Jejunal adenocarcinoma in an elderly presenting as obscure overt gastrointestinal bleeding
Introduction: Small intestine malignancies are rare comprising only 2% of gastrointestinal tumors. The jejunum is an uncommon location of small intestine adenocarcinoma since most are located in the duodenum.
Presentation of Case: A 60-year old man with no known co-morbidities presented with recurrent intermittent melena for two years. Repeated esophagogastroscopy and colonoscopy were not able to identify the source of the bleed. Abdominal CT scan showed wall thickening with focal nodularity at the jejunum, which may be caused by inflammatory reactions or vascular lesion. To rule out neoplasm, capsule endoscopy was done using SB Pillcam which showed a polypoid lesion at the proximal jejenum. Antegrade enteroscopy confirmed an obstructing polypoid mass. Biopsy revealed fragments of tubular adenoma with focal high grade dysplasia. The patient underwent surgical resection and final histopathologic results showed a well-differentiated adenocarcinoma at the jejunum with invasion up to the muscularis layer, and tubular adenoma with high grade dysplasia.
Discussion: Small bowel pathology is a major consideration when presented with obscure GI bleeding.The advent of capsule endoscopy and enteroscopy among other new modalities revolutionized how the small intestines are investigated.Capsule endoscopy provides small bowel visualization through noninvasive wireless video recording and has high diagnostic yield if bleeding is recent and overt. However, it cannot precisely locate the lesion and provide therapy. Enteroscopy is an endoscopic evaluation of the small bowel, used hand in hand with capsule endoscopy as it provides benefit of therapeutic intervention and tissue sampling.
Conclusion: Advancing technology in visualization of the gastrotinestinal tract to look for sources of bleeding and tumors is helpful in diagnosing obscure gastrointestinal bleeding from uncommon sites of malignancies. In this case, capsule endoscopy and enteroscopy provided the definitive diagnosis for the surgical management of the patient.