Colon cancer metastasis to small bowel detected by capsule endoscopy

Abstract

A 78 year-old male with history of colorectal carcinoma, diagnosed in 1997, surgically removed with negative lymph nodes. Four years later the patient developed a local recurrence without any metastasis, with positive lymph nodes. The patient underwent radiation and chemotherapy. He remained asymptomatic with normal lab. work up until last year when he presented with intermittent bouts of crampy abdominal pain and constipation, experiencing relief with self induced vomiting. These episodes grew more frequent and the patient then presented a drop in his hgb from 13 to 11.8g/dl with melena. At this time an EGD and colonoscopy were normal. Abdomino-pelvic CT Scan was also non diagnostic as was an UGIS's. After intestinal obstruction was excluded, capsule endoscopy was performed. The study showed a clear area of active oozing of blood associated to an ulcerated mass at the jejunum. The patient was refered for surgery. The only finding was the lesion originally detected by the capsule at the jejunum. It was resected followed by an end to end anastomosis. The histologic analysis of the mass revealed it to be a metastatic lesion from prior colon cancer, with spread limited to the small bowel. This is to our knowledge the first case of a colonic metastatic solitary lesion to the small bowel detected by the M2A endoscopic capsule. This finding shows that wireless endoscopy is an invaluable tool in cases of obscure GI bleeding as well as in chronic abdominal pain. It is noteworthy that in this case that the patient had two prior abdominal surgeries, and the possibility of partial small bowel obstruction secondary to adhesions was entertained. There is still controversy regarding the use of endoscopic capsule in that setting, but we think that the only absolute contraindication would be a patient who refuses to have surgery or who has serious contrindications for surgery should it become necessary to remove a capsule retained in an obstructed bowel. In this case, the prompt diagnostic approach with the M2A made early intervention possible due to the finding of the ulcerated mass where all other modalities were non-diagnostic. Without the use of the capsule endoscope, this patient may have gone undiagnosed for a long time allowing for progression of the metastasis. In conclusion, if there is a clinical suspicion that small bowel pathology is causing the patient's problem, M2A endoscopic capsule technology should be used more frequently and liberally in the early phases of the work up.