Small bowel adenocarcinoma (SBA) has generally been considered to have a poor prognosis because of nonspecific presentations and difficulties in detection of the disease. The advent of capsule endoscopy (CE) and double-balloon endoscopy (DBE) makes it possible to access to the small intestine for endoscopic interventions. We describe a successful case of early jejunum adenocarcinoma completely resected by endoscopic mucosal resection (EMR) using double-balloon endoscopy (DBE). Early diagnosis and EMR using new technologies such as CE and DBE may improve the recognition of this disease that, at present, has a poor prognosis.
Small bowel adenocarcinoma (SBA) is a rare malignancy, but has generally been considered to have a poor prognosis, with a five-year survival rate of 48% (stage I-II), 28% (stage III), and 6% (stage IV) [
A 42-year-old man appeared with melena and underwent several examinations, including esophagogastroduodenoscopy (EGD), colonoscopy, and abdominal CT with a contrast agent. Abdominal CT scan revealed a wall thickness in the small intestine (Figures
CT findings. (a) Abdominal CT showed the small bowel tumor (arrow). (b) Invagination of a part of the small bowel (arrow).
His hemoglobin level was 11.8 g/dl (normal range 11.3–15.5 g/dl). We conducted a capsule endoscopy and found part of a tumor in the small intestine, suggesting small bowel tumor (Figure
(a) Capsule endoscopy image: CE shows a mass located in the jejunum (arrow). (b) FICE image setting 1 (red 595 nm, green 540 nm, blue 535 nm). (c) FICE image setting 2 (red 420 nm, green 520 nm, blue 530 nm). The mucosal contrast of the tumor was enhanced by FICE settings 1 and 2.
Double-balloon endoscopy showing a 0-Ip polyp in the jejunum. The surface of the polyp was multinodular and villous, and its stalk was slightly reddened.
Histological analysis of the EMR specimen showed moderately-differentiated tubular adenocarcinoma with papillary adenocarcinoma. H&E stain. Magnification ×200 (bar = 100
In the last decade, CE and DBE have enabled visualization of the small bowel [
The American Gastroenterological Association (AGA) Institute states that patients with obscure gastrointestinal bleeding (OGIB) need comprehensive evaluation, including CE. In particular, CE is recommended as the third test in the evaluation of GI-bleeding patients after negative bidirectional endoscopy to obtain early diagnosis of small bowel tumors [
Imagawa et al. reported that FICE improves the visibility of angioectasia, erosion/ulceration, and various tumors of the small intestine [
In contrast, the usefulness of abdominal CT scans in patients with OGIB is unclear. We previously reported that abdominal CT scan is an effective modality to demonstrate duodenal varices in patients with OGIB [
To our knowledge, there are few reports of EMR of benign tumors in small intestine such as polyps due to the Peutz-Jeghers syndrome with DBE [
The present case implies that the combination of several imaging modalities, including CT scan, CE, and spiral or balloon endoscopies, is important to effectively manage a patient with OGIB.