Patients presenting with maelena require prompt investigation to discover the source bleeding. Upper and lower gastrointestinal endoscopy often identifies the cause. However, these methods fail to adequately interrogate the small bowel. Rarely metastatic malignancy can affect the small bowel. We present a case where the use of capsule endoscopy was able to identify the cause of blood loss from lung adenocarcinoma metastatic to the small bowel.
A 78 year old woman presented with a two week history of melena. She was a former smoker with a twenty pack year history. Laboratory results showed a hypochromic microcytic anaemia with a haemoglobin of 82g/L. No bleeding was found on endoscopy to the duodenum. At colonoscopy an isolated mass was removed from the descending colon, with histology confirming KRAS mutant lung adenocarcinoma.
Fluoro-deoxyglucose positron emission topography showed several sites of metastatic disease, and was reported as showing physiological uptake in the bowel. Due to ongoing maelena and transfusion requirements a capsule endoscopy was performed. This revealed over 50 ulcerated, friable, exophytic lesions that were actively bleeding throughout the small bowel consistent with metastatic deposits. The patient declined cytotoxic chemotherapy and pursued self-funded immunotherapy. Supportive transfusions were used for symptomatic control, but definitive intervention was not possible. The patient died from progression of central nervous system metastases one month after diagnosis.
The spread of metastatic malignancy to the small bowel is rare. In this case capsule endoscopy proved very useful. It was able to confirm the clinically suspected site of blood loss as well as defining the magnitude of the problem. The degree of involvement was not initially suspected on the basis of the imaging findings. Understanding the magnitude of the problem allowed a frank and honest discussion about the options for and difficulties of management in this patients’ care.