Indigo carmine chromoendoscopic appearances of enteropathy-associated T-cell lymphoma during double-balloon endoscopy in a patient with celiac disease

Patients with celiac disease have a 28-fold increased risk of developing enteropathy-associated T-cell lymphoma compared with the general population [1]. Early diagnosis is therefore required to improve their prospects. Indigo carmine chromoendoscopy highlights mucosal irregularities and improves the detection of malignant lesions [2]. Furthermore, it can delineate villous atrophy in celiac disease [3]. This method is commonly used in upper and lower gastrointestinal endoscopy but this is not yet the case in small-intestinal endoscopy. In this report we describe the chromoendoscopic appearances of jejunal enteropathy-associated T-cell lymphoma, before and after indigo carmine spraying, in a patient who was undergoing a double-balloon endoscopy procedure.

A 68-year-old Caucasian woman with celiac disease who had been on a gluten-free diet for 3 years was referred for double-balloon endoscopy because an abdominal computed tomography scan had shown thickened small-intestinal wall. Endoscopy was performed with a double-balloon endoscopy system (FMH Medical Inc., Veenendaal, The Netherlands). Using a catheter, 10 mL of a 0.1 % solution of indigo carmine was sprayed onto the jejunal mucosa on withdrawal of the endoscope.

Scalloping or loss of folds, a mosaic appearance of the jejunal mucosa, and round or circumferential ulcers (10 - 90 mm along their longitudinal axis) were detected with standard video endoscopy, but the villi were easier to recognize after indigo carmine staining of scalloped jejunal folds ([Figure 1]) and ulcers were also highlighted ([Figure 2], [3]). Histological examination revealed the presence of enteropathy-associated T-cell lymphoma in biopsies taken from the ulcers and partial to subtotal villous atrophy in the nonulcerated mucosa.

Figure 1 Endoscopic views of scalloped jejunal folds in a patient with celiac disease before dye staining (a) and after spraying with 0.1 % indigo carmine solution (b).

Figure 2 Endoscopic views of a round jejunal ulcer in a patient with celiac disease and enteropathy-associated T-cell lymphoma before dye staining (a) and after spraying with 0.1 % indigo carmine solution (b).

Figure 3 Chromoendoscopic views of circumferential jejunal ulcers in a patient with celiac disease which were proved histologically to contain enteropathy-associated T-cell lymphoma (0.1 % indigo carmine dye) (a, b).

In comparison with standard endoscopy, indigo carmine chromoendoscopy highlighted areas of villous atrophy [4] and ulcers, but did not add to the visual determination of other abnormalities such as scalloping, loss of folds, or the typical mosaic pattern [5]. The innovative double-balloon endoscopy method is allowing the use of such techniques in deeply located lesions that are not usually accessible by standard endoscopy. Chromoendoscopy appears to be a suitable technique for examining suspicious areas during small-intestinal endoscopy.

Endoscopy_UCTN_Code_CCL_1AC_2AC

References

• 1 Mearin M L, Catassi C, Brousse N. et al . European multi-centre study on coeliac disease and non-Hodgkin lymphoma.  Eur J Gastroenterol Hepatol. 2006;  18 187-194
• 2 Yoshida S, Yamaguchi H, Tajiri H. et al . Diagnosis of early gastric cancer seen as less malignant endoscopically.  Jpn J Clin Oncol. 1984;  14 225-241
• 3 Kiesslich R, Mergener K, Naumann C. et al . Value of chromoendoscopy and magnification endoscopy in the evaluation of duodenal abnormalities: a prospective, randomized comparison.  Endoscopy. 2003;  35 559-563
• 4 Lee S K, Green P H. Endoscopy in celiac disease.  Curr Opin Gastroenterol. 2005;  21 589-594
• 5 Niveloni S, Fiorini A, Dezi R. et al . Usefulness of videoduodenoscopy and vital dye staining as indicators of mucosal atrophy of celiac disease: assessment of interobserver agreement.  Gastrointest Endosc. 1998;  47 223-229