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UTILITY OF CAPSULE ENDOSCOPY TO DIAGNOSE INTESTINAL LYMPHANGIECTASIA IN LONGSTANDING MALABSORPTION
F Costea, EG Seidman
GI Division, McGill University Health Centre, Montreal
BACKGROUND: Primary intestinal lymphangiectasia (PIL) is a congenital disorder of the lymphatic system characterized by dilated and tortuous intestinal wall and mesenteric lymphatics. This condition, characterized by leakage of protein-rich chyle into the intestinal lumen, leads to clinical malabsorption (protein-losing enteropathy (PLE), hypoalbuminemia, and edema). The diagnostic accuracy of imaging techniques is generally unrewarding, either by endoscopic or radiological methods. Videocapsule endoscopy (VCE) can explore the entire small bowel mucosa, potentially increasing the diagnostic yield.
AIM: To document the accuracy of VCE to diagnose primary intestinal lymphangiectasia as a cause of longstanding idiopathic malabsorption.
PATIENTS: We present 3 cases of ‘idiopathic’ malabsorption, where only VCE led to a diagnosis of PIL. 1) 65 yr old man referred for a 2 decade history of chronic diarrhea and malabsorption, dependent on home TPN, with peripheral edema secondary to hypoalbuminemia. All previous investigations were negative, including endoscopic biopsies (gastroscopy and push enteroscopy) and small bowel imaging (barium, CT, MRI, and lymphoscintigraphy); 2) 37 yr old man referred for 1 decade history of chronic diarrhea and malabsorption, dependent on home TPN; PLE was documented by high stool alpha-1 antitrypsin. All previous investigations were negative (as per case # 1). Full thickness biopsies of the small bowel were suspicious for a lymphangiectasic syndrome. 3) A 3 yr old male was referred for evaluation of dyspnea and anasarca, with pleural effusions (transudates) and chylous ascites refractory to medical management. PLE was documented by high stool alpha-1 antitrypsin. No lymphedema, limb abnormalities or dysmorphic features were noted. All previous investigations were negative (as per case 1), including full thickness small bowel biopsies and histology of the liver and abdominal lymph nodes
METHODS & RESULTS: VCE was carried out after an overnight fast; bowel prep and prokinetics was administered to the adults. For case 3, the capsule was inserted in the duodenum endoscopically after a “lipid meal” (15 ml/m2 20% cream). In all cases, the capsule revealed florid lymphangiectasia involving the entire small bowel. VCE in a healthy control 10 yr old child after a “lipid meal” was entirely normal.
CONCLUSION: VCE is very promising for the diagnosis of PIL. It is potentially useful to guide management (surgery) by documenting the extent of disease.
Disclaimer: EGS is a consultant for Given Imaging Inc