Vnitřní lékařství 7/2020

CASE REPORT Small bowel adenocarcinoma diagnosed by video capsule endoscopy in a patient with celiac disease: a case report and review of literature E40 | VNITŘNÍ LÉKAŘSTVÍ / Vnitř Lék 2020; 66(7): e39–e42 /  www.casopisvnitrnilekarstvi.cz faktorům byla zahájena adjuvantní chemoterapie. Znalost maligních komplikací celiakie, jejich rizikových faktorů a možno- sti využití moderních enteroskopických metod může přispět k časné diagnostice a zlepšení prognózy těchto onemocnění. Vzhledem k nedostatku dat a absenci doporučených postupů se léčba adenokarcinomu tenkého střeva řídí názory expertů a doporučenými postupy léčby kolorektálního karcinomu. Chirurgická resekce je jediná potenciálně kurativní léčba. U stádia II s rizikovými faktory a stádia III by měla být zvážena adjuvantní chemoterapie. Klíčová slova: adenokarcinom, celiakie, chirurgie, video kapslová endoskopie, tenké střevo. Introduction Celiac disease (CD) is a chronic multiorgan autoimmune disease triggered by exposure to gluten in genetically predisposed individuals (1). Patients with CD are at a higher risk of malignant complications such as malignant lymphoma, small bowel adenocarcinoma and others (2). Diagnosis of these complications at an advanced stage is one of the factors of their unfavorable prognosis. The use of modern enteroscopic methods such as video capsule endoscopy (VCE) or double balloon enteroscopy has been helpful in the diagnosis of small intestinal ma- lignancies during recent years (3, 4). Due to rarity of these diagnoses there is a lack of a standardized therapeutic approach. Case report Our patient is a woman who was diagnosed with CD at 53 years of age. She was initially asymptomatic, with Sjögren syndrome in her past medical history and a positive family history of CD in her daughter. We performed targeted screening, according to recommendations (5), which showed a positivity of specific autoantibodies anti-tissue tran- sglutaminase (anti-TTG) in IgA and anti-deaminated gliadin peptides (anti-DGP) in IgA and IgG. A biopsy of the distal duodenum showed villous atrophy Marsh 3b according to the Marsh-Oberhuber classifi- cation. No anemia was detected at the time of the diagnosis of CD (hemoglobin 125g/L, MCV 88 fL, ferritin 41.4μg/L). The patient started a strict gluten-free diet and was in stable condition, without any signs of malnutrition during the follow-up visits. Anti-TTG IgA and anti-DGP IgA decreased to normal levels in seven months with a slight persistent positivity of anti-DGP IgG. After two years on a gluten-free diet the patient started to suffer from artralgies, for which prednisolone, hydroxychloroquine and non- -steroid-anti-inflammatory drugs were prescribed. She experienced slight intermittent epigastric pain and one episode of black stool. c) Fig. 1. VCE showing malignant tumor of the small bowel (a, b), with apparent bleeding (c) a) b)