LETTERS TO THE EDITOR

 

Ileal adenocarcinoma diagnosed by double-balloon enteroscopy

Adenocarcinoma ileal diagnosticado por enteroscopia de doble balón

 

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Key words: Adenocarcinoma. Enteroscopy. Small bowel.

Palabras clave: Adenocarcinoma. Enteroscopia. Intestino delgado.

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Dear Editor,

Double-balloon enteroscopy (DBE) is an endoscopic technique for examining practically the whole small bowel, in addition to facilitating the removal of biopsy specimens and applying therapies. The technique, initially described by Yamamoto (1), is considered complementary to the videocapsule endoscopy (CE) and is used, unless contraindicated, prior to DBE (2).

 

Case report

A 66-year-old man, with no pertinent medical/surgical history, who complained of symptoms occurring over a period of one month of self-limited abdominal pain episodes, associated with constipation, abdominal distension, vomiting, anorexia and weigth loss. Physical examination showed a mild abdominal distension, tympany on percussion, hiperresonant sounds, and mild widespread pain when depressed deeply. The blood analysis (haemogram, basic biochemical data and ferrokinetics) was normal, including tumour markers (CEA, CA 19.9). The abdomen X-ray showed dilation of the small bowel with air-fluid levels, normalising at 24 hours after admission. An abdominal CT showed enlargement of the pre-terminal ileum and identified a solid lesion of 13-20 mm. The small bowel follow-through showed enlargement of the distal ileum with multiple small nodules. In view of these findings and the contraindication of CE, a DBE was performed by the anal route and identified to 35 cm of Bauhin's valve a circumferential, villous-looking, friable tumour that partially obstructed the bowel (Figs. 1 and 2); allowing however the transposition of the endoscope. Multiple biopsies were performed and the presence of other lesions nearby was discarded. The histological examination demonstrated the existence of adenocarcinoma. Patient underwent surgical ileocolic resection with mechanical latero-lateral anastomosis. The histopathology was ileal mucinous adenocarcinoma.

 

Discussion

Malignant tumours in the small bowel account for 1 to 2% of all gastrointestinal tumours, the adenocarcinoma being the most common (40-63%). The second commonest is the carcinoid tumour (20-40%); lymphoma (14%) and sarcomas (11%) are less common (3). In a recent communication in our area were described, a total of 4 cases of small bowel tumours between the years 2000-2005 (4); Perez-Cuadrado et al. described 1 case of adenocarcinoma of the small intestine from 44 patients who had been conducted DBE (5). The way these types of tumours usually manifest themselves is by intestinal obstruction (which was a predominant symptom in our case), obscure gastrointestinal bleeding, abdominal pain, palpable mass, perforation, and anorexia/weight loss (6). These types of tumours are difficult to diagnose early on as they do not present specific signs or symptoms and so far, yield of diagnostic tests has been poor. In most cases, the diagnosis is late and the tumour appears when it is at an advanced stage, which means a worse prognosis. Currently the CE as a first-line examination technique and especially DBE have represented a major breakthrough for diagnosing malignant tumours of small bowel. The CE should be the initial technique for estudy of small intestine because it is non-invasivity. It predicts when a DBE must be performed and it's approach (oral or anal route). The CE and DBE have been shown to be complementary techniques. In our case, the intestinal stricture contraindicated the performance of CE. The endoscopic diagnoses were carried out by DBE and tissue samples were taken. The differential diagnosis was possible using histological study (Crohn's disease, intestinal linfoma or tumour) and determined the most appropriate treatment. In other cases, the DBE provides not only the biopsies, but also allows to carry out therapeutic measures: enteral stent placement, dilation and polypectomy.

We can conclude that the CE and DBE are two complementary techniques that have made a breakthrough in the study of the pathology of the small intestine, enabling the diagnosis and treatment.

 

P. Suárez-Callol, J. M. Huguet-Malavés, J. Sempere-García-Argüelles, P. Canelles-Gamir and E. Medina-Chuliá
Unit of Digestive Diseases. Hospital General Universitario de Valencia. Spain

 

References

1. Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-ballon method. Gastrointest Endosc 2001; 53: 216-20.        [ Links ]

2. Akahoshi K, Kubakawa M, Matsumoto M, et al. Double-ballon endoscopy in the diagnosis and management of gastrointestinal tract disease: methodology, indications, safety and clinical impact. World J Gastoenterol 2006; 12(47): 7654-9.        [ Links ]

3. Serour F, Dona G, Binkenfeld S, Balassiano M, Krispin M. Primary neoplasms of the small bowel. J Surg Oncol 1992; 49(1): 29-34.        [ Links ]

4. Bruna M, Galindo P, Roig JV, Salvador A, Ismail A, García Fadrique A. Adenocarcinoma primitivo de intestino delgado con presentación de novo. Rev Esp Enferm Dig 2006; 98(10): 789-98.        [ Links ]

5. Pérez-Cuadrado E, Mas P, Hallal H, et al. Double-ballon enteroscopy: a descriptive study of 50 explorations. Rev Esp Enferm Dig 2006; 98(2): 73-81.        [ Links ]

6. Zhan J, Xia ZS, Zhong YQ, Zhang SN, Wang LY, Shu H, Zhu ZH. Clinical analisis of primary small intestinal disease. A report of 309 cases. World J Gastroenterol 2004; 10(17): 2585-7.        [ Links ]