St. Elizabeth's Medical Center, Tufts University School of Medicine Brighton, Massachusetts
Introduction: Intestinal melanoma is a rare entity arising either from metastatic depositions or from primary mucosal involvement. Intestinal melanoma presenting as small bowel intussusception is exceedingly rare. Reported cases in the literature have been primarily managed surgically. We present a case of jejuno-jejunal intussusception due to intestinal melanoma successfully diagnosed and reduced with deep enteroscopy
Case Description/Methods: A 45-year-old man with history of chronic hepatitis B who presented with acute left upper quadrant abdominal pain, nausea, and vomiting. Review of systems was positive for one month of constipation, dark stool, and fatigue. Laboratory data were unremarkable apart from a mild iron deficiency anemia. CT scan of the chest, abdomen and pelvis revealed two large left upper lobe lung masses with ipsilateral mediastinal lymphadenopathy and pleural effusion, and a jejuno-jejunal intussusception with upstream dilation of the small intestine and stomach.
Instead of surgery, it was opted to pursue deep enteroscopy for possible diagnosis and therapy. Utilizing an enteroscope, the jejuno-jejunal intussusception was reached, which initially demonstrated a severely narrowed lumen with normal tissue [figure A]. The area was eventually traversed and undone revealing a large, ulcerated, hyper-pigmented mass [figure B], which was biopsied. Tissue immunohistochemical staining was positive for S100 protein and Sox10 establishing a diagnosis of melanoma [figure C].
Patient had significant symptomatic improvement after the procedure. A full skin and eye exam was normal. PET scan showed an extensive extra-nodal metastatic tumor burden. After a multidisciplinary discussion, the decision was made to proceed with medical therapy utilizing immunotherapy. Surgical management was going to be based on treatment response. Unfortunately, the disease progressed quickly prior to treatment and patient died due to complications of post-obstructive pneumonia
Discussion: This report of primary intestinal melanoma resulting in jejuno-jejunal intussusception describes a novel approach utilizing deep enteroscopy to diagnose and decompress intestinal intussusception. In the right patient population, this approach can have multiple added benefits including avoidance of emergency surgery, symptomatic relief, and reducing the extent of intestinal resection. More research is needed to determine if deep enteroscopy should be added to the treatment algorithm for adult intestinal intussusception
