Iron deficiency anaemia in a coeliac: a cause for concern?

A 70-year-old woman with a 15-year history of coeliac disease was admitted for treatment and investigation of symptomatic anaemia. Of note, she was recently commenced on aspirin therapy for retinal artery occlusion. This followed a normal gastro-duodenoscopy, colonoscopy and CT abdomen as workup for iron deficiency anaemia. On this occasion, the patient was further investigated with small bowel capsule endoscopy. This revealed an ulcerated lesion in her proximal jejunum suspicious for malignancy, namely lymphoma. A biopsy of the lesion confirmed adenomatous changes and high-grade dysplasia without malignant changes. Given the endoscopic appearances of the lesion, she was further evaluated with a small bowel MRI. This revealed a 3 cm lesion with associated lymphadenopathy but no distant metastases. She proceeded to resection of her small bowel which confirmed an invasive adenocarcinoma of her proximal jejunum. She is currently undergoing adjuvant chemotherapy on an outpatient basis.

Synchronous quintuple primary gastrointestinal tract malignancies: Case report.

Multiple primary malignancy is defined as two or more malignancies detected in an individual person. In particular, synchronous quintuple primary malignancy is extremely rare. A 52-year-old male with anal pain and intermittent blood-tinged stool was diagnosed with malignancies in the stomach, jejunum, ascending colon, transverse colon and rectum. He underwent a subtotal gastrectomy, segmental resection of the jejunum and total protocolectomy with end ileostomy. The postoperative pathologic findings were moderate differentiated gastric adenocarcinoma (pT1bN0M0, pStageIA), combined adenocarcinoma and neuroendocrine carcinoma of the jejunum (pT3N0M0, pStageIIA), three mucinous adenocarcinoma of the ascending colon (pT3N0M0, pStageIIA), transverse colon (pT1N0M0, pStageI) and rectum (pT3N1aM0, pStageIIIB). The tumors did not lack MLH-1 and MSH-2 expression, as the markers (bat26, D5S346, bat25, D2S123) suggest MSI-H presence. Adjuvant chemoradiotherapy was started according to regimen, FOLFOX 4 for advanced rectal cancer. Six years post-operation, the patient is currently attending regular follow-ups without recurrence or metastasis.

Small bowel adenocarcinoma of the jejunum: a case report and literature review.

BACKGROUND: In practice, small bowel cancer is a rare entity. The most common histologic subtype is adenocarcinoma. Adenocarcinoma of the small bowel (SBA) is challenging to diagnose, often presents at a late stage and has a poor prognosis. The treatment of early-stage SBA is surgical resection. No standard protocol has been established for unresectable or metastatic disease. CASE PRESENTATION: We report here on a 26-year-old man with SBA in the jejunum, lacking specific symptoms and with a delay of 6 months in diagnosis. The diagnosis was finally achieved with a combination of balloon-assisted enteroscopy, computed tomography scans, positron emission computed tomography scans and the values of carcino-embryonic antigen and carbohydrate antigen 19-9. The patient underwent segmental intestine with lymph node resection, followed by eight cycles of FOLFOX palliative chemotherapy with good tolerance. As of the 11-month postoperative follow-up, there has been no evidence of recurrent disease. CONCLUSIONS: This case is reported to arouse a clinical suspicion of SBA in patients with abdominal pain of unknown cause. We also provided evidence in this case of a response to palliative chemotherapy with FOLFOX. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome within the framework of international collaborations.

[A case of jejunal ectopic pancreatic cancer: the diagnostic usefulness of MRI].

A 70-year-old man was referred to our hospital because of elevated CA19-9. Magnetic resonance imaging revealed a jejunal tumor having duct and retention cyst-like structures, which suggested ectopic pancreatic cancer. We resected that part of the jejunum and the lymph nodes around the tumor. Pathological examination revealed an adenocarcinoma originating from a Heinrich type I ectopic pancreas in the jejunum. Adjuvant chemotherapy with gemcitabine was performed for half a year. After 8 months, CA19-9 remained elevated, and liver metastasis occurred. We began treatment with tegafur/gimeracil/oteracil potassium (S-1) and particle beam therapy. After 7 months, CA19-9 was normal, and the patient has remained in partial remission with S-1 treatment. Ectopic pancreas tissues typically occur in the stomach and duodenum and rarely become cancerous. Here, we report the features of a rare and illustrative case of jejunal ectopic pancreatic cancer.

Imaging of a small bowel cavernous hemangioma: report of a case with emphasis on the use of computed tomography and enteroclysis.

Hemangiomas of the small bowel are rare benign tumors, that are dangerous since they may cause massive or occult gastrointestinal bleeding. We describe a case of a jejunum cavernous hemangioma detected by computed tomography (CT) and barium studies. An abdominal CT scan (with intravenous contrast agent) depicted a pronounced contrast enhanced lesion arising from the front wall of a loop of the proximal ileum. Enteroclysis revealed a small intramural nodular defect.

[Diagnosis of a high-grade B-cell lymphoma of the small bowel by means of wireless capsule endoscopy]. / Diagnostik eines hochmalignen B-Zell-Lymphoms des Dünndarms mit der Kapselendoskopie.

Wireless capsule endoscopy is a new diagnostic procedure to detect diseases of the small bowel, in particular in patients with obscure gastrointestinal bleeding. We report on a 76-year-old patient who presented at our hospital with signs of gastrointestinal bleeding and hypochromic anaemia. Bidirectional endoscopy, push enteroscopy, angiography as well as small bowel barium enema rendered no pathologic findings. Wireless capsule endoscopy demonstrated a polypous space in the cantral area of the small bowel. Subsequent intraoperative endoscopy revealed a subtotal stenosing tumour of the upper jejunum which was resected. Based on the histology a high-grade B-Cell lymphoma was diagnosed. The postoperative staging examinations did not indicate any further extranodal involvement.

[Digestive hemorrhage caused by jejunoileal tumors]. / Hemorragia digestiva por tumoraciones yeyunoileales.

Between January-73 and February-92 twelve patients with digestive hemorrhage due to primary jejunoileal tumors were treated. Eight cases had rectal bleeding and four chronic gastrointestinal hemorrhage as first clinical manifestation. Patients underwent upper endoscopy, colonoscopy and barium enema. Three out of nine barium meals (33%), two out of four ultrasonographies (50%) and eight out of nine arteriographies (89%) were abnormal. The barium meals showed submucosal lesions on two occasions and a jejunal luminal mass. The ultrasonography detected two intrabdominal masses. All arteriographies, except one with extravased intestinal contrast and other which showed a hypovascular zone, depicted homogeneous hypervascular images. All patients were operated on. Seven segmental enterectomies, four limited resections and a polipectomy were performed. Seven tumours were found in the jejunum, three in the jejunoleum and two in the ileum. There were four leiomyosarcomas, three leiomyomas, two polyps, one leiomyoblastoma, one adenocarcinoma and one lymphoma. Rebleeding and mortality were absent.

[Primary lymphoma of the small intestine: clinico-radiological correlations]. / Linfomi primitivi dell'intestino tenue: integrazione clinico-radiologica.

From 1987 to 1989, 7 patients were diagnosed as having a primary lymphoma of the small bowel. The patients, 5 men and 2 women aged 14-66 years (average: 45), were studied by means of small bowel enema and CT. Using small bowel enema, our findings were: masses related to a loop, stenosis, mucosal patterns with thick, irregular, and nodular folds, and bowel walls thickening. In nearly all cases CT showed not only small bowel lesions but also mesenteric lymphadenopathy. Five of seven patients had lymphomas, 1 had IP-SID lymphoma (immunoproliferative small intestinal disease related lymphoma), and 1 had IPSID associated with a late prelymphomatous stage. The diagnosis of IPSID is very important in patients with malabsorption syndrome, which may or may not be related to alpha heavy chain disease, because IPSID may evolve into lymphoma but its prelymphomatous stage can be treated and cured. We have therefore reported the different features seen with enteroclysis and CT, comparing the results obtained in the various forms of lymphoma of the small bowel. The importance is stressed of an accurate diagnosis of IPSID forms, however uncommon in our Country.

[Primary carcinoma of the jejunum combined with colon polyp--report of a case].

A 47-year-old female patient with a primary carcinoma of the jejunum combined with colon polyp is presented. Having had an attack of vomiting, she visited our hospital. Oral small intestine radiography revealed a localized stricture with ulceration in the jejunum. Small intestinal endoscopy showed a tumor with an irregular surface and hemorrhagic ulceration. Selective superior mesenteric arteriography revealed a stenosis and deviation of arteries. These findings strongly indicated cancer of the jejunum, and a barium enema study and a colonoscopic examination revealed a polyp in the ascending colon. The resected tumor was histologically diagnosed as a well differentiated adenocarcinoma. CEA-positive cells also were observed. Further, a polypoid lesion in the colon was histologically diagnosed as an adenoma.

Radiological findings in small-bowel tumours.

Radiological findings were evaluated in a series of 25 cases with malignant and three with benign small bowel tumours with surgical or autopsy confirmation of diagnosis. 27 patients were operated, two of them without any radiography due to 'acute abdomen'. 23 patients were examined with ultrasound, 14 with barium examination, seven with CT, four with plain films and two with angiography. Ultrasound revealed 16 (70%) out of 23 tumours, in two cases result was abnormal but the tumour was not found and in five cases no abnormality was identified. Eleven barium examinations (78%) showed signs of tumour, one showed signs of occlusion but not the tumour and in two cases no abnormality was found. The tumour was seen in six of seven cases examined with CT. Our results proved that US is useful as screening study. Barium studies are needed for exact location of the tumour and in US negative cases.

Small bowel tumors: a continuing challenge.

Small bowel tumors are difficult to diagnose and are frequently not identified at initial evaluation. We retrospectively reviewed 25 consecutive cases to assess the efficacy of procedures currently used in diagnosis. Barium contrast studies were diagnostic in 14 (56%) of the cases. Enteroclysis provided one diagnosis after the initial barium study was negative. Of the 11 patients for whom barium studies were negative, angiography provided the diagnosis in six (three benign, three malignant). Endoscopy was never helpful. Laparotomy was required in five cases (three benign, two malignant) after repeated negative work-ups. An evaluation protocol which calls for each method as needed seems to provide the most reliable means of diagnosing small bowel tumors.