White submucosal plaques in small bowel on capsule endoscopy

We read with interest the study by Bellutti et al. [1] that attempted to characterize the white and yellow submucosal plaques found in the small bowel on double-balloon enteroscopy. We congratulate the authors on a good study that has helped a better understanding of various incidental abnormalities found on endoscopic imaging of the small bowel. This study will help in solving clinical dilemmas like the one we encountered on capsule endoscopy in one of our patients.

A 70-year-old man with anemia was referred to our center for capsule endoscopy. He had had symptomatic anemia for the last 3 months with no history of gastrointestinal bleeding. The hematological examination was suggestive of iron deficiency anemia. Stool examination was negative for occult blood. Upper gastrointestinal endoscopy and colonoscopy did not reveal any abnormality. Histopathological examination of the duodenal biopsy did not reveal any significant abnormality, and serological testing for celiac disease was negative. The barium meal follow-through and computed tomographic (CT) examination of the abdomen was normal. Capsule endoscopy, performed after overnight fasting and polyethylene glycol ingestion, revealed multiple (> 10) white submucosal plaques in the distal small bowel ([Fig. 1]). No bleeding lesion was identified in the small bowel. A push enteroscopy was performed and small bowel 80 cm distal to the pylorus was examined, which was normal. As no significant abnormality could be detected, the possibility of nutritional anemia was considered and the patient was started on oral iron supplements along with multivitamins. With this therapy, he experienced significant improvement with a rise in hemoglobin levels. At 6 months of follow-up the patient is asymptomatic with normal hemoglobin levels.

Fig. 1 a, b Capsule endoscopy: white colored submucosal plaques in the small bowel.

Capsule endoscopy has improved our ability to diagnose diseases of the small intestine and thus has helped considerably in the management of patients with obscure gastrointestinal bleeding [2]. Increasing use of capsule endoscopy has led to visualization of lesions in the small bowel that cannot be characterized accurately as it is not possible to biopsy them on capsule endoscopy. As many of these are unrelated to the presenting clinical features of the patient, they are labeled as lesions of uncertain significance. One such type of lesion is white or yellow small-bowel submucosal plaques as encountered in our patient. The study by Bellutti et al. [1] has demonstrated on the basis of double-balloon enteroscopy and histopathological examination of these lesions that the majority are lymphangiectasias and a normal anatomical variant. They do not require further work-up.

Competing interests: None

References

• 1 Bellutti M, Mönkemüller K, Fry L C. et al . Characterization of yellow plaques found in the small bowel during double-balloon enteroscopy.  Endoscopy. 2007;  39 1059-1063
• 2 Bhasin D K, Rana S S. Gastrointestinal bleeding: From overt to obscure.  Endoscopy. 2006;  38 116-121