ENDOSCOPIC SNAPSHOT

 

Sporadic Jejunal Lateral Spreading Tumor: A Rare Cause of Recurrent Jejunojejunal Intussusception

Lesão em tapete esporádica no jejuno: causa rara de invaginação jejunojejunal recorrente

 

Ana Ponte^a, Rolando Pinho^a, Adélia Rodrigues^a, Amélia Tavares^b, Joana Ferreira^b, Miguel Mendes^b, Silvia Costa^b, João Carvalho^a

Departments of ^aGastroenterology and ^bGeneral Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal

^* Corresponding author.

 

Keywords: Deep enteroscopy; Lateral spreading tumor; Enteric invagination

Palavras-Chave: Enteroscopia profunda; lesão em tapete; invaginação entérica

 

A previously healthy 74-year-old woman with no relevant family medical history was referred to our department to investigate a jejunojejunal intussusception incidentally diagnosed in an abdominal ultrasound performed for evaluation of self-limited episodes of abdominal pain and vomiting. To further investigate the ultrasound findings, computed tomography (CT) was performed and revealed a target sign resulting from an extensive jejunojejunal invagination that involved a large edematous jejunal segment and mesenteric blood vessels and leading to proximal dilation of small-bowel loops with air-fluid levels inside (Fig. 1). Due to partial obstruction and absence of an underlying lesion identified on CT, the patient was referred to antegrade single balloon enteroscopy (Olympus SIF-Q180, Japan) that revealed a type 0-IIa (Paris classification) granular lateral spreading tumor, measuring approximately 4 cm and occupying four fifths of the luminal circumference in the proximal jejunum (Fig. 2 , 3). As endoscopic mucosal resection (EMR) was considered high risk, tattooing was performed and biopsy samples were obtained. Histology revealed a tubulovillous adenoma with low-grade dysplasia and foci of high-grade dysplasia. The patient underwent a laparoscopic enterectomy, whose histology confirmed the initial diagnosis. After surgery, the patient remained asymptomatic.

 

 

 

 

In adult intussusception there is an underlying cause in more than 90% of the cases, with tumors representing the most frequent etiology [1]. Benign and malignant small-bowel tumors are rare and account for approximately 3–6% of all gastrointestinal neoplasms [2]. With the advent of capsule endoscopy and deep enteroscopy (DE), the reported incidence of small-bowel tumors has increased [2]. Although it accurately identifies adult intussusception, CT may be unrevealing in the evaluation of incomplete small-bowel obstruction and small-bowel tumors [1, 3] . In these cases, DE may provide additional diagnostic information [4] . Moreover, DE allows biopsy sampling and therapeutic interventions [2, 3]. Removal of small-bowel adenomas is advisable due to their predisposition for malignancy.

The boundaries of therapeutic enteroscopy are being continuously expanded [4] and include nowadays smallbowel EMR, as described in a recent series [5] . In this case, EMR was considered high risk, given the longitudinal and circular extension of the lesion, which could be associated with a high rate of incomplete resection, perforation, or delayed stenosis. Hence, laparoscopic surgery was considered a safer therapeutic option.

 

References

1 Honjo H, Mike M, Kusanagi H, Kano N: Adult intussusception: a retrospective review. World J Surg 2015;39:134–138.         [ Links ]

2 Islam RS, Leighton JA, Pasha SF: Evaluation and management of small-bowel tumors in the era of deep enteroscopy. Gastrointest Endosc 2014;79:732–740.         [ Links ]

3 Sun B, Shen R, Cheng S, Zhang C, Zhong J: The role of double-balloon enteroscopy in diagnosis and management of incomplete small-bowel obstruction. Endoscopy 2007;39:511–515.         [ Links ]

4 Pinho R: The vanishing frontiers of therapeutic enteroscopy. GE Port J Gastroenterol 2015;22:133–134.         [ Links ]

5 Kröner PT, Sancar A, Fry LC, Neumann H, Mönkemüller K: Endoscopic mucosal resection of jejunal polyps using double-balloon enteroscopy. GE Port J Gastroenterol 2015;22:137–142.         [ Links ]

 

Statement of Ethics

This study did not require informed consent nor review/approval

by the appropriate ethics committee.

Disclosure Statement

The authors have nothing to disclose.The authors have no conflicts of interest to declare.

 

^* Corresponding author.

Dr. Ana Ponte

Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia

Rua Conceição Fernandes

PT–4434-502 Vila Nova de Gaia (Portugal)

E-Mail ana.ilponte@gmail.com

 

Received: September 26, 2016; Accepted after revision: October 12, 2016