Indigo carmine chromoendoscopic appearances of enteropathy-associated T-cell lymphoma during double-balloon endoscopy in a patient with celiac disease

Patients with celiac disease have a 28-fold increased risk of developing enteropathy-associated T-cell lymphoma compared with the general population [ 1 ]. Early diagnosis is therefore required to improve their prospects. Indigo carmine chromoendoscopy highlights mucosal irregularities and improves the detection of malignant lesions [ 2 ]. Furthermore, it can delineate villous atrophy in celiac disease [ 3 ]. This method is commonly used in upper and lower gastrointestinal endoscopy but this is not yet the case in small-intestinal endoscopy. In this report we describe the chromoendoscopic appearances of jejunal enteropathy-associated T-cell lymphoma, before and after indigo carmine spraying, in a patient who was undergoing a double-balloon endoscopy procedure. A 68-year-old Caucasian woman with celiac disease who had been on a gluten-free diet for 3 years was referred for double-balloon endoscopy because an abdominal computed tomography scan had shown thickened small-intestinal wall. Endoscopy was performed with a double-balloon endoscopy system (FMH Medical Inc., Veenendaal, The Netherlands). Using a catheter, 10 mL of a 0.1 % solution of indigo carmine was sprayed onto the jejunal mucosa on withdrawal of the endoscope. Scalloping or loss of folds, a mosaic appearance of the jejunal mucosa, and round or circumferential ulcers (10 - 90 mm along their longitudinal axis) were detected with standard video endoscopy, but the villi were easier to recognize after indigo carmine staining of scalloped jejunal folds ([ Figure 1 ]) and ulcers were also highlighted ([ Figure 2 ], [ 3 ]). Histological examination revealed the presence of enteropathy-associated T-cell lymphoma in biopsies taken from the ulcers and partial to subtotal villous atrophy in the nonulcerated mucosa. Figure 1 Endoscopic views of scalloped jejunal folds in a patient with celiac disease before dye staining ( a ) and after spraying with 0.1 % indigo carmine solution ( b ). Figure 2 Endoscopic views of a round jejunal ulcer in a patient with celiac disease and enteropathy-associated T-cell lymphoma before dye staining ( a ) and after spraying with 0.1 % indigo carmine solution ( b ). Figure 3 Chromoendoscopic views of circumferential jejunal ulcers in a patient with celiac disease which were proved histologically to contain enteropathy-associated T-cell lymphoma (0.1 % indigo carmine dye) ( a, b ). In comparison with standard endoscopy, indigo carmine chromoendoscopy highlighted areas of villous atrophy [ 4 ] and ulcers, but did not add to the visual determination of other abnormalities such as scalloping, loss of folds, or the typical mosaic pattern [ 5 ]. The innovative double-balloon endoscopy method is allowing the use of such techniques in deeply located lesions that are not usually accessible by standard endoscopy. Chromoendoscopy appears to be a suitable technique for examining suspicious areas during small-intestinal endoscopy.