CAPSULE ENDOSCOPIC DIAGNOSIS OF A LOCALIZED SMALL BOWEL CANCER MISSED BY ENTEROCLYSIS IN A PATIENT WITH HNPCC

Abstract

Although the incidence of small bowel cancer in general population is low, patients with HNPCC are at high risk of developing small bowel cancer. Before the introduction of capsule endoscopy (CE), enteroclysis (gold standard for evaluation of small bowel) was the only imaging method employed for screening these patients. We report the limitation of such an approach by describing a patient in whom enteroclysis missed the diagnosis of a small bowel cancer that was clearly visualized by CE. Case Report: A 67-year-old white male with prior colon resections for two metachronous colon cancers and a family history suggestive of HN-PCC (three siblings and a parent with colon cancer) developed severe iron deficiency anemia. Traditional Work-up (EGD + Colonoscopy + Enteroclysis) Missed the Diagnosis: 1. Colonoscopy identified hyperplastic polyps. 2. EGD demonstrated Barrett's esophagus. 3. Enteroclysis was normal. Capsule Endoscopic Diagnosis of Adenocarcinoma of the Small bowel: Proximal small bowel images of CE showed a polypoid mass in just two frames (figure 1). Push enteroscopy showed a friable ulcerated mass near the D-J Flexure (figure 2); biopsies revealed adenocarcinoma.FigureFigureTherapy: Whipple resection demonstrated localized disease with sparing of lymph nodes. He recovered fully with resolution of his anemia. Conclusions: This case clearly illustrates the fact that CE should be done to evaluate small bowel disease in the high risk group for adenocarcinoma (such as HNPCC) even if the enteroclysis is normal. Whether CE should be used alone or in conjunction with enteroclysis needs further investigation, [figure 1] [figure 2]