A 73-year-old woman was referred to our tertiary care center for evaluation of occult gastrointestinal bleeding. After an unrevealing esophagogastroduodenoscopy and colonoscopy, wireless capsule endoscopy findings described as inflammatory nodules in the ileum were confirmed with computed tomography (CT) enterography. Repeat colonoscopy with deep ileal intubation was performed, but these nodules were not seen. Six months later, because of persistent anemia, a repeat CT identified a 2-cm polypoid mass in the distal ileum (Figure A).
We performed a retrograde single-balloon enteroscopy (SBE) (Olympus SIF-Q180 enteroscope with silicone overtube [ST-SB1]; Olympus America, Inc, Center Valley, PA), and a large, pedunculated, nonbleeding polyp was identified in the distal ileum (Figure B), approximately 25 to 30 cm from the ileocecal valve. Snare cautery polypectomy was performed with complete resection of the polyp.
Gross pathologic examination showed a pink–tan, focally lobulated, pedunculated polyp on a stalk with a large central core of white fibrous tissue containing at least one cystic space filled with clear fluid. Histologic examination showed proliferation of stromal cells with onion-skin arrangement around blood vessels and crypts (Figure C), accompanied by a marked inflammatory infiltrate including prominent eosinophils and plasma cells, consistent with the diagnosis of inflammatory fibroid polyp (IFP).
Discussion
IFPs are benign lesions arising from the submucosa of the gastrointestinal tract. Originally described as a gastric submucosal granuloma with eosinophilic infiltrate, Helwig and Ranier1 introduced the more common present nomenclature. The peak incidence of IFPs is in the sixth or seventh decade of life, symptoms are variable, and once removed the lesions rarely recur.2 The anatomic distribution of IFPs was described in a series of 89 cases, and only 18% were in the small intestine. Small intestinal IFPs can cause obstruction and intussusception, which requires surgery. While there have been several cases of endoscopic resection of gastric and colonic IFPs; we report an endoscopic removal of an ileal IFP.
Balloon-assisted enteroscopy (double- or single-balloon) is a tool for therapeutic intervention in the small intestine. It is especially useful to endoscopically evaluate abnormal findings on wireless capsule endoscopy. In addition, balloon-assisted enteroscopy can be used as a therapeutic and diagnostic complement to newer radiologic examinations such as CT or magnetic resonance enterography.
Miyata et al3 used double-balloon enteroscopy in the preoperative diagnostic work-up of a patient with an IFP of the ileum. The investigators used double-balloon enteroscopy to shorten a small intestinal intussusception and biopsy the mass that caused the intussusception. Laparoscopic surgery then was performed, rather than an open exploration.
In our case, we used retrograde SBE to access a lesion in the distal small intestine causing persistent anemia. We were fortunate to have serial CT enterographs showing an increase in size of the mass that could not be reached by standard colonoscopy. SBE allowed us to reach the lesion and endoscopically resect it.
With the advent of newer endoscopic technology, gastroenterologists are able to access deeper portions of the small intestine, which is vital in an era in which both wireless capsule endoscopy and more detailed radiologic examinations exist. Balloon-assisted enteroscopy provides a means to diagnose and treat lesions of the small intestine that previously required surgical management.
References
1. 1Helwig EB, Ranier A. Inflammatory fibroid polyps of the stomach. Surg Gynecol Obstet. 1953;96:335–367. MEDLINE
2. 2Johnstone JM, Morson BC. Inflammatory fibroid polyp of the gastrointestinal tract. Histopathology. 1978;2:349–361. MEDLINE |
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3. 3Miyata T, Yamamoto H, Kita H, et al.A case of inflammatory fibroid polyp causing small-bowel intussusception in which retrograde double-balloon enteroscopy was useful for the preoperative diagnosis. Endoscopy. 2004;36:344–347.
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⁎Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
‡Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
Conflicts of interest The authors disclose no conflicts.
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