Small intestinal adenocarcinoma diagnosed by capsule endoscopy in a patient with occult gastrointestinal bleeding – a case report

Introduction: Adenocarcinoma of the small intestine is a rare type of gastrointestinal malignancy, especially in young adults. Optimal surgical therapy necessitates early diagnosis, which is difficult in endoscopically inaccessible places of the GI tract.

Case report: A young, 33 year-old male patient was admitted to our department because of chronic sideropenic anaemia (Hgb: 81g/l), which was treated with oral supplement therapy and transfusions for one year. Detailed previous examinations (upper GI endoscopy, colonoscopy, abdominal CT scan) were negative. No other haematological or systemic explanation was explored. Histology from the deep duodenal biopsy and oral iron absorption test were normal. Based on the consequently positive fecal occult blood testing, we first repeated gastroscopy and colonoscopy, but no evident bleeding source was found. Small bowel enterography (small bowel barium series) was also performed with completely negative results and no sings of obstruction (selective technique was not accessible in our hospital at that time). Therefore, the patient was referred for capsule endoscopy that was demonstrated multiple exulcerated small bowel lesions interpreted as possible bleeding sources with a suspicion of lymphoma. Since the most proximal lesion was described 15cm under the Treitz ligament, jejunoscopy was performed to take biopsy. During jejunoscopy, at the second jejunal loop a subtotal, circumferential stricture of the small bowel was found with a low grade active bleeding. Histological analysis from the biopsy samples demonstrated mucinosus adenocarcinoma. Then a selective enterography could be done, which demonstrated a single stricture at the endoscopically proven site, but no other lesion. Therefore surgical exploration and complete resection was accomplished with local success of resecability. On the follow up, our patient is completely asymptomatic and participating in oncological chemotherapy.

Conclusion: Optimal diagnosis of small bowel malignancy necessitates the availability of both capsule endoscopy and selective small bowel enterography. Both of these modalities should be considered in obscure cases of occult, endoscopy negative GI bleeding patients, regardless of their age and risk of cancer.