Human small intestine accounts for 75% of the gastrointestinal (GI) length but for only 1-5% of GI tumors. The reason remains as yet unclearly understood. our study was designed to examine whether increased apoptosis and expression of related genes/proteins, especially those of the Bcl-2 family, contribute to this difference. For this purpose, 77 samples from patients were examined by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling and immunohistochemistry, including 40 cases from normal small intestine (jejunum), 7 cases from jejunum and ileum adenocarcinomas, and 30 cases from normal colon. The results showed that a significantly higher level of enterocyte apoptosis was observed in normal small intestine compared with small intestinal adenocarcinomas and normal colon (median of apoptotic index, 15.2% vs 0.1% and 1.6%, p<0.01). A similar pattern was observed for Bax (expression-positive, 77.5% vs 28.6% and 53.3%, p<0.05) but not for Bcl-2 (42.5% vs 42.9% and 46.7%, p>0.05) or Bax/Bcl-2 ratio (percent of samples having a ratio >= 1, 45.0% vs 14.3% and 36.7%, p>0.05). In conclusion, increased apoptosis and expression of Bax, not Bcl-2 or the Bax/Bcl-2 ratio, may play some role in the relatively lower incidence of human small intestinal carcinomas. However, more studies are required for a better understanding of these changes. (J Histochem Cytochem 57:1139-1148, 2009)