Hemorrhagic Small Bowel Renal Cell Metastasis Diagnosed by Double Balloon Enteroscopy

Abstract

Recent advances in enteroscopy have made evaluation of the small bowel feasible. The utility of capsule endoscopy is solely diagnostic. Double balloon enteroscopy (DBE) permits examination of the entire small bowel and allows for diagnostic and therapeutic maneuvers. Through tattooing DBE provides a means for rapid laparascopic localization of small bowel lesions. Case Report: We report a case of a 65 year old woman transferred for melena without hemodynamic instability. Medical history was remarkable for hypertension, and left nephrectomy for renal cell carcinoma. Upper endoscopy and colonoscopy were negative. She was transfused three units and discharged with a hemoglobin of 10.6. Four days after discharge, labs revealed a hemoglobin of 7.2. On readmission, bleeding scan identified a source in the right upper quadrant small bowel region. Capsule endoscopy revealed a possible AVM, and ulcers in the ileum. The patient was transferred to our institution for DBE to specifically localize, identify, and treat the bleeding source. The DBE system allowed deep insertion into the small bowel. A mass with a friable surface was identified on a broad stalk with ulcer at the base. Multiple small biopsies were obtained. India ink injections were placed 120 degrees apart, 3 cm proximal to the lesion. Biopsy results were consistent with metastatic renal cell carcinoma and the patient was taken to the OR for resection. Discussion: The small bowel is an uncommon source of GI bleed. Approximately 5% of gastrointestinal bleeds cannot be localized after extensive workup including panendoscopy and capsule endoscopy. Of these, 27% are small bowel AVMs or tumors. Other small bowel bleeding lesions include gastrointestinal stromal tumors, carcinoids, and lymphomas. At our center DBE is utilized in the evaluation of obscure-occult, and obscure-overt bleeding. We have found DBE to be safe and effective in diagnosing and treating many unusual lesions of the small bowel. Renal cell metastasis to the small bowel are rare and scant reports of intussusception and bleeding secondary to these lesions can be found in the literature. Here we present the first case report of a small bowel renal cell metastasis diagnosed at DBE, which was subsequently removed laparoscopically. Tatooing of this endoluminal lesion permitted an expeditious and directed laparoscopic resection of the lesion.