Previously unknown stricture due to radiation therapy diagnosed by capsule endoscopy

J. Romero Vázquez, A. Caunedo Álvarez, M. Rodríguez-Téllez, A. Sánchez Yagüe, F. Pellicer Bautista and J. M. Herrerías Gutiérrez

Service of Gastroenterology. Hospital Universitario Virgen Macarena. Sevilla, Spain

 

ABSTRACT

Radiation enteritis is a complex clinical entity secondary to the affectation of intestinal epithelial cells as a result of radiation in the management of pelvic malignancies that may occasionally cause intestinal strictures.
We present the case of a 60 year-old woman who had been diagnosed ten years before with endometrial adenocarcinoma, and who underwent hysterectomy with double adnexectomy and subsequent radiation therapy. The patient consulted for abdominal pain and ferropenic anemia of several years' standing, and had negative results following radiographic and endoscopic conventional techniques, reason why she was subjected to a capsule endoscopy study that revealed the presence of an ulcerated ileal stricture, which caused the asymptomatic retention of the capsule within the ileum. A laparotomy was subsequently performed - the strictured segment was resected and the capsule retrieved. The histologic examination of the resected segment confirmed the capsule endoscopy-raised suspicion of radiation enteritis. This case shows the role capsule endoscopy may play in the diagnosis of this condition.

Key words: Radiation enteritis. Capsule endoscopy. Ileal stricture. Capsule retention.

---

Romero-Vázquez J, Caunedo Álvarez A, Rodríguez-Téllez M, Sánchez-Yagüe A, Alcázar Guijo J, Herrerías Gutiérrez JM. Previously unknown stricture due to radiation therapy diagnosed by capsule endoscopy. Rev Esp Enferm Dig 2005; 97: 449-454.

---

Recibido: 28-09-04.
Aceptado: 14-12-04.

Correspondencia: Juan Manuel Herrerías Gutiérrez. Servicio de Aparato Digestivo. Hospital Universitario Virgen Macarena. Avda. Dr. Fedriani, s/n. 41071 Sevilla. e-mail: jmhg@us.es; javiromerov@supercable.es

 

INTRODUCTION

Radiation enteritis is a complex clinical entity secondary to the affectation of intestinal epithelial cells as a result of the radiotherapic treatment of pelvic malignancies (1). Although the rectosigmoidal region is most frequently involved, the small intestine can also become affected with this condition. The histopathological characterization of the intestinal lesion corresponds to progressive vasculitis with endothelial proliferation, obliterating endarteritis, fibrosis, and stricturing (2). Its diagnosis is difficult to arrive at in the majority of patients, and is in many cases confirmed when severe complications already exist.

CLINICAL CASE

A 60-year-old woman consulted for diffuse, occasional, intermittent, colicky abdominal pain, mainly in the right hemiabdomen, for 3-4 years. Nausea and bilious vomiting were seen during episodes. The patient had been diagnosed with endometrium adenocarcinoma, and treated with double adnexectomy and subsequent radiotherapy ten years before, and had remained in remission ever since with an otherwise uneventful medical history. She was admitted for abdominal pain on five occasions in another center, showing epigastric tenderness on deep palpation, preserved peristaltism, and no masses or organ enlargements. Plain abdominal x-rays revealed no air-fluid levels. During the last 12-24 months she used to localize pain in her lower right quadrant; this was associated with ferropenic anemia, hemoglobin levels lower than 10 mg/dl, and malnutrition. During this period three upper gastrointestinal endoscopies, two colonoscopies with ileoscopy, four small-bowel follow-through series, and an abdominal CT scan were performed with no relevant findings (Fig. 1).

A capsule endoscopy to explore the small bowel was then indicated, and a mottled mucosa with marked villositary alterations preceding a strictured bleeding area with a great ulceration on its border could be seen in the ileum (Figs. 2 and 3).

At the end of the exploration the capsule was not naturally excreted, so a plain abdominal film was obtained to assess its location. It was localized in the lower right quadrant of the abdomen, but the patient remained asymptomatic with preserved intestinal movement, so an elective surgery was scheduled a week later. During the operation surgeons identified the strictured zone by palpation of the retained capsule in the terminal ileum, 25 cm proximal to the ileocecal valve. The stenotic segment (approximately 30 cm) was then resected, an ileocolonic anastomosis was performed, and the capsule was retrieved (Figs. 4 and 5). The histopathologic findings in the surgical specimen revealed a mucosa preserving its architecture and habitual cell population, a thickened submucosa with evidence of fibrosis, and vessels with hyaline thickening. No evidence of malignancy, Crohn´s disease, or other specific diaseses were identified, and a diagnosis of submucosal post-radiation fibrosis was established (Fig. 6). After twelve months the patient is still asymptomatic (has had no abdominal pain, nausea or vomiting) and exhibits normal blood test values (with no signs of ferropenic anemia).

DISCUSSION

Chronic radiation enteritis is an almost inevitable condition resulting from the affectation of epithelial cells in the small intestine as a result of radiation effects that causes fibrosis, obliterative endarteritis, edema, fragility, perforation, and partial obstruction (1,2). Clinical presentations include subocclusive lesions, malabsorption, obscure-origin gastrointestinal bleeding (3), and rarely perforation. Its severity is associated with the extension and characteristics of radiation injuries in the small intestine (4). Although the prevalence of chronic radiation enteritis has been underestimated in the majority of surgical series, most patients were not diagnosed until severe complications occurred. The eating intolerance related to abdominal pain, nausea, and vomiting usually results in loss of weight and malnutrition (5). Although several conservative approaches have been suggested in the management of these patients (glutamine, hyperbaric oxygen, gamma-interferon…), sometimes surgical treatment should be considered, specially for occlusive or subocclusive presentations (6). Surgical management (usually a resection of the stenotic segment) is considered a high-risk intervention, with high morbidity and mortality rates (7).

The diagnosis of radiation enteritis requires strong clinical suspicion as it is rarely reached by endoscopic techniques, including push enterosocopy and ileocolonoscopy. On the one hand, radiological techniques (small-bowel follow-through, enteroclysis, CT scans, MRI) may miss intestinal strictures, mainly when they are solitary or in the case of NSAID-related diaphragms (8). It is important to achieve a final diagnosis, as the differential diagnosis includes not only benign stricture-inducing entities such as those related to NSAIDs or secondary to ischemia or eosinophilic enteritis, but also intestinal tumors (adenocarcinomas, lymphomas or GIST).

The case we report here shows the role of capsule endoscopy in this pathology. In our patient, capsule endoscopy allowed the diagnosis of a stricture not detected by radiological techniques, orienting then appropriate management. Wireless capsule endoscopy is a recently developed imaging technique that allows to study the small intestine (9). Its main indication is the study of obscure gastrointestinal bleeding, but has also been used in patients with ferropenic anemia, suspected Crohn's disease, and chronic diarrhea, as well as in the evaluation of tumor extension and in pediatrics (10-15). Recent studies confer capsule endoscopy a wider diagnostic yield in the detection of small intestine pathology versus enteroscopy, small-bowel follow-through series, and CT scans (16-18).

We should highlight that in our patient no stricture of this narrowness was detected after 3 small bowel follow through explorations. This situation has been also described previously by several authors, so we should think that a normal radiological study is not enough to rule out an intestinal stricture (19-22).

In the case reported here, only capsule endoscopy was able to detect the huge ileal stricture that caused capsule retention. Capsule retention is almost always asymptomatic, and several cases of retention lasting for months have been reported with no clinical involvement. As long as patients have no high risk for surgery, retention is really not considered a complication. This is because it allows intestinal strictures to be identified and helps locate them during surgery, which anyway would be the best management approach for these patients. That is why several authors call this fact "a therapeutical complication".

In our case capsule retention was not considered an adverse effect, as it allowed surgeons to locate the stricture by palpation of the retained capsule, and its subsequent resection resulted in the final diagnosis of radiation enteritis following the histopathologic study of the surgical piece.

The rate of capsule retention -about 1.4% as shown in the vast majority of published series (21)- has led capsule manufacturers (Given Imaging Ltd, Yoqneam, Israel) to develop a dissolvable capsule. The patency capsule is the same size as the regular capsule with a tiny Radio Frequency Identifier tag that is covered by a dissolvable material containing barium. It is designed to remain intact in the gastrointestinal tract for 80 hours, approximately. After this time, if still within the body the capsule begins to dissolve spontaneously except for the Radio Frequency Tag, which is tiny (3 x 11 mm) enough to go through narrow strictures. Recently preliminary results from a multi-center study have been reported showing its utility in the diagnosis of strictures over 11 mm. However, several patients had abdominal pain, and in 2 patients the capsule was retained in long, narrow strictures demonstrated by small-bowel follow-through (23,24).

We conclude that radiation enteritis must be considered in patients with subocclusive presentation and a past history of radiation therapy. The diagnosis of this disease is difficult by means of conventional radiological or endoscopic methods, and capsule endoscopy may be a good diagnostic tool for patients in whom eventual surgery is not contraindicated.

REFERENCES

1. Napolitano L, Costantini R, Napolitano AM. A clinical study of chronic actinic enteropathy. G Chir 1999; 20 (4): 165-8.        [ Links ]

2. Galland RB, Spencer J. The natural history of clinically established radiation enteritis. Lancet 1985; 1 (8440): 1257-8.        [ Links ]

3. Martínez Ares D, González Conde B, Souto Ruzo J, et al. Hemorragia digestiva de origen oscuro secundaria a enteritis actínica: diagnóstico por cápsula endoscópica. Rev Esp Enferm Dig 2004; 96: 132-7        [ Links ]

4. Bismar MM, Sinicrope FA. Radiation enteritis. Curr Gastroenterol Rep 2002; 4 (5): 361-5.        [ Links ]

5. Fernández de Bustos A, Pita Mercé AM. Dietetic-nutritional treatment in chronic radiaton enteritis. Apropos a complex clinical case. Nutr Hosp 2003 XVIII (4): 226-31.        [ Links ]

6. Cosnes J. Medical treatment of chronic radiation induced enteritis. Ann Chir 1996; 50 (1): 36-9.        [ Links ]

7. Regimbeau JM, Panis Y, Gouzi JL, Fagniez PL; French University Association for Surgical Research. Operative and long term results after surgery for chronic radiation enteritis. Am J Surg 2001; 182 (3): 237-42.        [ Links ]

8. Schmutz G, Jahn C, Benhaim M, Drape JL, Chapuis A, Vaxman F. Value of small intestine transit by enteroclysis in obstructive syndromes of the small intestine. Apropos 212 examinations. J Radiol 1987; 68: 23-9.        [ Links ]

9. Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature 2000; 405: 417.        [ Links ]

10. Caunedo A, Herrerías JM. Papel de la capsuloendoscopia en el diagnóstico de las enfermedades digestivas. Med Clin (Barc) 2004 (En prensa).        [ Links ]

11. Pennazio M, Santucci R, Rondonotti E, et al. Clinical outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004; 126: 643-53.        [ Links ]

12. Herrerías JM, Caunedo A, Rodríguez-Téllez M, Pellicer F, Herrerías Jr JM. Capsule endoscopy in patients with suspected Crohn's disease in negative endoscopy. Endoscopy 2003; 35: 1-5.        [ Links ]

13. Caunedo A, Gómez BJ, García Montes JM, et al. Cápsula endoscópica en la enteropatía por AINE. Rev Esp Enferm Digest 2004; 1: 27-34.        [ Links ]

14. Mascarenhas-Saraiva M, Da Silva LM. Small bowell tumors diagnosed by wireless capsule endoscopy: report of five cases. Endoscopy 2003; 35: 865-8.        [ Links ]

15. Argüelles.Arias F, Caunedo A, Romero J, et al. Utility of capsule endoscopy in children with small bowell disorders. Endoscopy 2004; 36: 869-74.        [ Links ]

16. Costamagna G, Riccioni ME, Foschia F, et al. Prospective trial comparing small bowel barium radiography versus the GIVEN M2A wireless video capsule endoscopy. Gastrointest Endosc 2002; AB88.        [ Links ]

17. Liangpunsakul S, Vidyasree C, Douglas K, et al. Wireless capsule endoscopy detects small bowel ulcers in patients with normal results from state of the art enteroclysis. Am J Gastroenterol 2003; 98 (6): 1295-8.        [ Links ]

18. Mylonaki M, Fritscher-Ravens, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Gut 2003; 52: 1122-6.        [ Links ]

19. Caunedo A, Rodríguez-Téllez M, García-Montes JM, et al. Utilidad de la cápsula endoscópica en pacientes con sospecha de patología de intestino delgado. Rev Esp Enferm Dig 2004; 96: 10-7.        [ Links ]

20. Mergener K, Enns R, Brandabur J, et al. Complications and problems with capsule endoscopy: Result from two referal centers. Gastrointest Endosc 2003; 57: 170A        [ Links ]

21. Rondonotti E, Herrerías JM, Pennazio M, Caunedo A, Mascarenhas-Saraiva M, de Francis R. Technical and clinical pitfalls and challenges of capsule endoscopy: A review of 733 cases. Proceedings of the 3rd Conference on Capsule Endoscopy. Miami, 2004.        [ Links ]

22. Barkin JS, O'Loughlin C. Capsule endoscopy contraindications: complications an how to avoid their recurrence. Gastrointes Endos Clin N Am 2004; 14: 61-5.        [ Links ]

23. Riccioni ME, Spada C, Spera G, et al. "M2A Patency capsule" in the evaluations of patients with intestinal strictures: preliminary results. Endoscopy 2003; 35: A6.        [ Links ]

24. Caunedo A, Rodríguez-Téllez M, Romero J, et al. Evaluation of the "M"A Patency capsule" in the gastrointestinal tract: one centre preliminary data from a multicentre prospective trial. Endoscopy 2003; 35: A182.        [ Links ]