M2A Wireless Capsule Endoscopy for Diagnosing Ulcerative Jejunoileitis Complicating Celiac Disease

M2A wireless capsule endoscopy (Given Imaging, Ltd., Yoqneam, Israel) is an innovative diagnostic method that makes it possible to visualize the entire small bowel during normal peristalsis [1]. This new method appears to be superior to small-bowel radiography (enteroclysis or barium follow-through, or both) for evaluating small-bowel diseases [2] [3]. However, its true diagnostic yield is still under evaluation. We describe here the case of a 76-year-old man with a 5-year history of celiac disease, who initially had complete clinical remission and histological improvement after switching to a gluten-free diet, but whose symptoms subsequently recurred despite strict adherence to dietary restrictions.

A barium follow-through showed dilation of the proximal small bowel, with loss of mucosal folds and segmentation of the barium contrast. M2A capsule endoscopy was then carried out and revealed multiple benign-appearing ulcers throughout the small bowel (Fig. [1], [2]), with patchy mucosal inflammation. The patient did not report any use of nonsteroidal anti-inflammatory drugs, and there was no evidence of bowel ischemia. Enteroscopy was subsequently carried out, and histological examination of multiple biopsies throughout the proximal small bowel did not reveal T-cell monoclonality. A laparotomy with full-thickness biopsies of the small bowel was suggested in order to exclude malignancy, but the patient declined. Computed tomography of the abdomen was normal, and prednisolone 20 mg daily was therefore administered, with iron and calcium supplements, to which the patient responded well. He is still receiving close clinical follow-up and has been in clinical remission for a period of 6 months.

Figure 1 M2A capsule image of an ulcer in the proximal small bowel.

Figure 2 M2A capsule image of an ulcer in the distal small bowel.

Ulcerative jejunoileitis appears to be a rare complication of celiac disease [4]. However, in cases of refractory celiac disease, small-bowel radiology is often unhelpful [5] and enteroscopy is sometimes unavailable; the diagnosis often remains vague. This case highlights the usefulness of capsule endoscopy in diagnosing small-bowel diseases. The new method appears to be more helpful than classic small-bowel radiography. However, the inability to take biopsies during capsule endoscopy means that enteroscopy is still a necessary diagnostic tool.

Endoscopy_UCTN_Code_CCL_1AC_2AZ

References

• 1 Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy.  Nature. 2000;  405 417
• 2 Costamagna G, Shah S K, Riccioni M E. et al . A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease.  Gastroenterology. 2002;  123 999-1005
• 3 Waye J D. Small-bowel endoscopy.  Endoscopy. 2003;  35 15-21
• 4 Ciclitira P. AGA technical review on celiac sprue.  Gastroenterology. 2001;  120 1526-1540
• 5 American Gastroenterology Association. Medical position statement: celiac sprue.  Gastroenterology. 2001;  120 1522-1525