PICTURES IN DIGESTIVE PATHOLOGY

 

Radiation enteritidis diagnosed by wireless capsule endoscopy

Enteritis por radiación: diagnóstico por cápsula intestinal

 

 

María Lourdes Ruiz-Rebollo, Fernando de la Calle, Benito Velayos, Luis Fernández Salazar, Rocío Aller de la Fuente and José Manuel González

Department of Digestive Disease. Hospital Clínico Universitario. Valladolid, Spain

 

 

Case report

A 55 year-old patient was attended at our institution due to epigastric pain. She had suffered an apendicectomy in her childhood and an endometrial carcinoma treated with surgery and radiotherapy 10 years ago. She had been attended at emergency room on several occasions for nausea, bilious vomiting, and abdominal pain. No abnormalities were seen either on her analyses or in her abdominal X-ray. Along these years (2008-2011), two upper gastrointestinal endoscopies, one colonoscopy with ileoscopy, an abdominal CT scan, a nuclear magnetic cholangioresonance and a small bowel barium enema were performed, which yielded no pathological findings. Only abdominal CT scan finally identified thickened bowel loops and free fluid suggesting radiation enteritis. So, wireless capsule endoscopy was indicated. This study showed angiectasias, severe villous edema and diffuse lymphangiectasias with mucosal denudation (Fig. 1). There were at least 3 strictures in the proximal small bowel (Fig. 2 A and B). The capsule remained stationary for almost two hours in one of them. After 7 hours recording, it had not reach the cecum, but it was retrieved 24 hours later spontaneously. Chronic radiation enteritidis was diagnosed on the basis of the clinical and capsule findings. We added pentoxifylline and decided to follow up. Surgery will be indicated if symptoms become severe or more frequent.

 

 

Discussion

Wireless capsule endoscopy provides the examination of the small intestine (1). It has better sensitivity than barium enema, is better tolerated and less time-consuming than push enteroscopy. The diagnosis of chronic radiation enteritidis requires a great suspicion. The incidence is increasing as more patients undergo radiotherapy for cancer treatment (2). An immunological imbalance probably plays a role in the pathological changes (3). Strictures are common and difficult to diagnosis by means of barium meal, CT scan or enteroclysis (4). Corticosteroids, pentoxifylline and probiotics are among the medical treatments (5); balloon dilatation can be performed if the strictures are accessible to endoscopy; surgery is the last option.

 

References

1. ASGE Technology Status Report: Wireless capsule endoscopy. Gastrointes Endosc 2006;63:539-45.         [ Links ]

2. Ruiz-Tovar J, Morales V, Hervás A, Sanjuanbenito A, Lobo E, Martínez-Molina E. Late gastrointestinal complications after pelvic radiotherapy: radiation enteritis. Clin Transl Oncol 2009;11:539-43.         [ Links ]

3. Grémy O, Benderitter M, Linard C. Acute and persisting Th2-like immune response after fractionated colorectal gamma-irradiation. World J Gastroenterol 2008;14:7075-85.         [ Links ]

4. Romero Vázquez J, Caunedo Álvarez A, Rodríguez-Téllez M, Sánchez Yagüe A, Pellicer Bautista F, Herrerías Gutiérrez JM, Previously unknown stricture due to radiation therapy diagnosed by capsule endoscopy. Rev Esp Enferm Dig 2005;97:449-54.         [ Links ]

5. Theis VS, Sripadam R, Ramani V, Lal S. Chronic Radiation Enteritis. Clinical Oncol 2010;22:70-83.         [ Links ]