Jejunojejunal intussusception after polypectomy by spiral enteroscopy in Peutz–Jeghers syndrome

Enteroscopy makes it possible to resect small-bowel polyps and avoid intestinal obstruction in patients with Peutz–Jeghers syndrome [1]. We report the case of a 54-year-old man with Peutz–Jeghers syndrome, referred to our center because of recurrent episodes of intestinal occlusion.

Computed tomography showed a voluminous polyp in the proximal part of the jejunum causing small-bowel obstruction. While the patient was under general anesthesia, we performed a spiral enteroscopy (enteroscope EN-450T5; Fujifilm, Saitama, Japan) with good and fast progress until we reached the proximal part of the jejunum, where the polyp occupied the entire digestive lumen ([Fig. 1 a, b]). A snare with Endocut current was used to resect the polyp after the submucosal injection of saline with 1:10 000 diluted epinephrine ([Video 1]). We did not use clips before the resection because the large, short foot of the polyp did not allow them to be placed.

Fig. 1 Large jejunal polyp in a 54-year-old patient with Peutz–Jeghers syndrome and recurrent episodes of intestinal occlusion. a The head of the polyp (arrow). b The large foot of the polyp (arrow).

The steps of the endoscopic mucosectomy, from identification to resection.

Moderate acute bleeding after the resection was stopped with epinephrine injection, and further bleeding was treated with four hemostatic clips (Resolution Clip; Boston Scientific, Natick, Massachusetts, USA) ([Fig. 2]). The hemoglobin levels were normal thereafter.

Fig. 2 Moderate acute bleeding after polyp resection was treated immediately with epinephrine injection, then the application of four hemostatic clips.

After 24 hours, the patient had fever and leukocytosis (12 000/mm³) without abdominal pain or vomiting. Abdominal computed tomography showed a jejunojejunal intussusception upstream of an area of edema of the intestinal wall ([Fig. 3]). The results of bacteriological sampling were negative. The patient received an intravenous antibiotic for 3 days (3 g of cefotaxime per day). He recovered quickly without any endoscopic treatment and was discharged after 3 days.

Fig. 3 Abdominal computed tomography shows a jejunojejunal intussusception (arrow) upstream of an area of intestinal wall edema.

The advent of enteroscopy has improved our ability to conduct deep exploration of the small bowel and to resect voluminous polyps [2]. Peutz–Jeghers syndrome is a hereditary disorder characterized by areas of mucocutaneous pigmentation and hamartomatous polyps, mainly in the small bowel. Endoscopic polypectomy can prevent the complications of Peutz–Jeghers syndrome, such as intestinal obstruction, avoiding the need for repeated laparotomies. Therapeutic double-balloon enteroscopy is associated with a 1 % to 5 % rate of complications, mainly bowel perforation, bleeding, and pancreatitis [3].

This is the first report of the spontaneous resolution of a jejunojejunal intussusception due to edema of the intestinal wall after polypectomy during spiral enteroscopy.

Endoscopy_UCTN_Code_CPL_1AI_2AD

 

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Competing interests: None

• References

• 1 Gorospe EC, Alexander JA, Bruining DH et al. Performance of double-balloon enteroscopy for the management of small bowel polyps in hamartomatous polyposis syndromes. J Gastroenterol Hepatol 2013; 28: 268-273
• 2 Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53: 216-220
• 3 Moschler O, May A, Muller MK et al. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy 2011; 43: 484-489