We investigated 20 patients (10 males and 10 females, mean age 55,8 years, range of age 34–80 years) who had gastrointestinal symptoms and the main indications for performing a SBE were anaemia with or without a positive Faecal Occulted Blood Test (FOBT) (45%), a small bowel thickening at the computer tomography (CT) scan (20%), abdominal pain with diarrhoea (20%), follow-up for a non-Hodgkin lymphoma involving small bowell (5%) and for celiac disease non responder(5%) and a suspected upper small bowel involvement in Crohn’s disease contest (5%).
Of these 20, 17 patients did VCE before SBE which highlighted different type of lesions: submucosal lesions (41%), neoformations involving mucosa (23%) of which three were ulcerated and one was a polypoid lesion, a jejunum/ileum oedema (12%), multiple erosions of jejunum and ileum (6%), a distal ileum scar (6%) and non conclusive alterations (12%).
All patients received SBE which detect lesions in 14 of the cases, we found: submucosal jejunal neoformations (36%), ulcerated neoformations in the proximal jejunum (29%) of which one was red volcano shaped covered by fibrin and hemosiderin, localised mucosal oedema in jejunum or ileus (14%), a polypoid lesion with ulcer in the distal jejunum (7%), a sub-stenosis (7%) and a distal scar (7%). In 6 patients, the SBE did not highlight pathological finding.
In all cases EUS with miniprobe “UM-3Y” was performed using the enteroscope instrumental port for a better characterization of the small bowel lesions.
For instance, we described the submucosal jejunal neoformations with EUS: two of them were homogeneous hypoechoic nodules histologically compatible with neuroendocrine tumours, the other two were echoic formations surrounded by a hyperechoic capsule consistent with cysts and the last one turned out to be normal mucosal fold with a well-preserved layer structure.
Moreover, mucosal ulcerated neoformations in the proximal jejunum has all been described as non-homogeneous hypoechoic neoformations by EUS and the histological analysis revealed a gastrointestinal stromal tumour (GIST – Fig. 2), one intestinal adenocarcinoma, one low differentiated adenocarcinoma and a Kaposi’s sarcoma on an HIV-positive patient. Considering the two localized mucosal oedema detected by SBE, one of them was described as a hypoechoic thickening of both mucosa and submucosa layer by EUS and histologically was a Non-Hodgkin Lymphoma, while the other oedematous lesion had no pathological sonographically findings but histologically turned out to be an eosinophilic ileitis. Finally, the polyp appeared as an anechoic area made by mucosa and submucosa via EUS and histologically was a hamartomatous polyp. In all the other cases, EUS examination and histological analysis did not report pathological aspects.
All the findings are summarized in Table 1.
Table 1: Clinical Characteristic of patients according with clinical question, video-capsule endoscopy (VCE), single balloon enteroscopy (SBE), EUS UM-3Y miniprobe analysis and histological result. NET = Neuroendocrine Tumor; GIST = Gastrointestinal Stromal Tumor; FU = follow up; NHL = Non-Hodgkin Lymphoma; FOBT = Fecal Occulted Blood Test; CT scan = Computed Tomography scan.
ID
|
Age
|
Sex
|
Indication
|
VCE
|
SBE
|
EUS UM-3Y miniprobe
|
Histology
|
1
|
80
|
F
|
Jejunal submucosal neoformation
(CT scan)
|
Jejunal submucosal neoformation
|
Jejunal submucosal neoformation
|
Submucosal
Homogeneous
hypoechoic nodule
|
NET
|
2
|
68
|
F
|
Anemia and FOBT+
|
Proximal ileum submucosal 3 neoformations
|
Jejunal submucosal neoformation
|
Submucosal
Homogeneous
hypoechoic nodule
|
NET
|
3
|
49
|
M
|
Anaemia
|
Jejunal submucosal neoformation
|
Jejunal submucosal neoformation
|
Submucosal
anechoic
hypoechoic oval formation
(Simple cyst)
|
Not performed
|
4
|
51
|
F
|
Crohn's disease
|
Proximal jejunum submucosal formation
|
Proximal jejunum submucosal formation
|
Submucosal
anechoic oval formation (Simple cyst)
|
Not performed
|
5
|
61
|
M
|
Anaemia
|
Proximal jejunum submucosal neoformation
|
Submucosal neoformation
|
No alterations
|
No alterations
|
6
|
55
|
F
|
Anaemia and FOBT+
|
Proximal jejunum ulcerated neoformation
|
Proximal jejunum ulcerated neoformation
|
Non-homogeneous hypoechoic neoformation arises from 3rd and 4th layer
|
GIST
|
7
|
66
|
F
|
Anaemia and FOBT+
|
Proximal jejunum neoformation
|
Proximal jejunum ulcerated neoformation
|
Non-homogeneous hypoechoic neoformation of all the layers
|
Intestinal adenocarcinoma
|
8
|
71
|
F
|
Anaemia
|
Jejunal and ileal multiple lacerations
|
Proximal jejunum ulcerated neoformation
|
Non-homogeneous hypoechoic neoformation of all the layers
|
Low differentiated adenocarcinoma
|
9
|
34
|
M
|
Diarrhea in HIV
|
Jejunal red volcano-shaped neoformations
|
Jejunal red volcano-shaped neoformation covered by fibrin and hemosiderin
|
Mucosal and submucosal non-homogeneous hypoechoic neoformation
|
Kaposi’s sarcoma
|
10
|
57
|
M
|
Jejunal loops thickening (CT scan)
|
Not performed
|
Edematous jejunal mucosa
|
Mucosal and submucosal hypoechoic thickening
|
NHL
|
11
|
64
|
M
|
Diarrhea
|
Distal jejunum and ileal edema
|
Ileal and proximal jejunum mucosa oedema
|
No alterations
|
Eosinophilic ileitis
|
12
|
46
|
F
|
Anaemia
|
Polypoid neoformation of distal jejunum
|
Polypoid neoformation with ulcer
|
Mucosal and submucosal anechoic areas
|
Hamartomatous polyp
|
13
|
52
|
M
|
Anaemia and FOBT+
|
Distal ileum scar of small polyp
|
Distal ileum scar
|
No alterations
|
No alterations
|
14
|
51
|
F
|
Jejunal wall thickening (CT scan)
|
Not performed
|
Sub-stenosis and lumen dilation
|
No alterations
|
No alterations
|
15
|
50
|
M
|
Jejunal loops dilations (CT scan)
|
No alterations
|
No alterations
|
No alterations
|
No alterations
|
16
|
45
|
F
|
Anaemia
|
Ileum
submucosal neoformation
|
No alterations
|
No alterations
|
No alterations
|
17
|
67
|
F
|
Chronic diarrhea
|
Not alterations
|
No alterations
|
No alterations
|
No alterations
|
18
|
48
|
M
|
FU in celiac disease
|
Proximal
jejunum edema
|
No alterations
|
No alterations
|
No alterations
|
19
|
67
|
M
|
FU NHL
|
Not performed
|
No alterations
|
No alterations
|
No alterations
|
20
|
34
|
M
|
Diarrhea and abdominal pain
|
Proximal jejunum submucosal neoformation
|
No alterations
|
No alterations
|
No alterations
|
Surgery was performed in the event of malignant disease; the post-operative histology confirms the endoscopic evidence. While the hamartomatous polyp was successfully removed during SBE. Follow-up was performed closely, and no recurrence occurred after surgery.