S3694 Terminal Ileum Intubation Turning out to Be a Lifesaver in a Young Patient

Introduction: Terminal ileoscopy (TI) is an essential procedure for the diagnosis and definition of terminal ileal pathology, providing accurate visualization of the last 20 cm of the ileum. Persistent diarrhea, abdominal pain, lower GI tract bleeding, iron deficiency anemia, suspected inflammatory bowel disease and irritable bowel syndrome are the most common indications for TI. Case Description/Methods: A 20-year-old African-American woman presented with diarrhea and intermittent abdominal pain since 8 months. Patient did not have hematochezia. Routine labs including complete blood count, complete metabolic panel, stool studies for infectious etiologies, thyroid studies and celiac serologies were negative. CT scan and ultrasound abdomen performed for intermittent abdominal pain were unremarkable as well. Colonoscopy was performed which showed normal colon mucosa but a single aphthous ulcer of approximately 8-9 mm in the terminal ileum. Random colon biopsies were negative for microscopic colitis. The terminal ileum ulcer biopsy showed a well differentiated neuroendocrine tumor grade 1(carcinoid tumor), WHO Grade 1, extending into muscularis propria. Laparoscopic right hemicolectomy was performed successfully and 1 out of 13 lymph nodes removed was positive for metastatic tumor. Patient tolerated the surgery well, without any intraoperative complications and recovered uneventfully, discharged thereafter. Discussion: Gastrointestinal neuroendocrine tumors/carcinoids(NET) are rare tumors with incidence of 6.98 per 100, 000 which start in digestive system and approximately 40 out of 100 start in small bowel. Patients suffering from small bowel NETs may experience abdominal pain, diarrhea, or carcinoid syndrome. In practice, ileoscopy is not performed routinely with colonoscopy due to the perceived difficulty in intubating the ileocecal valve (ICV), the added time required to do so and a lack of acceptance regarding diagnostic yield. Ileoscopy is a valuable addition to colonoscopy that not only helps to modify but also establish diagnosis. Ten-year survival for patients with small bowel NETs depends on the stage of the disease upon diagnosis. It drops from 95% in stage I to around 40% in stage IV. This case highlights the need of TI when indicated during diagnostic colonoscopy as it can enhance overall outcome. Recognizing this at early stage is crucial in order to avoid identifying such tumors and masses in the terminal ileum at later stages of development.Figure 1:: Terminal Ileum.