Chronic Radiation Gastroenteropathy Diagnosed by Small Bowel Capsule Endoscopy: A Case Report

Abstract

Radiation therapy plays an important role in a vast array of both benign and malignant disease processes. However, gastrointestinal toxicity limits the total radiation dose that can be prescribed. Chronic radiation gastroenteropathy may arise as early as 6 months to as late as several decades after the initial exposure. Microvascular sclerosis, mucosal atrophy, and intestinal wall fibrosis lead to altered intestinal transit, gut dysmotility, malabsorption, and potentially intestinal obstruction, fistulization, and perforation. We present a case of chronic radiation gastroenteropathy diagnosed by small bowel capsule endoscopy. A 56 year old man presented to the gastroenterology clinic for evaluation of chronic refractory iron-deficiency anemia (IDA). He had a history of Hodgkin lymphoma 30 years prior treated at that time with chemoradiation therapy with which he achieved remission; he then suffered from complications of radiation including mild pulmonary fibrosis, cardiomyopathy, coronary artery disease, and myelopathy resulting in paraplegia. As part of the workup for IDA, prior esophagogastroduodenoscopy (EGD) and colonoscopy had been remarkable for diffuse duodenal lymphangiectasias and a benign traversable transverse colon stricture attributed to radiation therapy. At our institution repeat EGD showed a bleeding gastric Dieulafoy lesion treated with bipolar electrocoagulation leading to hemostasis, and repeat colonoscopy was unremarkable except for the colonic stricture. Postprandial bloating, distention, and flatulence responded to a short course of ciprofloxacin, supporting a presumptive diagnosis of small intestinal bacterial overgrowth; recurrent symptoms were treated with a second course of ciprofloxacin and subsequently amoxicillin/clavulanic acid. Given persistent IDA he underwent small bowel capsule endoscopy, which showed mucosal atrophy interspersed with mucosal congestion and erythema as well as diffuse lymphangiectasias throughout the small bowel; these findings were consistent with chronic radiation enteropathy. Despite the decreasing incidence of radiation-induced enteropathy, we continue to encounter patients who present with significant complications after a prolonged latency period. A presumptive diagnosis is often made clinically, although small bowel capsule endoscopy remains a valuable and minimally invasive method to confirm this clinical entity.FigureFigureFigure