Patients with celiac disease have a 28-fold increased risk of developing enteropathy-associated
T-cell lymphoma compared with the general population [1]. Early diagnosis is therefore required to improve their prospects. Indigo carmine
chromoendoscopy highlights mucosal irregularities and improves the detection of malignant
lesions [2]. Furthermore, it can delineate villous atrophy in celiac disease [3]. This method is commonly used in upper and lower gastrointestinal endoscopy but
this is not yet the case in small-intestinal endoscopy. In this report we describe
the chromoendoscopic appearances of jejunal enteropathy-associated T-cell lymphoma,
before and after indigo carmine spraying, in a patient who was undergoing a double-balloon
endoscopy procedure.
A 68-year-old Caucasian woman with celiac disease who had been on a gluten-free diet
for 3 years was referred for double-balloon endoscopy because an abdominal computed
tomography scan had shown thickened small-intestinal wall. Endoscopy was performed
with a double-balloon endoscopy system (FMH Medical Inc., Veenendaal, The Netherlands).
Using a catheter, 10 mL of a 0.1 % solution of indigo carmine was sprayed onto the
jejunal mucosa on withdrawal of the endoscope.
Scalloping or loss of folds, a mosaic appearance of the jejunal mucosa, and round
or circumferential ulcers (10 - 90 mm along their longitudinal axis) were detected
with standard video endoscopy, but the villi were easier to recognize after indigo
carmine staining of scalloped jejunal folds ([Figure 1]) and ulcers were also highlighted ([Figure 2], [3]). Histological examination revealed the presence of enteropathy-associated T-cell
lymphoma in biopsies taken from the ulcers and partial to subtotal villous atrophy
in the nonulcerated mucosa.
Figure 1 Endoscopic views of scalloped jejunal folds in a patient with celiac disease before
dye staining (a) and after spraying with 0.1 % indigo carmine solution (b).
Figure 2 Endoscopic views of a round jejunal ulcer in a patient with celiac disease and enteropathy-associated
T-cell lymphoma before dye staining (a) and after spraying with 0.1 % indigo carmine solution (b).
Figure 3 Chromoendoscopic views of circumferential jejunal ulcers in a patient with celiac
disease which were proved histologically to contain enteropathy-associated T-cell
lymphoma (0.1 % indigo carmine dye) (a,
b).
In comparison with standard endoscopy, indigo carmine chromoendoscopy highlighted
areas of villous atrophy [4] and ulcers, but did not add to the visual determination of other abnormalities such
as scalloping, loss of folds, or the typical mosaic pattern [5]. The innovative double-balloon endoscopy method is allowing the use of such techniques
in deeply located lesions that are not usually accessible by standard endoscopy. Chromoendoscopy
appears to be a suitable technique for examining suspicious areas during small-intestinal
endoscopy.
Endoscopy_UCTN_Code_CCL_1AC_2AC
