Ileal cancer and erosions in the small intestine revealed by capsule endoscopy

Table of Contents

An 80-year-old man with persistent anemia was suspected to have a hemorrhagic lesion in the small intestine and he underwent investigation by capsule endoscopy. This examination revealed several erosions and reddened lesions in the pelvic small intestine (Figure [1]). On 17 May 2005 he was started on a prostaglandin inducer, rebamipide, at a daily dose of 300 mg, and although the iron preparation he was on was stopped, there was no decrease in his hemoglobin level. On 1 July a second capsule endoscopy examination revealed marked improvement - the erosions and reddened lesions in the small intestine had resolved (Figure [2]). The second capsule endoscopy allowed observation nearly as far as the terminal ileum, where a protruding lesion was detected (Figure [3]). Double-balloon endoscopy revealed a red type Ip polyp, about 30 cm proximal to the ileocecal valve (Figure [4]). In addition, there was an advanced cancer resembling a type IIc early cancer in the ascending colon (Figure [5]).

Figure 1 Erosions in the small intestine detected by the first capsule endoscopy.

Figure 2 The second capsule endoscopy showed that there had been improvement in the small-intestinal lesions.

Figure 3 A protruding lesion near the terminal ileum that was detected by the second capsule endoscopy examination.

Figure 4 An ileal polyp found at double-balloon endoscopy.

Figure 5 A malignant tumor in the ascending colon found at double-balloon endoscopy.

On 29 August 2005 the patient underwent surgery. The lesion in the large bowel was diagnosed as a moderately differentiated adenocarcinoma (ss, ly1, v1, n0) and the lesion in the ileum as a well-differentiated adenocarcinoma with a component of tubular adenoma (sm1, ly0, v0). There was also a type IIc early cancer in the stomach and this lesion was resected endoscopically. The entire clinical course is summarized in Figure [6]. It was not possible to determine whether this patient’s anemia had been caused by the small-intestinal lesions or by the advanced large-bowel cancer. Rebamipide, a mucoprotective agent, might be effective for the management of patients with erosions or reddened lesions in the small intestine [1] [2] [3].

Figure 6 The patient’s clinical course, showing the blood hemoglobin and serum iron levels, and the treatments he received over a period of nearly 1 year (PPI, proton-pump inhibitor).

Capsule endoscopy proved useful for the diagnosis of the small-intestinal lesions in this patient, but we should be aware that this method cannot provide a diagnosis of lesions that the capsule cannot reach and that it can miss small lesions in stomach.

Endoscopy_UCTN_Code_CCL_1AC_2AC

References

• 1 Haruma K, Ito M. Review article: clinical significance of mucosal-protective agents: acid, inflammation, carcinogenesis and rebamipide.  Aliment Pharmacol Ther. 2003;  18 (Suppl 1) 153-159
• 2 Mizoguchi H, Ogawa Y, Kanatsu K. et al . Protective effect of rebamipide on indomethacin-induced intestinal damage in rats.  J Gastroenterol Hepatol. 2001;  16 1112-1119
• 3 Kojima M, Iwakiri R, Wu B. et al . Effects of antioxidative agents on apoptosis induced by ischaemia-reperfusion in rat intestinal mucosa.  Aliment Pharmacol Ther. 2003;  18 (Suppl 1) 139-145