Our case is thermal therapy with a heater probe through double balloon and neuroscopy and altered bowel anatomy. These are our disclosures. Our patient was a 68 year old female with a history of hypertension and diabetes with a Roux-en-Y gastric bypass in 2001 with revision in 2010, which was about 11 years prior to presenting to our service. She also had complications with small bowel obstruction in 1990 with 13 inches of small bowel removed and again in 2016 with 15 inches removed. She presented to our service with a one-week history of nausea, vomiting, and melanin. Her vitals were notable for mild hypertension, an exam notable for mild abdominal tenderness, and lab significant for anemia with a hemoglobin of 9.3. EGD and colonoscopy did not show any active bleeding and further imaging with CT and neurography and a nuclear medicines can did not show a source of the bleed. Our patient underwent a video capsule endoscopy that showed a proximal small bowel bleeding and we scheduled her for a double balloon and neuroscopy. Our patient had a Roux-en-Y gastrointestinal and going through the double inner scope through the mouth and into the esophagus. There's two difficult to maneuver locations. First through the proximal pouch at the gastro jejunal anastomosis and then through the jejunal jejunal anastomosis to the bypass duodenum which where our patient's ulcer was located. After traversing the esophagus and the proximal pouch, we encountered the gastrojejunal anastomosis and the jejunal jejunal anastomosis. Through the bypass duodenum, we were able to identify the duodenal ulcer causing the bleeding. Using a double balloon enteroscope, we were able to go through the mouth and advance into the mid-jejunum, traversing the esophagus, the gastrojejunal anastomosis, and the pouch to jejunum limb that were all characterized by healthy mucosa. Here you can see the duodenal ulcer, which was about 20 cm from the jejunal jejunal anastomosis and was characterized by ulceration. We injected the area with a 4 mL solution of epinephrine for hemostasis, and using a bipolar heater probe, we were able to coagulate the ulceration that is seen here. Using the double enteroscopy method, we were able to identify the source of bleeding at the duodenum to jejunum limb seen previously, as well as apply thermal therapy with our heater probe for further coagulation. After injecting with epinephrine and coagulating with our heater probe, we were able to successfully place one hemostatic clip at the identifiable duodenal ulcer. Our patient tolerated the procedure well without any significant blood loss. Our case highlights a unique method of using a heater probe through a double balloon enteroscope channel in altered gastrointestinal anatomy. The use of a heater probe through a double balloon enteroscopy allows for endoscopic hemostatic intervention in patients with surgically altered anatomy, for example in patients with Roux-en-Y gastric bypasses or small bowel resections, as well as allowing for treatment in other gastrointestinal diseases, including inflammatory bowel disease. Thermotherapy with a heater probe can be used as part of the endoscopic tools for hemostasis to reach and treat targeted areas of bleeding and should be considered as a non-surgical option for use in patients with altered bowel anatomy and patients presenting with gastrointestinal bleeding.

thermal therapy

heater probe

double balloon

neuroscopy

altered bowel anatomy