Diagnosis of a Germ Cell Tumor by Capsule Endoscopy: 779

Purpose: A 32 year old male with no significant past medical history presented with a 3 day history of dyspnea, left-sided pleuritic chest pain and 2 weeks of melena. He denied abdominal pain, nausea, vomiting, cough, fevers and hemoptysis. He was on no medications and did not have a family history of GI malignancies. Physical exam revealed prominent sinus tachycardia with a rate in the 120s and significant conjunctival pallor. Initial laboratory studies revealed a hemoglobin of 4.9, mcv 72, hematocrit of 14%, and platelets of 550,000. Initial CXR revealed multiple nodules throughout both lung fields. After volume resuscitation an EGD was performed but was non diagnostic. Capsule endoscopy identified the bleeding source in the proximal jejunum within an area of ulceration and stenosis. Push enteroscopy exposed two large, 2–4 cm ulcerated mass lesions 40 cm distal to the pylorus. Multiple biopsies were obtained and pathological analysis was consistent with metastatic choriocarcinoma. CT scans of the head, chest, abdomen, and pelvis revealed multiple metastatic lesions within the brain, lungs, liver, spleen and bilateral kidneys. The patient was started on aggressive chemotherapy and in the immediate follow up period the patient has done well and has had no recurrence of GI bleeding. Capsule endoscopy has rapidly emerged as an effective, non-invasive modality for detecting obscure GI bleeding. A recent study revealed that capsule endoscopy was able to detect small bowel pathology in 82% of patients with GI bleeding of unknown etiology with prior negative results for colonoscopy, EGD, small bowel series, and even angiography. Specifically, it was able to accurately identify small bowel angiodysplasias, polyps, carcinoid tumors, Crohn's disease and metastatic melanomas. Its potential use for early recognition of small bowel tumors is of the utmost importance. As seen in this case, caspsule endoscopy was able to detect a case of previously undiagnosed metastatic germ cell tumor. Only 5% of germ cell tumors (usually embryonal and choriocarcinoma) involve the GI tract. Jejunal involvement is exceedingly rare as around 95% of cases are found within the duodenum. The majority of cases are metastatic upon initial diagnosis and thus confer a relatively poor prognosis. The major complications include intestinal obstruction, bleeding and perforation.