An unusual cause of iron deficiency anemia
Ken-Sheng Cheng, M.D. 1,2, Tsung-Wei Chen3 Jen-Wei Chou, M.D.1,2 1School of Medicine, China Medical University, Taichung, Taiwan
2Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
3Department of Pathology, China Medical University Hospital, Taichung, Taiwan
Conception and design: Dr. Ken-Sheng Cheng
Analysis and interpretation of the data: Dr. Tsung-Wei Chen
Critical revision of the article for important intellectual content: Dr. Jen-Wei Chou Correspondence and reprint requests to: Dr. Jen-Wei Chou
Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung 40447, Taiwan E-mail: codecol@yahoo.com.tw
Telephone: + 886-4-22052121 Ext. 2220, Fax: +886-4-22023119 No conflicts of interest exists
Keywords: capsule endoscopy, double-balloon enteroscopy, hamartomatous polyp, Peutz-Jeghers syndrome
Question
anemia presented to our hospital because of black stool for 3 days. She was diagnosed having iron deficiency anemia since 10 years ago. Positive occult blood in stool was also found sometimes. She previously underwent esophagogastroduodenoscopy “(EGD) but it was normal. Iron supplement was prescribed to her. Physical examination showed pale conjunctivae but without mucocutaneous pigmentation. Laboratory tests showed a hemoglobin level of 6.5 g/dL. EGD, colonoscopy and abdominal computed tomography-angiography all failed to detect a bleeding lesion. Thus, mid-gastrointestinal (GI) bleeding was suspected. Capsule endoscopy demonstrated some blood clots in the proximal jejunum.
Antegrade double-balloon enteroscopy (DBE) disclosed a pedunculated polyp with nodular and erosive surface, measuring 3 x 1.5 cm in diameter, in the proximal jejunum (Figure A). Moreover, the pedunculated polyp had a long and thick stalk. Close observation by endoscopy revealed the presence of diffusely scattered white spots on the surface of the polyp. What is your diagnosis of this jejunal polyp?
Answer
We decided to resect the polyp endoscopically. Firstly, we applied an endoloop to loop the base of the polyp (Figure B). Secondly, we used two hemoclips to clamp the stalk of the
polyp (Figure C). Finally, we successfully performed a total polypectomy of the polyp by using an electrosurgical snare (Figure D). The histopathological examination of the resected polyp showed composed of dilated glands devoid of atypia, separated by bundles of smooth muscle fibers, which are thick in the center of the lesion and thinner on the periphery, confirming a diagnosis of hamartomatous polyp (Figure E, hematoxylin and eosin; original magnification, × 100).
A solitary Peutz-Jeghers (PJ) type hamartomatous polyp is a rare disease in the GI tract, mostly in the stomach and the duodenum [1]. It is usually considered to be either a variant of PJ syndrome or a separate entity [1]. A few reports have described its endoscopic features, an irregularly lobular or nodular surface, whereas adenomas often show a regularly nodular or granular surface [2]. Because of the malignant potential, a solitary PJ-type hamartomatous polyp should be removed endoscopically or surgically [3]. To our knowledge, this is the first case of jejunal solitary PJ type hamartomatous polyp treated with endoscopic polypectomy using DBE.
References
1. Jamaludin AZ , Telisinghe PU, Yapp SK, et al. Solitary duodenal hamartomatous polyp with malignant transformation: report of a case. Surg Today 2009;39:527-532.
hamartomatous polyp in the duodenum. World J Gastroenterol 2008;14:944-947.
3. Chen YY, Chen TS, Chen YF. Asymptomatic Multiple Gastric and Duodenal Tumors. Gastroenterology 2013; 145: e7-e8.
