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CC BY 4.0 · Endoscopy 2025; 57(S 01): E1336-E1337
DOI: 10.1055/a-2739-2280
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First application of carbon dioxide digital subtraction enterography for stricture evaluation in Crohn’s disease

Authors

  • Akihiro Maruyama 

    1   Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan (Ringgold ID: RIN37036)
    2   Department of Gastroenterology, Nagoya University Hospital, Nagoya, Japan (Ringgold ID: RIN36590)

  • Kohei Takano

    1   Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan (Ringgold ID: RIN37036)

  • Junya Yamada

    1   Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan (Ringgold ID: RIN37036)

  • Hiroki Kato 

    1   Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan (Ringgold ID: RIN37036)

  • Sakurako Isobe

    1   Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan (Ringgold ID: RIN37036)

  • Makoto Kobayashi 

    1   Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan (Ringgold ID: RIN37036)
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Digital subtraction imaging (DSI) is a radiological technique used to enhance the visualization of anatomical structures. It subtracts a pre-contrast image from a post-contrast image, thereby effectively eliminating background noise. This method is commonly used in angiography and interventional radiology [1], and recent reports have also suggested its utility in gastrointestinal imaging [2] [3] [4]. We applied CO2 digital subtraction enterography (CDDSE) as a novel approach during double-balloon endoscopy.

A 57-year-old man with a 10-year history of Crohn’s disease, notable for poor treatment adherence and irregular follow-up, presented with a 1-month history of recurrent nausea and progressive abdominal distension. Abdominal computed tomography demonstrated wall thickening at the terminal ileum. A transanal double-balloon endoscopy was performed using an EN-580T (FUJIFILM, Tokyo, Japan) equipped with a Cast Hood (TOP, Tokyo, Japan) at its tip. Conscious sedation was achieved with intravenous midazolam, and an antispasmodic agent, hyoscine butylbromide, was administered. DSI was conducted with the Ultimax-i DREX-U180 fluoroscopy system (Canon, Tokyo, Japan). CDDSE was then performed, which enabled evaluation of the stricture and the bowel up to the previously placed clip marking the maximal oral reach ([Video 1] and [Fig. 1]).

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Fig. 1 Panels (a–d) show serial CDDSE digital subtraction images. Compared with the pre-image, areas with greater CO2 accumulation appear white (blue arrows), whereas those with less CO2 appear black (orange arrows), reflecting CO2 flow and enabling assessment of the intestine. The stricture is visualized as indicated by the red arrowhead.
Carbon dioxide digital subtraction enterography (CDDSE) performed during double-balloon endoscopy provided clear delineation of an ileal stricture in Crohn’s disease, demonstrating feasibility and procedural simplicity.Video 1

No adverse events occurred during the procedure. The total procedure time from endoscope insertion to balloon dilation was 31 minutes, and the cumulative duration of the two CDDSE acquisitions was 30 seconds. The total radiation dose was 27.3 mGy, of which 4.9 mGy was attributable to the two CDDSEs. Balloon dilation was subsequently performed ([Fig. 2]), leading to prompt improvement of the patient’s clinical symptoms.

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Fig. 2 Balloon dilation was performed using a 15-mm balloon dilator, maintained for 1 minute.

As the technique requires only pressing the endoscopic insufflation button in synchrony with DSI acquisition, it enables clear delineation of intestinal strictures in a short time and with great procedural simplicity. Because CO2 flows more readily than liquid contrast agents, CDDSE may enable visualization of longer intestinal segments within shorter acquisition times.

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Publication History

Article published online:
21 November 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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