Small Bowel-UPPER SINGLE BALLOON ASSISTED ENTEROSCOPY WITH ENDOSCOPIC MUCOSAL RESECTION OF A BLEEDING JEJUNAL LYMPHANGIOMA

Video Transcription

Single-balloon-assisted enteroscopy with EMR of a bleeding jejunal lymphangioma.  The authors do not have any disclosures.  A healthy 75-year-old male was found to have a new-onset normalcytic anemia during a routine examination. His baseline hemoglobin a year prior was 15 grams per deciliter.  Now it is 12.9. He denied any bloody or black stools. He denied any weight loss. Initial EGD and colonoscopy at another hospital were normal.  Over subsequent months, he developed fatigue and weakness. Repeat tests revealed a worsening microcytic anemia with hemoglobin of 8.5 grams per deciliter,  mean corpuscular volume of 77.1 femtoliter, and an iron deficiency with ferritin of 6 nanograms per milliliter. Screening for celiac disease was negative.  This prompted further evaluation with video capsule endoscopy.  A submucosal polyploid lesion with a white and red speckled surface is captured in one single image, approximately 25% of the small bowel transit time.  Fresh blood is noted just distal to this lesion.  An upper single-balloon assisted enteroscopy localizes a 12-millimeter, white speckled, bleeding sessile polyp in the proximal jejunum.  Hetastarch and epinephrine stained with methylene blue is injected at the base of the polyp in the submucosa.  The post-polypectomy site is inspected and to reduce the risk of delayed bleeding, the resection site is closed with two hemostatic clips.  Two carbon black tattoos are placed proximal to the resection site to aid in future identification of the site.  The polyp was retrieved in its entirety. Pathology reveals dilated lymphatic vessels in the lamina propria consistent with a lymphangioma.  Lymphangiomas are rare tumors with less than 1% found in the jejunum or ilium.  Localization of the lesion in the small bowel is technically difficult and video capsule endoscopy can be a useful tool.  Surgical resection is the typical standard for management of symptomatic jejunal or ileal lymphangiomas.  However, endoscopic treatment via balloon-assisted enteroscopy can be successful.  Our case demonstrates successful identification of occult bleeding of small bowel ideology with video capsule endoscopy.  Endoscopic resection of lymphangiomas is technically feasible with experienced endoscopists.

Video Summary

The video discusses the case of a 75-year-old male who presented with new-onset anemia and subsequent fatigue and weakness. Initial tests were normal, but further evaluation with video capsule endoscopy revealed a submucosal polyploid lesion in the jejunum, causing bleeding. The lesion was successfully treated through single-balloon-assisted enteroscopy, involving injection of hetastarch and epinephrine, closure with hemostatic clips, and placement of tattoos for future identification. Pathology confirmed a jejunal lymphangioma, a rare tumor. The video highlights the usefulness of video capsule endoscopy in identifying occult bleeding in the small bowel and the technical feasibility of endoscopic resection in experienced hands. No disclosures were given.

Asset Subtitle

Honorable Mention

Keywords

anemia

video capsule endoscopy

bleeding

jejunal lymphangioma

occult bleeding