Radiol Oncol 2005; 39(3): 193-6.
case report
Small-bowel carcinoid presenting with acute bleeding detected upon wireless capsule endoscopy
Živa Mrevlje1, Marko Sever2, Borut Kocijančič1
1Clinical Department of Gastroenterology, University Medical Center Ljubljana, Slovenia 2Clinical Department of Abdominal Surgery, University Medical Ljubljana, Slovenia
Background. Intestine carcinoid usually presents with clinical symptoms and signs deriving from its en-docrinological influences and rarely bleeds profusely.
Case report. We present a patient with intestinal bleeding of unknown origin. After conventional diagnos-tic procedures only wireless capsule endosopy was able to discover a tumour of small bowel, which was the reason of bleeding. On patohistological examination after the surgical resection it proved to be a small bow-el carcinoid.
Conclusions. There are indications that WCE, besides being the first small bowel imaging technique, is a very important diagnostic tool, deserving consideration in the early phases of diagnosing small-bowel dis-ease, especially in less intensive or occult bleeding.
Key words: intestinal neoplasms-dignosis; carcinoid tumor; endoscopy
Introduction
The small intestine has to-date been a prob-lematic section of the gastrointestinal (GI) tract for exploration. In patients with obscure or manifest GI bleeding the major part of the small bowel was unreachable by means of esophagogastroduodenoscopy (EGDS), push enteroscopy (PE) and coloileoscopy (CIS), the
Received 19 July 2005 Accepted 1 August 2005
Correspondence to: Živa Mrevlje, MD, Department of Gastroenterology, Clinical Center Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; E-mail: ziva@mrevlje.org
Abbreviations: GI – gastrointestinal, EGDS – esopha-gogastroduodenoscopy, PE – push enteroscopy, WCE – wireless capsule endoscopy, RBC – red blood-cell count, MCV – medium red blood-cell volume
major limitations being its remoteness from GI tract openings and its length (3.4-7.9m ap-prox.). Other conventional diagnostic proce-dures in small bowel bleeding are blood pool scintigraphy, angiography and barium small bowel series. Virtual endoscopy, employed lately, is an interesting alternative to conven-tional diagnostic techniques.1
In recent years a novel endoscopic tool, the wireless capsule endoscopy (WCE) has been developed.2 It allows to endoscopically ex-plore the small intestine in its entirety using a system composed by a peristalsis propelled video capsule with a radio transmitter, a sen-sor-array attached to the patients abdominal wall and a data recorder worn at the patient’s belt. The data collected can then be retrieved and analyzed using a workstation.
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We present a case of manifest GI bleeding in which WCE facilitated identification of the bleeding site, its localization and treatment.
Case report
A 58-year-old man with maelena lasting for 3 days prior to the admission was referred to our hospital. On admission the patient was complaining of minor fatigue during the past few days. He had been on antihypertensive and statin therapy for several years. He was otherwise in good health, somewhat pale; on rectal examination black semi-fluid stools were found. The only pathological laboratory finding was normocytic anaemia (red blood-cell count - RBC 3.75 109/L, Hb 11.4 g/dL, medium red blood-cell volume - MCV 89.5 fL). He underwent oesophagogastroscopy with no positive finding. On colonoileoscopy, two polyps in the sigmoid without any sign of recent haemorrhage were found and frank maelena was seen to be flowing from the ileum into the caecum. Blood pool scintigra-phy showed some active bleeding in a region projecting into the right upper abdominal quadrant, most probably a part of the small bowel.  On  angiography  of  the  superior
Figure 1. Capsule endoscopy view of the tumour.
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mesenteric artery and celiac trunk no ex-travasate was found in their course. On WCE performed with an M2A plus capsule and an-alyzed using the RAPID software (both Given Imaging Inc., Yoqneam, Israel) small bowel mucosa showed few small angiodisplasia-like mucosal changes in the proximal jejunal region. Following 3.5 hours of small bowel transit time we visualized a bleeding site in the vicinity of the tumour of 7 mm in diameter. The tumour was projected into the right low-er quadrant of the abdomen (Figure 1).
On explorative laparotomy, a small umbil-ication of jejunal serosa lying 50 cm distally to the ligament of Treitz was found. At this site a 10 mm fixed tumour was palpable. Distally from it the lumen was filled with blood, which was even more evident on transillumination. A jejunal segmental resection of 5cm (Figure 2), followed by a one-layer ter-minoterminal anastomosis, was performed. The surgeon found no pathology on palpato-ry examination of the liver.
On patohistological examination the re-sected formation was found to be a well dif-ferentiated malignant (more than 10 mm in diameter) carcinoid of the small intestine, initial stage T2 N0. The tumour cells expressed serotonin, some of them somatostatin. There
Figure 2. Tumour after excision.
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was no need for the additional therapy, only the follow-up was recommended.
Discussion
When haemorrhage from the GI tract is sus-pected, we usually choose from, or combine, upper GI tract endoscopy and colonoscopy, which gain visual access to both end-sides of the GI tract and only to a small part of the small bowel, proximal jejunum and distal ileum. We performed both in this case, but didn’t visualize any actively bleeding sites, and consequently deduced that bleeding de-rived from the small intestine.
PE has a diagnostic yield ranging between 13 and 38%; in a randomized trial its sensitiv-ity was 37% compared to 64% for WCE.3,4 It has the advantage of allowing treatment and specimen cropping and has higher specificity in its range.5 Because of the proximity of the bleeding lesion to the ligament of Treitz (50cm) in our patient’s case PE would have probably led to the diagnosis without any need to perform WCE, but we didn’t perform it. In regard to its lower diagnostic yield and the possibility of performing WCE, we didn’t perform barium small bowel series. Besides involving patient radiation, trial barium small bowel series were in different studies shown to be less diagnostic than WCE (27% vs. 45%
of cases).6,7
The explorative surgery unaccompanied by additional techniques has a yield of ap-proximately 10%.8 The recognition of vascular lesions cannot be achieved without the aid of transillumination or intraoperative en-doscopy. The latter is invasive and associated with many complications, i.e. postoperative paralytic ileus and perforation. We refrained from performing explorative surgery with intraoperative endoscopy, as the bleeding wasn’t haemodinamically or otherwise threatening to the patient in the immediate time, not ad-vocating for such an invasive technique.
Other morphologic and functional tech-niques, such as angiography of the superior mesenteric artery and blood pool scintigra-phy with marked erythrocytes promised to bring some insight into the diagnostic problem.
Blood pool scintigraphy gives a positive scan with at least 5 ml of intraluminal blood. It may confirm small intestinal bleeding, it confers no information about the nature of the bleeding lesion and accurate localization is impossible. With sequential scanning it al-lows the detection of intermittent bleeding. Angiography of mesenteric arteries can demonstrate active bleeding and well vascu-larized nonbleeding lesions. Its diagnostic yield is 50-70%, but falls to 25-50% when the bleeding slows or stops; a positive find can only be gained with bleeding rates exceeding 0.5 or 1 ml/min.9 In our case blood pool scintigraphy pinpointed to a bleeding site in the small intestine, whereas with angiogra-phy no bleeding site was identified. It might be that the bleeding site in our patient was smaller than required for identification, the more probable explanation is that at the time of angiographical examination there was no bleeding from the site.
Following angiography and blood pool scintigraphy we performed WCE. We visual-ized a bleeding site just before the tumorous formation and concluded it could be an an-giodisplasia. When surgery was performed, besides the tumour, no angiodisplastic lesion was found. During WCE we probably wrong-ly interpreted blood in the lumen as deriving from a »lesion« of the intestinal mucosa, which, revising the WCE images, we conclud-ed could well be an adherent coagulum or just superimposed blood. As we know of, our diagnostic mistake had no repercussions on the patients’ well being.
Aftermath, we reconsidered the diagnostic path we took in view of the diagnostic yield of single diagnostic techniques and their cost. EGDS and colonoscopy were well employed
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in our case as they helped eliminate the regions inspected as possible sites of bleeding and gave ground to suspicion of ongoing bleeding in the small intestine. From here we proceeded to angiography and blood pool scintigraphy, costly techniques, which drew us no nearer to the diagnosis. The cost of WCE is approximately that of angiography alone and in our case it gave the only definitive information, which in consequence led to the cessation of bleeding by removal of the tumour. Therefore, it would have been more cost-effective, if we had performed WCE be-fore employing other techniques.
It has been demonstrated that WCE has many advantages over conventional proce-dures; it produces visual images and has a greater sensitivity in uncovering small bowel disease. It is also safe, easy for the patient, can be repeated many times, it has limited contraindications and a low complication rate. Its limitations are almost as obvious as its advantages; it confers diagnostic potential, but lacks possibilities of tissue sampling and treatment,10 the exact site of the abnormality is not readily determined and it is demanding in view of the time needed to view the pro-duced images.
More experience will be needed in this field, but there are indications that WCE, be-sides being the first small bowel imaging technique, is a very important diagnostic tool, deserving consideration in the early phases of diagnosing small-bowel disease, especially in less intensive, or occult bleeding.
3.   Eli C, Remke S, May A, Helou L, Henrich R, Mayer G. The first prospective controlled trial comparing wireless capsule endoscopy with push en-teroscopy in chronic gastrointestinal bleeding. Endoscopy 2002; 34: 685-9.
4.   Appleyard M, Fireman Z, Glukhovsky A, Jacob H, Shreiver R, Kadirkamanathan S, et al. A random-ized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small bowel lesions. Gastroenterology 2000; 119: 1431-8.
5.   Berner J, Mauer K, Lewis B. Push and sonde en-teroscopy for the diagnosis of obscure gastrointesti-nal bleeding. Am J Gastroenterol 1981; 19: 113-5.
6.   Costamagna G, Shah SK, Riccioni ME, Foschia F, Nutignani M, Perri V, et al. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel dis-ease. Gastroenterology 2002; 123: 999-1005
7.   Maglinte DD, Kelvin FM, O’Connor K, Lapps JC, Chernish SM. Current status of small bowel radi-ography. Abdom Imaging 1996; 21: 247-57.
8.   Lewis BS. Small intestinal bleeding. Gastroenterol Clin North Am 2000; 1: 67-95.
9.   Browder W, Cerise E, Litwin M. Impact of emer-gency angiography in massive lower gastrointesti-nal bleeding. Ann Surg 1986; 204: 530-6.
10. Scapa E, Jacob H, Lewkowicz S, Migdal M, Gat D, Gluckhovski A, et al. Initial experience of wireless capsule endoscopy for evaluating occult gastroin-testinal bleeding and suspected small bowel pathology. Am J Gastroenter 2002; 97: 2776-9.
Reference
1.   Kuwayama H, Iimuro M, Kitazumi Y, Luk G. Virtual endoscopy: current perspectives. J Gastroenterol 2002; 37(Suppl 13): 100-5.
2.   Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature 2000; 405: 417.
Radiol Oncol 2005; 39(3): 193-6.