A 24-year-old man was referred for further evaluation of
obscure-occult gastrointestinal bleeding. He had presented 5 years earlier with
an episode of acute iron-deficiency anemia at 9.7 g/dL without overt
hemorrhage. He was treated by oral iron supplementation, but a low ferritin
level persisted at 35 µg/L. He was asymptomatic and used no
medication. He was twice explored unsuccessfully by gastroscopy, colonoscopy,
and small-bowel follow-through.
A first capsule endoscopy (Pill cam SB 2; Given Imaging, Yoqneam,
Israel) showed a sessile polypoid lesion at three-quarters of the small-bowel
transit time ([Fig. 1]).
Fig. 1 First capsule endoscopy
showing a polypoid lesion at three-quarters of the small-bowel transit
time.
A second capsule endoscopy confirmed the presence of the same lesion
at the same location. This time the lesion was visualised inside a cavity ([Fig. 2]) and a double lumen was seen, suggesting a
Meckel’s diverticulum.
Fig. 2 Images recorded by the
second capsule endoscopy revealed that the polypoid lesion was inside a
cavity.
No double-balloon enteroscopy was performed due to the need for
surgical treatment.
The patient underwent single-port laparoscopy and a Meckel’s
diverticulum with a palpable lesion inside was detected ([Fig. 3]).
Fig. 3 The diagnosis of
Meckel’s diverticulum was confirmed by single-port laparoscopy.
After resection of a 5-cm-long segment, the diverticulum was opened
and a 2-cm sessile polypoid lesion with three superficial erosions was
revealed. Histologically, the lesion corresponded to a hypervascularised
epithelium of gastric fundic and antral mucosa, with superficial ulcerations,
without Helicobacter pylori infection ([Fig. 4]).
Fig. 4 The polypoid lesion
corresponded to an ectopic gastric mucosa with exulcerations (arrowhead). The
mucosa and submucosa were congestive (C) with patchy interstitial bleeding
(arrows). The asterisk shows the transition between the ectopic fundic mucosa
(left) and the intestinal mucosa (right) (hematoxylin and eosin staining;
original magnification × 20).
In the era of capsule endoscopy, a few cases of Meckel’s
diverticulum have been reported where the diagnosis was suggested either
because of active bleeding [1]
[2]
or by the endoscopic aspect of a double orifice [3]
[4]. In our patient, we had the additional finding of a
polypoid lesion inside the Meckel’s diverticulum that corresponded
surprisingly to an ectopic gastric mucosa. There is one more case of an ectopic
gastric mucosa detected by capsule endoscopy [5]; however
these are the first images where close visualization has been achieved.
Endoscopy_UCTN_Code_CCL_1AC_2AF
