Unusual presentation of jejunal adenocarcinoma and ovarian metastasis.

It is rare to find a small bowel tumour presenting as intestinal obstruction. This type of cancer is an extremely unusual condition often misdiagnosed until late stages. We report the case of a patient with persistent vomiting secondary to an obstructing jejunal adenocarcinoma not related to intestinal bowel disease. After resection and chemotherapy treatment a huge mass was detected in the left ovary. The anatomopathological findings confirmed a metastatic cancer consequent to the jejunal adenocarcinoma previously resected. This case illustrates a successful outcome of a jejunal adenocarcinoma with very poor prognosis after a extremely unusual ovarian metastasis. It is highly important to suspect other causes than intestinal bowel disease when doing a differential diagnosis in a young patient presenting with clinical symptoms of intestinal obstruction.

FDG PET/CT in Follicular Dendritic Cell Sarcoma of the Jejunum With Hepatic Metastasis.

ABSTRACT: Follicular dendritic cell sarcoma of the gastrointestinal tract is a rare malignancy. We describe contrast-enhanced CT and FDG PET/CT findings in a case of jejunal follicular dendritic cell sarcoma with hepatic metastasis. The primary jejunal tumor showed inhomogeneous enhancement on contrast-enhanced CT and intense FDG uptake on PET/CT mimicking adenocarcinoma or gastrointestinal stromal tumor. The hepatic metastatic tumor showed hypovascularity on contrast-enhanced CT and mild FDG uptake on PET/CT. This case indicates that follicular dendritic cell sarcoma should be included in the differential diagnosis of the hypermetabolic intestinal lesions.

Obscure gastrointestinal bleeding from a large jejunal lipoma treated using an endoscopic unroofing technique with double balloon enteroscopy: a case study.

Small intestinal lipomas are rare, but may cause obscure gastrointestinal bleeding. The endoscopic unroofing technique excises only the upper third of the lipoma and allows both histological confirmation and complete treatment with minimal risk of perforation. We present a rare case of obscure gastrointestinal bleeding caused by a jejunal lipoma. A 75-year-old man on antiplatelet therapy presented to our department with melena and anemia. Computed tomography revealed he had a 45-mm jejunal submucosal tumor with fat attenuation. Endoscopic resection using an endoscopic unroofing technique with double balloon enteroscopy was successfully performed. The tumor was confirmed to be a lipoma.

An atypical presentation of small bowel adenocarcinoma; a case report.

Small bowel malignancy (SBM) is a rare malignancy in the gastrointestinal tract. Duodenum is the most commonly involved segment and the most common histological subtype is adenocarcinoma (40%). Due to a lack of screening tools and vague symptoms, its clinical detection is very challenging. A 27-year-old man presented at the surgical emergency of Lahore General Hospital in February 2019 with non-specific gastrointestinal symptoms (vomiting, abdominal pain), for which he had previously visited the hospital multiple times. Later, on further workup, he had been diagnosed as a case of intussusception on CT scan. On exploration, he had an impassable stricture in the jejunum. Resection anastomosis of the jejunum was done, but later, on histopathology it turned out to be adenocarcinoma. Adenocarcinoma of the small bowel is a rare entity, and, particularly in Pakistan, the available literature is limited. SBM should be included in the differentials of patients with vague abdominal symptoms. Future studies for the evaluation of new investigations and treatment modalities should be encouraged to improve the overall outcome of the patients.

Valor de la tomografía abdominal para el diagnóstico del fibroleiosarcoma yeyunal / Abdominal tomography importance on the Leiomyosarcoma of jejunum diagnosis

RESUMEN Se presentó el caso de un paciente de 49 años de edad, que acudió a la consulta de Medicina Interna del Hospital General Docente "Dr. Agostinho Neto" por perder unas 20 libras de peso en dos meses y presentar heces fecales con aspecto aparente a "borra de café". El examen físico reveló desnutrición ligera y mucosas hipocoloreas. El ultrasonido abdominal mostró en hipocondrio y flanco izquierdo una imagen hipoecogénica heterogénea polilobulada que midió 68x61 mm con aspecto de paquete adenomegálico. En la tomografía computarizada de abdomen se identificó una imagen con densidad entre 33 y 57 UH, de 100 x 80 mm, polilobulada en topografía del yeyuno, que con el estudio contrastado realzó hasta 67 UH con aspecto tumoral. Se realizó resección quirúrgica del tumor con anastomosis termino-terminal. La biopsia informó fibroleiomiosarcoma. Se concluye que el estudio de las imágenes resulta útil para el diagnóstico de esta enfermedad.

ABSTRACT A 49-year-old patient presented to the internal medicine consultation office at the "Dr. Agostinho Neto" General teaching Hospital because of weight loss (20 pounds) and black stools in a period of 2 months before the evaluation. The physical examination revealed mild malnutrition and hypochlorous mucous membranes. The abdominal ultrasound image in the left hypochondrium showed a heterogeneous - polylobate - hypoechogenic mass measuring 68 x 61 mm with appearance of an adenomelagia. Computed tomography (CT) scan of the abdomen revealed an image with a density of 33 and 57 Hounsfield units (HU), measured 100 mm by 80 mm, polylobulated in jejunum topography, which with the contrasted study enhanced up to 67 UH with a tumor appearance. Surgical resection of the tumor with termino-terminal anastomosis was performed. Tumor biopsy diagnosed leiomyosarcoma. It was concluded that the study of the images was useful for the diagnosis of this disease.

Misdiagnosis of multiple synchronous small bowel adenocarcinomas as intestinal tuberculosis: a case report.

BACKGROUND: Small bowel adenocarcinoma (SBA) is a rare malignancy that primarily occurs in the duodenum. Multiple synchronous SBA is unique rare and difficult to diagnose due to non-specific disease presentation. Protocols to identify multiple synchronous SBA during early disease stages are urgently required. CASE PRESENTATION: An elderly man experienced left lower abdominal pain and melena for 3 months. Abdominal CT showed thickening of the multiple segmental small intestinal walls. As the patient had pulmonary tuberculosis simultaneously, he was misdiagnosis as intestinal tuberculosis and received anti-spasm therapy. The treatment delayed radical resection surgery and the patient underwent palliative segmental resection of the jejunum after 4 months due to intestinal obstruction. Resected specimens showed multiple synchronous SBA (five tumors). The patient accepted chemotherapy postoperatively. Six months postoperatively, the patient died of brain metastasis. CONCLUSIONS: We highlight how multiple synchronous SBA is rare and easily misdiagnosed. We should rule out multiple synchronous SBA when diagnosing intestinal diseases (e.g. inflammatory bowel disease, IBS). Intestinal tuberculosis may also be one of the risk factors for multiple synchronous SBA. High-risk patients should be assessed for known tumor makers, and receive gastroscopy, enteroscopy or capsule endoscopy. Doctors should obtain the pathology under endoscopy to the greatest possible degree. For suspected patients, laparotomy should be performed.

A case of jejunal neurofibroma in von Recklinghausen's disease with active hemorrhage, detected and located with gastrointestinal bleeding scintigraphy: A case report with literature review.

A 69 year old patient was admitted to hospital with massive gastrointestinal hemorrhage. The clinical presentation of the patient, except for bleeding, was dominated by the presence of neurofibromatosis type 1 - Von Recklinghausen disease. The patient was referred to multislice computed tomography (CT) angiography, magnetic resonance imaging (MRI), esophagogastroduodenoscopy and colonoscopy, which were performed without successful detection of the bleeding site. The MRI examination showed the existence of a tumor located in the small pelvis. After that, gastrointestinal bleeding scintigraphy (GIBS) with technetium-99m (99mTc) pyrophosphate in vivo labeled erythrocytes was done. Gastrointestinal bleeding scintigraphy showed active intraluminal bleeding from the projection of jejunum, which flowed through the small intestine to the descending colon and the sigmoidal and rectal segment of the colon. Surgical resection of the abdomen revealed the existence of tumors in the jejunum with active bleeding and resection and anastomosis was done. Histopathological verification showed intestinal neurofibroma. In this case GIBS showed usefulness in proving the existence of active bleeding in the small intestine and its localization, and it was of a great help in planning the surgical treatment of a patient.

Jejunal hemolymphangioma: A case report.

RATIONALE: Hemolymphangioma is a benign tumor comprised of the newly-formed lymph spaces and blood vessels, which can usually be found in the head and neck of the affected children. There are few reports regarding cases with hemolymphangioma in small intestine, spleen, esophagus, and other organs. PATIENT CONCERNS: Herein, a 55-year-old woman was presented in this study, she had complained of discomfort in the right upper abdomen for 2 months, and was discovered with a space-occupying lesion in proximal jejunum on computed tomography (CT). Eventually, the lesions were confirmed through double-balloon enteroscopy (DBE) to be located in the jejunum 60 cm away from the Treitz ligament. DIAGNOSE: Subsequently, the small intestine was partially resected, and postoperative pathology had confirmed the diagnosis of small intestinal hemolymphangioma. INTERVENTIONS: Excisional surgery of the lesion was planned. On surgery, the lesions were discovered to be about 33 cm to 22 cm when engorged the superficial vessels. No enlarged lymph nodes were seen at the root of the mesentery, and no obvious lesion was observed in the remaining small intestine. OUTCOMES: Follow-up for 6 months showed no recurrence. LESSONS: Hemolymphangioma lacks typical clinical symptoms, and the correct preoperative diagnosis of hemolymphangioma remains challenging. Due to the increasing use of endoscopic diagnostic techniques, it is expected that hemolymphangioma in gastrointestinal tract may be detected and endoluminal located before surgery more feasibly. This case report aimed to highlight the contributions of CT and DBE to an accurate preoperative diagnosis and surgical strategy planning.

A case of small bowel adenocarcinoma wherein nivolumab conferred temporary benefit in disease control.

Small bowel adenocarcinomas are rare. There is no definite consensus as to whether they should be treated in a manner similar to gastric or to colon cancer. We report the case of a young woman with a primary jejunal adenocarcinoma, bilateral ovary metastases, and peritoneal dissemination. First- and second-line chemotherapy for the gastric cancer failed. She was then treated with the immune checkpoint inhibitor nivolumab and had temporary improvement in her condition. To the best of our knowledge, this is the first case wherein nivolumab has been used to treat small bowel adenocarcinoma.

Jejunal stromal tumor and neurofibromatosis / Tumor estromal de jejuno e neurofibromatose

Abstract Gastrointestinal stromal tumors, although rare, are the most common primary mesenchymal neoplasms of the gastrointestinal tract and originate from the interstitial cells of Cajal. They present slow growth and symptoms such as bleeding, abdominal pain or discomfort, and the presence of an abdominal mass. The most affected organs are the stomach and small intestine. Differential diagnoses for gastrointestinal stromal tumor include adenocarcinoma and small intestine lymphoma, metastasis, and carcinoid tumor. Gastrointestinal stromal tumors have been associated with familial syndromes such as type 1 neurofibromatosis, considered a predisposing factor for tumors in the small intestine. This study aimed to report a case of gastrointestinal stromal tumor in the jejunal region in a patient with type 1 neurofibromatosis, followed-up for two years, who underwent laparoscopic segmental enterectomy and diagnosis determined by histopathology and immunohistochemistry. The diagnosis of small intestine gastrointestinal stromal tumor is challenging because of its low incidence, nonspecific symptoms, relative inaccessibility of the small intestine to conventional endoscopic examination, broad spectrum of radiological appearances, and the fact that the nature of the mass is difficult to determine with imaging examinations of the abdomen alone. Thus, the small intestine gastrointestinal stromal tumor may be erroneously diagnosed as pancreatic, gynecological, or mesenteric tumors. The literature does not present many reports on the association of jejunal gastrointestinal stromal tumor with neurofibromatosis. Understanding the tumoral behavior of small intestine gastrointestinal stromal tumor in this subgroup of patients would allow better follow-up.

Resumo Os tumores estromais gastrointestinais, embora raros, são as neoplasias mesenquimais primárias mais comuns do trato gastrointestinal e originam-se das células intersticiais de Cajal. Apresentam crescimento lento e manifestam sintomas como sangramento, dor ou desconforto abdominal e presença de massa abdominal. Os órgãos mais acometidos são estômago e intestino delgado. Os diagnósticos diferenciais para tumores estromais gastrointestinais incluem adenocarcinoma e linfoma de intestino delgado, metástases e tumor carcinoide. Os tumores estromais gastrointestinais têm sido associados a síndromes familiares como a neurofibromatose tipo 1, considerada um fator predisponente para tumores no intestino delgado. O objetivo desse trabalho é relatar um caso de tumor estromal gastrointestinal em região jejunal em paciente portadora de neurofibromatose tipo 1, com 2 anos de seguimento, submetida a enterectomia segmentar laparoscópica e diagnóstico determinados pela histopatologia e imuno-histoquímica. O diagnóstico de tumor estromal gastrointestinal do intestino delgado é desafiador, devido a sua baixa incidência, sintomas inespecíficos, relativa inacessibilidade do intestino delgado ao exame endoscópico convencional, amplo espectro de aparências radiológicas e difícil determinação da natureza da massa apenas com exames de imagens do abdome. Assim, tumor estromal gastrointestinal no intestino delgado podem ser erroneamente diagnosticados como tumores pancreáticos, tumores ginecológicos, ou tumores do mesentério. A descrição científica da associação de tumor estromal gastrointestinal de jejuno com neurofibromatose é incomum. Tais descrições permitem melhor seguimento dos pacientes a partir do momento que se entende o comportamento tumoral do tumor estromal gastrointestinal de intestino delgado nesse subgrupo de pacientes.

Duodenal Adenocarcinoma at the Ligament of Treitz: Management and Outcome.

Primary small bowel neoplasms at the ligament of Treitz are extremely rare and require advanced surgical technique for extirpation. The insidious onset of disease allows for a delayed presentation, often accompanied by moderate-size growth of the neoplasm, causing intestinal bleeding and bowel obstruction. The partial retroperitoneal location of these tumors pose a unique challenge for surgical resection. We present an unusual case of a primary small bowel adenocarcinoma at the Ligament of Treitz, requiring segmental resection of the fourth portion of the duodenum plus the proximal jejunum.

[Rare cause of gastrointestinal bleeding]. / Seltene Ursache einer gastrointestinalen Blutung.

HISTOLOGY AND CLINICAL FINDINGS: We report on a 66-year-old-patient with plasmocytoma, who presented with melena since 3 days, dyspnea and dizzyness. INVESTIGATION AND DIAGNOSIS: Because of the laboratory and clinical examination the suspected diagnosis was an active gastrointestinal bleeding. The performed gastroduodenoscopy and sigmoidoscopy could not verify an active bleeding. Thus a contrast-enhanced computed tomography was performed additionally and showed abnormal enhancement as well as a ballooning of the proximal jejunum. Subsequently a jejunoscopy was performed where an actively bleeding mass was found. TREATMENT AND COURSE: Due to the known medical history of a plasmocytoma and in conjunction with the performed examinations the suspected diagnosis of an extramedullary metastasis of a plasmocytoma in the jejunum was made. Since only temporary control of the bleeding could be achieved, a segmental resection of the small bowel was performed. The following histological examination confirmed the diagnosis. CONCLUSION: The differential diagnosis for gastrointestinal bleeding includes also rarely neoplastic manifestations in the small bowel. Contrast-enhanced computed tomography can aide in the localization of the bleeding side and determination of the cause of hemorrhage.

Cystic lymphangioma in the peripheral jejunal mesentery in an adult and excision with laparoscopic-assisted surgery: a case report.

BACKGROUND: Lymphangiomas are uncommon congenital malformations that present mainly in the head, neck, and axillar regions in pediatric patients. Mesenteric cystic lymphangiomas (MCLs), which occasionally present with substantial growth and the invasion of adjacent vital structures, are rarely reported in adults. We report a case of MCL in an adult who was treated with laparoscopic-assisted excision. CASE PRESENTATION: A 40-year-old Japanese man visited his family physician for prolonged periumbilical pain. Plain computed tomography (CT) showed a low-density mass in his left abdomen, and he was referred to our hospital 2 weeks later. His abdomen was flat and soft, and no mass was felt upon palpation. Routine laboratory data showed no abnormalities in the blood cell counts. The levels of tumor markers, such as carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and cancer antigen 125 (CA125), were within normal ranges. Contrast-enhanced CT was performed, and a low-density mass was observed with an irregular outline and poor contrast, as well as involvement of the peripheral mesenteric artery and partial compression of the adjacent jejunum without dilatation of the oral side of the bowel. The patient was diagnosed with lymphatic cysts and observed for 1 month without symptom exacerbation. Follow-up CT showed no increase in the size of the mass but showed apparent invasion of the jejunal wall without bowel obstruction. Magnetic resonance imaging (MRI) showed intermediate intensity on T1-weighted imaging (T1WI) and high intensity on T2-weighted imaging (T2WI). The coronal view on T2WI clearly showed an accumulation of cystic lesions. We performed tumor excision with partial resection of the jejunum in a laparoscopic-assisted manner. Pathological examination showed multicystic lesions with an attenuated endothelial lining, surrounding rich adipose tissue and scattered smooth muscle fibers; the patient was diagnosed with MCL. Immunohistochemical assays supported this diagnosis. CONCLUSIONS: This is rare case of MCL presenting in an adult who underwent successful laparoscopic-assisted resection. Mesenteric lymphangioma (ML) should be considered in the differential diagnosis of patients with intraabdominal cysts. Radical excision is optimal, even when the patient is asymptomatic. Laparoscopic-assisted tumor resection is a suitable surgical method for treating MLs located in the peripheral mesentery.