a leading plumb, at the tip of the scope to guide it into the distal parts of the intestine more quickly. We have five types of the sonde type scope.
Prototype o] this scope (type I, 11, I H and I V ) have neither biopsy channel nor angle mechanism to make the scope slender. On the other hand, recent type, type V, is improved to have biopsy channel and angle mechanism. However, its diameter is 7.8 m m and is thicker than the prototype. A f t e r pharyngeal anesthesia with xylocaine spray, a patient swallows the scope by himself in the same manner as a duo- denal tube. Figure 4 shows the x-ray picture de- monstrating the loops of this scope. T h e tip of this scope usually arrives at the terminal ileum within 2 or 3 hours without any hazard to patients. Narrow or stenotic lesions which w o u l d interfere with pas- sage of the push type scope or the transintestinal string, are amenable to examination by the sonde
type fiberscope.
C a s e 1 ; A 58 years old female, complaining of
abdominal pain and emaciation was admitted to our hospital. Using the push type fiberscope, an anular constriction with irregular granules and erosions on the surface were observed. Biopsy revealed adeno- carcinoma arising from the jejunum. Thus entero- scopy with the push type fiberscope can be per- formed with ease as well as gastroduodenoscopy
(figure 5).
C a s e 2 ; A 49 years old male, complaining of
lower abdominal pain was admitted to our hospital.
X - r a y picture revealed a large tumor with ulcer near the terminal ileum. Push type fiberscope, sonde type scope and colonoscope could not reach the lesion. Enteroscopy with the rope-way type fiber- scope revealed a large tumor with central depression in the ileum (figure 6). Histologically, this tumor was a malignant l y m p h o m a arising from the ileum.
Thus by the rope-way method, endoscopic observa- tion and target biopsy is possible even in the deeper small intestine.
C a s e 3 ; A 48 years old man was admitted to our
hospital complaining of fullness and dull epigastric
2 9 0 Volume 12 - N ~ 4 - 1982 Acta Endoscopica
and unzbilical pain for three months. Barium meal study s h o w e d no abnormalities in the esophagus, stomach and d u o d e n u m , however, shipped multiple stenosis and the m a r k e d proximal dilatation were detected in the ileum. Sonde type scope, type III, was introduced to the lesion within a short time.
There was too m u c h intestinal juice in the m a r k e d dilatated intestinal canal. A f t e r removing the intes- tinal juice by an aspiration apparatus, an annular constriction with circular ulcer, skipped multiple irregular erosions, convergence of folds and m a r k e d dilatated intestinal canal were inspected clearly which strongly impressed tuberculosis of the ileum.
Histologically, it was diagnosed tuberculosis of the ileum. In this case p u s h type fiberscope cannot reach to the lesion and the intestinal string cannot pass through the stenotic lesion. So only sonde type fiber- scope can be used to such stenosing cases.
C a s e 4 ; A 68 years old nzan, complaining of re- current melena, was admitted. H e had been repeated- ly examined radiologically and endoscopically but the hemorrhagic source had not been diagnosed.
A f t e r a massive melena, enteroscopy with the sonde type scope was p e r f o r m e d immediately as an emer- gency examination for the gastrointestinal bleeding and revealed a whitish t u m o r floating in the blood at the j e f l m u m . B y operation, this tumor, sized 3 • 2 cm, was histologically diagnosed as leio- m y o m a arising f r o m the upper jejunum. T h e sonde type scope can be inserted without hazard. There- fore, sonde type scope will be useful as a screening filter of the small intestinal diseases and valuable for the emergency examination of massive intestinal
hemorrhage.
Table II shows the summarization of merits and demerits of each enteroscope. Each type entero- scope has both merits and demerits. W e m u s t choose them according to the shape of the lesions or the location in the smaU intestine as shown in table III.
the observation of the whole intestine. On the other hand, sonde type scope is used for the examination of enzergency to gastrointestinal bleeding, for the examination of poor general condition cases, steno- sing lesion located at the distal parts of the small intestine where neither push type scope nor rope-way type scope can be introduced. Thus, wherever small intestinal disease arise, we can observe them suffi- ciently with a suitable enteroscope.
F U R T H E R A D V A N C E S I N E N T E R O S C O P Y
D e v i c e o f a m o r e e c o n o m i c a l e n t e r o s c o p e
A s above mentioned, none of three types of ente- roscope gives a perfect examination and all oJ t h e m have better to be prepared for perfect enteroscopy.
H o w e v e r , it is economically difficult to equip with three enteroscopes at one hospital. A newly devised enteroscope, S I F - R P ( O l y m p u s ) , has features oJ both the rope-way type and push type scope. This scope has 1 425 m m effective length with an external diameter of 11 m m at the bending section. T h e internal size of a biopsy channel is 2.8 m m . In optical system, it has 100 ~ in an angle of view field with a round image. It has f o u r - w a y tip angulation, 180 ~ in the up and d o w n w a r d , 160 ~ in the right and left directions.
B y the rope-way m e t h o d , the scope is inserted into the whole parts oJ the small intestine as well as the conventional r o p e - w a y type fiberscope. On the other hand, the upper j e j u n u m is observed by the push method, as the extension of upper gastrointes- tinal endoscopy. Therefore, S I F - R P which has Junc- tions of both push and rope-way types is regarded as a more economical enteroscope.
TABLE II M E R I T S A N D D E M E R I T S O F ~ I H R E E K I N D S O F E N T E R O S C O P E
merits
demerits
P u s h Rope-way Sonde
t y p e type type
Short time examination (20-40 min.)
O b s e r v a t i o n is l i m i t e d w i t h i n u p p e r j e j u n u m
W h o l e o b s e r v a t i o n of the i n t e s t i n e
L o n g time to pass the i n t e s t i n a l string pa- t i e n t ' s tole- r a n c e ( + + )
Short time e x a m i n a t i o n (2-3 hours) P a t i e n t ' s tolerance ( • Lower ileum is not e x a m i n e d
TABLE III
I N D I C A T I O N O F E N T E R O S C O P Y
Push type
Lesion on the u p p e r j e j u n u m Biopsy to a diffusely s p r e a d i n g lesion Rope-way type
O b s e r v a t i o n of the w h o l e intestine M a g n i f y i n g o b s e r v a t i o n
Sonde type
E m e r g e n c y to G - I b l e e d i n g E x a m i n a t i o n for c h i l d r e n
Patients with p o o r general c o n d i t i o n Stenosing lesion
Push type fiberscope is suitable for the lesion on the upper j e j u n u m or the biopsy to a diffusely spreading lesion. R o p e - w a y type scope is chosen for A cta Endoscopica
P e d i a t r i c e n t e r o s c o p y
With the recent d e v e l o p m e n t of thin and wide- viewing fiberscopes, it is possible to perform a de- Volume 12 - N ~ 4 - 1982 2 9 1
tailed observation even in the narrow gastrointestinal lumen o[ in[ants and children. H o w e v e r , experiencies of enteroscopy in children have been reported sparse- ly, because o[ a lack o[ the enteroscope which is suitable to children and o[ the technical di[liculties o[ enteroscopy. Ordinary enteroscopes [or the adults were neither suitable nor sale to children and there was a need for proper instruments in pediatric entero-
scopy.
Sonde type [iberscope which is not so hazard to patients was i m p r o v e d to be used [or children. N e w l y devised SSIF type V I ( O l y m p u s ) was i m p r o v e d to have a biopsy channel but no angulation m e c h a n i s m and became to be m o r e slender than the prototype type V. W o r k i n g length o[ SSIF type V I is 2 864 m m which is almost same as type I - V . Outer diameter of the insertion tube is 6.8 m m which is thicker than type I - I V but thinner than type V. Optical system o[ type V I is almost the same as previous
SSIF. It has 65 ~ in an angle of view [ield and a fixed locus. During the last one year, three pediatric cases were examined with S S I F type V I in our clinic.
T h e y were an l 1-year-old boy who complained o[
repeated episodes o[ abdominal pain of u n k n o w n cause, a 12-year-old girl w h o underwent partial jeiu- nectomy [or intussusception due to Peutz-Jeghers syndrome and a 13-year-old boy who was diagnosed as granulomatous colitis and was suspected of s o m e lesions in the small intestine. A[ter local pharyngeal anesthesia with xylocaine spray, the scope was swallowed actively in the same manner as the inser- tion o[ a duodenal sonde. T h e scope was inserted into the distal portion o] the small intestine (110- 140 cm distant [rom the Treitz' ligament and sus- pected radiologically to be the upper ileum) in 50- 60 minutes (table I V ) . T i m e for total examination was 70 minutes in case 1 and 3, and 75 minutes in case 2, which was tolerable enough [or the children ([igure 7).
TABLE I V
RESULTS OF ENTEROSCOPY BY S S I F - T Y P E VI
Case i[ Inserted
(age, sex) portion (*) 1. 11, boy . . . 110 cm 2. 12, girl . . . 120 cm 3. 13, boy . . . 140 cm
Time for insertion
50 min.
50 min.
60 min.
Time for total ex.
70 min.
75 min.
70 min.
Endoscopic findings
normal polyposis
normal
(*) Distance f r o m the Treitz' L i g a m e n t .
Enteroscopy especially in the rope-way m e t h o d is so distress[ul to not only children but also adults.
There[ore, enteroscopy in children have not been reported. In general, children cannot understand the necessity of the examination, so the patient's coope- ration is not always obtained. Such a case should be examined under general anesthesia. H o w e v e r , only pharyngeal anesthesia m a y be su[[icient [or the exa- mination o] elder children with SSIF type VI. In [act, children as well as adults were e x a m i n e d with mi- n i m u m hazard by this scope. Depending on a skill[ul technique and experiences of the endoscopist, it is expected that enteroscopy with type V I b e c o m e s a routine examination also in the children. W h e n enteroscopy b e c o m e s more widely available even in pediatric patients, further detailed patho-physiologi- cal in[ormation o[ the small intestine o[ children will be obtained.
E n d o s c o p i c s u r g e r y in e n t e r o s c o p y
Endoscopic p o l y p e c t o m y is one of the rapidly advancing fields and widely spread m e t h o d s in gastrointestinal endoscopy since the introduction ol electrosurgical techniques. A l t h o u g h the endoscopic removal o[ polyps arising [rom the esophagus, sto- mach, d u o d e n u m , colon and rectum can be per-
f o r m e d with ease and safety, p o l y p e c t o m y [or the polyps of the small intestine has never been per- ]ormed because o[ the technical di[[iculties to handle the scope in the small intestine. T w o channel entero- scope, type SIF-2 C ,(Olympus), resolved the problem as the ]ollowing case report.
Case 5 ; A 22 year-old [emale with pigmentation on the lips, arround the m o u t h , in the buccal mucosa and on the extremities was admitted to our hospital complaining o[ a b d o m i n a l colic pain and vomiting.
Partial ileostomy was p e r [ o r m e d [or intussusception due to big polyps. O n the microscopical examination, polyps were hamartomatous, so that they were diag- nosed as Peutz-Jeghers polyps. Barium meal study alter operation revealed small polyposis scattering in the ileum and j e j u n u m . Endoscopic p o l y p e c t o m y was applied r e m o v i n g p o l y p s of the small intestine by a rope-way type [iberscope, SIF-2 C. SIF-2 C has two channels which are 2.8 m m and 2.0 m m in inner diameter respectively. SIF-2 C was introduced into the small intestine as the conventional rope-way method. A f t e r passage through the gastrointestinal tract, the string was passed through one of the biopsy channels o[ this scope. SIF-2 C was inserted slowly into the intestine of the subject per-orally under ge- neral anesthesia. A l t e r introduction into the ter-
2 9 2 Volume 12 - N ~ 4 - 1982 Acta Endoscopica
minal ileum, the scope was pulled out slowly without losing the string from the channel. B y pulling the string, the scope can be prevented from slipping d o w n and falling away at a time. A n electrosurgical snare was passed through the other channel (figure 8).
Large polyps over 1 cm in size were taken out but small or tiny polyps were left intact. Thus, as the scope was pulled out to the proximal intestine, polyps were removed one by one, and after all three polyps were removed from the ileum and one from the jejunum. A l l polyps were cut without any bleeding nor perforation, but they were able to be taken out from the intestine because many polyps were cut at one procedure.
Even though in a narrow intestinal canal, snare or basket catheter is well managed. One of the technical cares during endoscopic polypectomy is that the string is slackened not to touch the snare.
Thus, polyps are resected with ease and safety. With the completion of SIF-2 C, enteroscopy of rope-way m e t h o d will become much more established and the indications of enteroscopy for the treatment and diagnosis will be more widely extended.
Magnifying view of the villi
Endoscopic magnifying observation method for gastrointestinal mucosa has been developed and widely applied in recent years. It is not necessary to say that magnifying endoscopy is useful for the early detection of minute cancer or polyp and the approach to the pathophysiological aspect of the gastrointestinal mucosa. However, observation of the small intestine was not always easy because of diffi- culties in leading the magnifying enteroscope into the small intestine which is the most distant portion both from the m o u t h and anus.
During the last 3 years, a newly devised magni- fying enteroscope, type S I F - M (Olympus), and a magnifying colonoscope, type C F - H M (Olympus), which is already in market were used in our clinic.
S I F - M has 1 860 m m effective length. Its outer dia- meter of the insertion tube is 10 mm. Internal size oJ its biopsy channel is 2.8 m m . In optical system, it has a 65 ~ angle view field. Its close-up obser- vation enables us to magnify the mucosa ten times larger, so that the minute villi may be clearly
observed. According to the rope-way technique, S I F - M or C F - H M is introduced into the small intes- tine per anus. S I F - M is used for the observation of the whole parts of the small intestine and C F - H M , for the ileum. After the usual observation of the small intestine, 10 ml of 0 . 1 % methylene blue solution is sprayed on the mucosa. Then, adjusting the focus of the magnifying endoscope, the shape and arrangement of the villi are carefully observed.
Villi are stained quickly and inspected clearly by the magnifying scope (figure 9). The villi of the normal mucosa show finger-form, leaf-form, ridge convolu- tion form in shape. Shape, size and arrangement are quite regular in the normal villi. However, they are destroyed and irregularly formed in the inflammatory bowel diseases. N o t only the patients suffering from inflammatory bowel diseases but also the post- gastrectomy cases showed malabsorbtive condition according to the morphological abnormalities of the intestinal villi. Magnifying the intestinal mucosa, minute morphological changes of the villi are able to be observed clearly, so that the absorbability of the intestine may be clarified by endoscopy. There- [ore, it is emphasized that the endoscopic magnifying observation of the individual villi will be useful not only for the correct diagnosis of the small intestine but also for the approach to the pathophysiological aspect of the small intestine.
F U R T H E R PROBLEMS IN ENTEROSCOPY
We have basis for the correct diagnosis of the small intestinal diseases, and further problems ir~
enteroscopy is how to utilize it for the studies of pathophysiology of the small intestine. Magnifying m e t h o d by S I F - M is one of the useful techniques for
this purpose.
Technique of enteroscopy is more difficult than other gastrointestinal endoscopy. Only a few endosco- pists can perform enteroscopy. N e x t problem is how to improve its technique to be m u c h easier. W e hope that enteroscopy becomes a widespread m e t h o d so that m u c h more diseases of the small intestine could be diagnosed endoscopically and pathophysiology of the small intestine could be clarified by enteroscopy.
Acta Endoscopica Volume 12 - N o 4 - 1982 293
