A 49-year-old woman was transferred to our hospital because of
hematochezia, which had lasted for 24 hours. Her past medical history was
positive for osteogenesis imperfecta type 4 and asthma. On clinical
examination, the patient was pale and tachycardic with a resting pulse rate of
110. Her blood pressure was 80/40. Hemoglobin was 4.4 mmol/L (reference
values 7.4 – 10.0) and hematocrit 0.21
(0.35 – 0.47). The remaining laboratory parameters were
within the reference range.
The patient was transfused with six units of packed red blood cells
and underwent an esophagogastroduodenoscopy (EGD) which was normal.
Ileocolonoscopy revealed a very long and tortuous colon, and blood emanating
from the terminal ileum valve. The patient then underwent an oral
double-balloon enteroscopy (DBE), which disclosed a bleeding lesion
400 cm distal to the pylorus ([Fig. 1]).
The bleeding was stopped using argon plasma coagulation (APC; Erbe,
Tübingen, Germany) ([Fig. 2]). After
achieving hemostasis, we injected 0.5 ml India ink into the submucosa,
4 cm proximal to the tumor. The patient had no further episodes of
bleeding and remained stable during her hospitalization.
After 2 weeks, the patient underwent an elective laparotomy. During
the operation the marked segment was easily identified, there was no retraction
of the mesentery, and a 7-cm-long segment of ileum was resected. Histopathology
revealed a 1.2-cm-diameter neuroendocrine tumor (NET) ([Fig. 3]). The resection margins were free. Computed
tomography (CT) of the abdomen revealed multiple metastases. The patient was
placed on a long-lasting somatostatin analog (Sandostatin) and remained
clinically stable.
Fig. 1 Bleeding neuroendocrine
tumor localized in the ileum, 400 cm distal to the pylorus. The lesion
was raised with an ulcerated center with active bleeding.
Fig. 2 Application of pulsed
argon plasma coagulation (30 W) via a thin probe. A total of five
applications each lasting 5 seconds were necessary to stop the bleeding.
Fig. 3 Histology revealed a
typical neuroendocrine tumor. Immunohistochemistry using antibodies against
chromogranin A was strongly positive. Histological photo courtesy of Dr M.
Schmitt, Institute of Pathology, Otto-von-Guericke University, Magdeburg,
Germany.
Despite their low incidence, NETs are the second most frequent
tumors of the small intestine [1]
[2]. The most common symptoms of gastrointestinal NET are
non-specific and include abdominal pain, bloating, and diarrhea
[1]
[2]. Gastrointestinal bleeding
is very rare, usually resulting from ulceration of the mucosa
[2]. Laboratory diagnosis is established by demonstration
of elevated plasma chromogranin A or urinary 5-hydroxyindoleacetic acid levels,
while localization is accomplished by octreotide scintigraphy or CT scan
[1]. Recently, capsule endoscopy has been reported as a
useful method to localize small-bowel NET [2]
[3]. Because of the ability to investigate the small bowel,
DBE is another potential method to search for NETs.
Our case is interesting for several reasons. First, we show that
small-bowel NET should be kept as a differential diagnosis of midgut bleeding.
Second, we demonstrate that an ileal NET can be diagnosed by performing an oral
DBE. Third, endoscopic therapy using APC was successful to stop the bleeding
from the ulcerated carcinoid. And finally, DBE was also a useful method to mark
the site of this small tumor by using India ink. We conclude that DBE may be a
potential method to investigate the presence of small-bowel NET, to treat a
bleeding lesion, and to help the surgeon localize the lesion intraoperatively
by having marked the site during endoscopy.
Endoscopy_UCTN_Code_CCL_1AC_2AC
