The Ulility of Urgent Video Capsule Endoscopy and Double Balloon Enteroscopy to Identify, Treat, and Diagnose a Bleeding Ileal Carcinoid Tumor

Abstract

Purpose: Video Capsule Endoscopy (VCE) and double balloon enteroscopy (DBE) are frequently utilized modalities to evaluate the small bowel in an elective outpatient setting. We present a case in which an actively bleeding carcinoid tumor was identified, treated for hemostasis, and localized with tattoo on an urgent, inpatient basis. This process assisted the surgeons in their pre-operative planning and inpatient management of the patient.Figure: Left image: hemoclip placed for active bleeding. Right image: bleeding ileal carcinoid.Case presentation: A 26-year-old otherwise healthy female presented with four episodes of rectal bleeding at home, initially described as hematochezia which evolved to appear more consistent with melena. At the time of presentation she was anemic with hemoglobin of 7.4 mg/dL. She was admitted and underwent an EGD and colonoscopy. The EGD was normal and the colonoscopy revealed coagulated blood in the terminal ileum without a source of bleeding. She then had a Meckel's scan that was negative. Due to the persistence of ongoing bleeding, VCE was performed, which identified active bleeding in the distal small bowel. The following morning the patient underwent an enterograde DBE which identifi ed an ulcerated, actively bleeding polypoid lesion at 400cm beyond the ligament of Treitz. A hemoclip was placed on to the visible vessel, leading to hemostasis. The lesion was then tattooed and general surgery was consulted. She underwent a laparoscopic partial small bowel resection and was discharged on post-op day 3. Pathology of the lesion revealed a 1.6-cm carcinoid tumor. She was later evaluated for metachronous lesions with CT imaging, Octreoscan, and labs; all which were unremarkable. This case demonstrates the effectiveness of urgent small bowel evaluation with video capsule endoscopy and double balloon enteroscopy in patients with ongoing overt obscure gastrointestinal hemorrhage.