Introduction: Since its introduction by Yamamoto et al. in 2001, double balloon enteroscopy (DBE) has been demonstrated to have important advantages when compared to push enteroscopy. DBE has the potential to access the entire length of small bowel if performed by both routes, and the equipment used during the procedure allows for therapeutic interventions along the length of visualized bowel. We present a case where DBE was instrumental in diagnosing a jejunal ulceration in a patient who initially presented with gallstone pancreatitis.
Case Report: A 25 year-old male complained of upper abdominal discomfort and was subsequently diagnosed with gallstone pancreatitis. He then underwent laparoscopic cholecystectomy, which was converted to open cholecystectomy on account of reported inflammation around the gall bladder and stomach. The patient’s abdominal discomfort was not resolved with the surgery, and he developed diarrhea. It was at this point in time that the patient was referred to our care. An abdominal CT was performed to further evaluate the source of his discomfort, and it showed a loop of dilated small bowel in the proximal jejunum that had become inflamed. A push enteroscopy was performed, but it was unable to reach the portion of the jejunum in question. Then, a capsule enteroscopy showed abnormal mucosa and a DBE demonstrated circumferential ulceration at 190 cm distal to the pylorus. A colonoscopy was also performed to rule out Crohn’s disease. It was not present; however, varices in the area of the hepatic flexure were observed during the procedure. The patient then underwent MRA/MRV of his mesenteric vasculature because of the aforementioned varices and family history of hypercoagulability. While he had a patent arterial circulation, it was also shown that he had an occluded superior mesenteric vein (SMV) suggesting that the jejunal ulceration was a direct result of the occluded SMV. The patient was then started on Lovenox and approximately one week later had laparoscopic resection of his small bowel lesion along with laparoscopic lysis of adhesions.
Conclusion: This case illustrates how an uncommon jejunal mucosal ulceration can result from SMV thrombosis, which is a relatively infrequent complication of gallstone pancreatitis. It also demonstrates the utility of DBE in accessing increased lengths of the small bowel. For this patient, push enteroscopy was not able to reach the jejunal lesion; however, DBE provided an alternative to aid in the diagnosis and characterization of the small bowel lesion.
Program Number: P297