Small Bowel Metastatic Melanoma: An Emblematic “Coal-Black” Appearance at Videocapsule Endoscopy

A 80-year-old woman underwent vulvar melanoma resection and segmental lung resection for pulmonary metastasis. Immunotherapy with Nivolumab was performed. One year later, the patient was admitted for gastrointestinal (GI) recurrent bleeding and severe anemia. Esophagoastroduodenoscopy and colonoscopy did not show any abnormality, while videocapsule endoscopy (VCE) revealed an irregular and exophytic whitish area with a “coal-black” central depression. Small bowel resection was performed and histological examination revealed S100 protein strongly positive melanoma metastasis. The patient died six months later from disease progression. A “coal-black” appearance of intestinal metastatic melanoma has been described only twice before this report. In one case the patient had been treated by immunotherapy with interferon A and dendritic cell-based vaccination. In our patient, it is presumable that the picture we observed was a consequence of Nivolumab treatment inducing the disappearance of melanocytes in the area surrounding the metastasis with the onset of the central coal-black lesion encircled by whitish tissue. This picture should be emblematic of intestinal metastatic melanoma in subjects treated with immunotherapy showing occult/obscure bleeding.

Upper gastrointestinal endoscopy

Endoscopy is the procedure of choice in patients with retrosternal or upper abdominal symptoms who require investigation, and is essential in significant gastrointestinal bleeding to identify and—in most cases—treat the cause, with various therapeutic methods possible for erosions, ulcers, and oesophageal varices. More recent developments in the practice of upper gastrointestinal endoscopy include the use of enteroscopy for direct vision of the small bowel, video capsule endoscopy for diagnosis of obscure bleeding lesions, and an expanding range of minimally invasive therapeutic techniques. Endoscopic retrograde cholangiopancreatography is the standard of care for the removal of gallstones from the common bile duct, and palliating obstructing pancreatobiliary tumours.

CROSSING POINT IN THE MANAGEMENT ALGORITHM OF ACUTE LOWER GASTROINTESTINAL BLEEDING – CASE REPORTS AND LITERATURE REVIEW

Acute lower gastrointestinal bleeding is a significant problem, a rare and life threatening situation, that has a mortality rate situated between 2 and 4% (1). According to recent studies up to 15% of them present as massive bleeding and 5% require surgery (2). Acute lower gastrointestinal bleeding can be divided according to their location in the small or large bowel. The small intestine is less interested and is known to be the commonest cause of obscure bleeding. About 5% of total lower gastrointestinal bleeding comes from the small intestine (3). When conservative medical treatment associated with interventional endoscopy can not handle the bleeding, endovascular therapy can be salutary. Also in some rare cases of acute lower gastrointestinal bleeding with hemodynamic instability the last therapeutic resource remains surgery. Thus, we will present two cases of acute lower gastrointestinal bleeding which were managed different, we will then summarize the different variants of available treatment and finally, in the conclusions, we will underscore the most important steps of the management algorithm and highlight the crossing point in acute lower gastrointestinal bleeding.

A case report of brunner gland adenoma

Brunner gland adenoma are rare tumor and etiology remains obscure. Bleeding is the most common symptom, Gastric outlet or duodenal obstruction may also occur. The incidence is less than 5%. This case is presented here for rarity of clinical presentation. A 69 years female came with history of melena . Gastroduodenoscopy diagnosed with duodenal polyp.