Why the small intestine is special
Standard endoscopy reaches the stomach from above and the colon from below, but the small intestine in between is long, looped and mostly out of reach of a conventional scope. When bleeding or disease hides there, we need two purpose-built tools: capsule endoscopy and device-assisted enteroscopy. They are complementary – one finds the problem, the other reaches it.
Capsule endoscopy – the camera you swallow
A capsule endoscope is a vitamin-sized camera that you swallow with water. As it passes naturally through the digestive tract over several hours it takes thousands of pictures, which are transmitted to a recorder worn on a belt. You go about your day and return the recorder; the images are then reviewed as a video. The capsule passes out naturally in a bowel motion – nothing needs to be retrieved. It is painless and needs no sedation, and it is the best test for seeing the whole small-bowel lining.
Its main limitation is that it can only look, not treat, and it cannot be steered. If it spots something, a second procedure is needed to biopsy or treat it. There is also a small risk that the capsule gets stuck (retention) if there is a narrowing or stricture, which is why we screen carefully in patients with suspected Crohn’s disease or previous bowel surgery.
Device-assisted enteroscopy – reaching deep
Device-assisted enteroscopy uses a long, specialised scope with a balloon or spiral system that pleats the small bowel over the instrument, allowing the endoscopist to travel far deeper than an ordinary scope can, often from the mouth downwards, or from the anus upwards, and sometimes both to meet in the middle. Crucially, because it is a true endoscope with a working channel, it can take biopsies, stop bleeding, remove polyps, and mark lesions – everything the capsule cannot do. It requires sedation and takes longer than a routine gastroscopy.
When these tests matter – including in liver patients
- Obscure or occult GI bleeding: when a patient bleeds or is persistently anaemic but the upper and lower endoscopies are normal, the small bowel is the prime suspect. Capsule endoscopy is usually the first step.
- Small-bowel disease: Crohn’s disease, tumours, angiodysplasias (fragile vessels), and rare polyp syndromes.
- Portal hypertensive enteropathy: patients with cirrhosis can bleed from the small bowel itself, not only from oesophageal or gastric varices. When variceal sources have been excluded and bleeding continues, small-bowel evaluation can find the cause.
Dr Kalal’s role
Diagnostic endoscopy is core to Dr Kalal’s practice, and he uses capsule endoscopy as the first-line map when small-bowel bleeding is suspected. Device-assisted (balloon) enteroscopy is an advanced-endoscopy procedure; depending on the finding and the treatment required, it is performed by, or coordinated with, the therapeutic-endoscopy team, with Dr Kalal directing the work-up and interpreting how it fits the patient’s liver and bleeding picture.