The development of capsule endoscopy and balloon-assisted endoscopy revolutionized the diagnosis and management of small bowel diseases. Capsule endoscopy enables non-invasive observation of the entire small bowel. Balloon assisted endoscopy enables precise observation, biopsy and therapeutic procedures in the deep small bowel. In addition, cross-sectional imaging modalities, especially contrast-enhanced (preferably dynamic) CT provide informative images to detect the abnormalities in intramural and extramural structures. These modalities are complementary to each other. We need to use them efficiently. We recommend performing dynamic-contrast-enhanced CT as first examination for the diagnosis of small bowel disease. If any abnormalities are found on CT, balloon-assisted endoscopy should be performed via a route near the lesion. If no abnormalities are found on CT, capsule endoscopy is useful in identifying lesions. If no abnormalities are found on capsule endoscopy, follow-up should be performed, or in patients who have a history of frequent hemorrhage/massive bleeding/severe anemia, balloon-assisted endoscopy would be recommended as the best diagnostic performance tool.
The water exchange method is effective to maintain the low intraluminal pressure in the small intestine and may improve maneuverability while reducing the patient’s discomfort and risk of aspiration pneumonia and gas embolism. However, during endoscopic hemostasis for small intestinal bleeding, it is often difficult to secure the visual field because its relatively small lumen is easily filled with blood, and injected water is rapidly mixed with blood. The gel immersion method is useful to secure the visual field because the injected gel does not mix with blood. The hemostatic procedure can be performed in the space occupied by the transparent gel. These new techniques are helpful to perform safe and effective treatment using balloon-assisted enteroscopy.