Solitary hamartomatous duodenal polyp; a different entity: report of a case and review of the literature

Solitary hamartomatous duodenal polyps are a clinical entity considered until now to express an incomplete or initial form of Peutz-Jeghers syndrome (PJ syndrome). Following our experience of 1 case, we analyzed the clinical characteristics of the 12 previously reported cases of solitary hamartomatous duodenal polyps. In none of these cases did we find any documentation of mucocutaneous pigmentation, a family or personal history of intestinal polyps, or local neoplastic degeneration of the disease, and all cases presented during the fifth or sixth decade of life. Thus, we conclude that solitary hamartomatous duodenal polyps constitute a different entity to PJ syndrome, the most appropriate elective treatment for which is endoscopic electrosurgical polypectomy.

[Pedunculated polyp of the sigmoid. Initial detection by ultrasonography with compressive technique]

A man with a history of intermittent blood stained feces for 3 years was found with US to have a 3 cm polyp, presumably of the sigmoid colon. Double contrast barium enema and colonoscopy first missed the polyp, which was confirmed with surgery.

Polypoid lesions at the anorectal junction: barium enema findings

Although the anorectal junction is easily accessible, this area may be difficult to evaluate both radiologically and endoscopically because it is relatively collapsed. This pictorial essay illustrates the barium enema radiographic findings and reviews the radiologic and endoscopic pitfalls in the diagnosis of lesions of the anorectal junction.

Colon filling defect

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Chronic nausea as the leading symptom: an indication for double-contrast examination of the upper intestinal tract following normal gastroscopy

We report a patient with chronic nausea as the leading symptom of a primary carcinoma of the duodenum located at the flexura duodeno-jejunalis. The tumour was not reached at gastroscopy, which was performed twice. Since this area usually cannot be seen upon gastroscopy or upon small bowel enteroclysma according to Sellink, a double-contrast investigation of the upper gastrointestinal tract using a hypotonic agent should be performed when nausea persists although gastroscopy is normal.

[Endorectal ultrasound in diagnosis and therapy planning of broad-base rectal adenomas]

In this study the value of endorectal ultrasound in diagnosis and therapy of large rectal adenomas is shown. Between January 1988 and August 1992 93 patients with the primary diagnosis of adenoma proven by biopsy were examined by endorectal ultrasound. Sonographical differentiation of adenoma and carcinoma was done by echo-structure. Enlarged lymph nodes can be detected too. In 34 of 91 patients carcinoma was found by endorectal ultrasound and 28 were verified histologically. Sensitivity of endorectal ultrasound in detection of carcinoma in enlarged adenomas is 96%. Only preoperative endorectal ultrasound could give decisive criteria to take a second biopsy, to avoid mucosectomy in case of a malignoma or give the advice for a radical operation according to the tumor stage. Further staging of adenomas and small carcinomas is excellent by endorectal ultrasound and the right indication of local therapy can be confirmed.

Diagnostic difficulty in a case of heterotopic pancreatic tissue of the ileum

We describe a case of heterotopic pancreatic tissue of the ileum causing acute gastrointestinal tract bleeding. It was initially clearly demonstrated as an ileal polyp preoperatively by radiologic means. Exploratory surgery was performed, and the segment of ileum containing the mass was resected. Histopathologic examination of the lesion revealed heterotopic pancreatic tissue of Heinrich type II. There was no histological evidence of acute or chronic pancreatitis, but erosion was confirmed at the tip of the mass. Even symptomatic heterotopic pancreatic tissue of the ileum may give difficult diagnostic problems. The present case is reported to show the possibility of diagnosing rare abnormalities of the ileum.

Benign tumors of the small intestine: preoperative evaluation with a barium infusion technique

During a seven year period 18 benign small intestinal tumors were histologically documented in patients referred to us for a small bowel study, using a barium infusion technique. These included seven leiomyomas, five adenomatous polyps, two Peutz-Jeghers hamartomas, one myoepithelial hamartoma, one lipoma, one Brunner's gland adenoma and one neurilemmoma. Ten of the patients were women and eight were men, with their ages ranging from 20 to 75 years (mean age 45 years). Presenting symptoms were gastrointestinal bleeding in 12, anemia in 9, abdominal pain in 4, partial intestinal obstruction in 3 and bloody diarrhea in one. The time elapsed from onset of symptoms to radiological diagnosis ranged between one month and seven years (mean time 16 months). Multiple lesions were encountered in four cases and solitary in fourteen. The site of involvement was the duodenum in 3 patients, the jejunum in 8 and the ileum in 7 of them. Main radiological appearances included solitary or multiple intraluminal filling defects, mass effect on neighbouring loops and dilation of intestinal loops proximally to the lesion. The primary tumor, in the form of a mass or other abnormality of the small intestine was identified in all study cases. Correlation with surgical or endoscopic findings showed that radiology depicted all single lesions, whereas multiple lesions were underestimated in one case. The individual morphological changes shown on examination of the resected specimens resembled the appearances on the barium study in all cases. However, enteroclysis missed four out of seven ulcers and a stalk in one of the five pedunculated lesions. A specific tumor-type diagnosis was reached preoperatively in eleven patients, it was suggestive in five and mistaken in two of them. Our experience indicates that enteroclysis is an effective means in evaluating patients with suspected benign small bowel tumors, preoperatively.

Inflammatory fibroid polyp of the ileum

We report a patient who presented with recurrent right upper quadrant colics after a previous cholecystectomy. Radiological examination revealed the presence of a polypoid mass in the ileum caused by an anatomo-pathologically proven inflammatory fibroid polyp (IFP) in the ileum. Clinical and pathological aspects related to this rare benign lesion are discussed.

Benign colorectal neoplasms undetected by colonoscopy

This retrospective investigation assessed the sensitivity of colonoscopy for the detection of colonic polyps seen previously at barium enema examination. Included in the study were 77 patients with 106 polypoid lesions. Films showing lesions not subsequently seen at colonoscopy were reviewed and only those lesions with a visible point of attachment, exhibiting no movement in response to filling or change in position of the patient, and confidently diagnosed as a polyp by both reviewing radiologists were included among the 106 lesions. Sixteen lesions (15%) seen radiologically were not located colonoscopically, indicating an endoscopic sensitivity of 85%. Contrary to previous reports, most of the lesions missed endoscopically were in the left colon in regions thought to have been traversed by the instrument. The 15% false-negative rate found for colonoscopy is consistent with existing reports on colonoscopic errors and is approximately the same as the false-negative error rate for radiologic detection of colonic polyps.

[Endoscopic Doppler ultrasonography in lower intestinal bleeding:vascular diagnosis and monitoring of therapy]

Endoscopic Doppler sonography is a relatively new method for evaluating the sources of intestinal bleeding. For the most part our experiences derived from cases of gastroduodenal ulcer bleedings, in which Doppler sonography permits the identification of arterial vessels relevant for recurrent ulcer bleedings as well as follow-up of therapy after sclerosing. In the lower intestinal tract endoscopic Doppler has, however, only rarely been used, e.g. for diagnosing vascular malformations. This method is of theoretical interest for evaluating colorectal sources of bleeding but is nonetheless of some practical importance, as our investigations of angiodysplasias, ulcers of the rectum and polyps demonstrate.

Colorectal cancer: the case for barium enema

Both colonoscopy and barium enema are important techniques for examining the colon for polyps and cancer. They are approximately equally sensitive in detecting polypoid lesions of 7 to 10 mm or larger. A major limitation of colonoscopy is that the cecum cannot be visualized in 10 to 36% of cases. The comparable accuracy for detecting significant lesions, greater safety, and greater cost-effectiveness of barium enema favor its use in most patients.

Pitfalls in scintigraphic detection of neuroendocrine tumours

We report 4 cases of abnormal results using iodine-123 metaiodobenzylguanidine (123I-mIBG) or technetium-99m (V) dimercaptosuccinic acid (99mTc(V)-DMSA) scintigraphy in the diagnosis and follow-up of presumed neuroendocrine tumours. The present series consisted of 2 false-positive cases (1 adenomatous polyp of the caecum with mIBG and 1 follicular adenoma of the thyroid with DMSA) and 2 cases of anomalous uptake of (V)-DMSA in a non-neuroendocrine tissue.

Inflammatory fibroid polyps of the gastrointestinal tract: radiologic evaluation

Inflammatory fibroid polyps (IFPs) are uncommon lesions of the gastrointestinal tract. Only scattered case reports have appeared in the radiology literature. The authors reviewed the cases of 33 patients (20 women and 13 men; average age, 45 years) to determine if these polyps had any distinctive diagnostic radiologic features. The IFPs were located in the stomach (n = 16), small bowel (n = 13), and colon (n = 4). The lesions originated in the submucosa and were composed of fibroblasts, inflammatory cells, and a network of blood vessels. Gastric IFPs were most often located in the antrum and were usually ulcerated. Most of the patients presented with clinical evidence of gastrointestinal blood loss. Small bowel polyps were usually located in the ileum, and patients were typically older women with intestinal obstruction due to intussusception. Most of the lesions appeared as large, intramural masses at radiologic examination. Some of the lesions were pedunculated, and all were solitary. There were no distinctive features to differentiate IFPs from other mural or intraluminal lesions of the gastrointestinal tract.

Single-visit screening and treatment of first-degree relatives. Colon cancer pilot study

A pilot study has been carried out to evaluate three aspects of screening of first-degree relatives of patients with colon cancer in four Hamilton hospitals; yield of adenomas, feasibility of a one-visit approach to screening and treatment, and compliance. Protocol included flexible sigmoidoscopy after full bowel preparation, followed immediately by either therapeutic colonoscopy or diagnostic barium enema, depending on the flexible sigmoidoscopy findings. We found adenomas in 19 percent of 88 first-degree relatives, with a mean age of 52, compared with an expectation of 8 percent. The protocol was found to be acceptable to the relatives and workable for the various groups of physicians in three of four hospitals, despite many initial logistic difficulties. Numerous problems were encountered with compliance of referring physicians, index patients, relatives, and investigating physicians.

Crohn's disease of the small intestine with polypoid configuration

We describe three patients with Crohn's disease of the small intestine with a polypoid configuration. In two patients, the polypoid masses were the only radiologic abnormalities and were suggestive of jejunoileal lymphoma and terminal ileal adenomas. The diagnosis of Crohn's disease was established only at laparotomy. In the third patient, a polypoid mass simulating a sessile adenoma was seen along with other typical features of ileitis and was recognized preoperatively as a manifestation of the ileitis. The resected ileal segments of all three patients showed mural thickening, luminal narrowing and distortion, and mucosal ulceration and fissuring. The asymmetry of the mural thickening and the resultant luminal narrowing simulated sessile polyps to which mucosal ulceration and fissuring gave a lobulated appearance.

Giant hyperplastic polyps of the gastric remnant simulating carcinoma

Large hyperplastic polyps of the gastric remnant were detected in 2 male patients who had undergone Billroth II gastrojejunostomy for peptic ulcer disease 13 and 18 years earlier. Both patients presented with iron deficiency anemia due to chronic occult gastrointestinal bleeding. The clinical and radiographic findings were initially suggestive of gastric stump malignancy, and one of the resected hyperplastic polyps contained foci of carcinoma in situ. We illustrate the radiographic and pathologic features of these lesions together with a review of the pertinent literature.

Double contrast small bowel enema in a case of selective duodeno-jejunal amyloidosis

Double contrast small bowel enema in a patient with selective amyloidosis of the duodenum and jejunum revealed an unusual radiologic pattern, mimicking multiple polyposis. Many submucosal polypoid lesions, sessile or pedunculated, were scattered throughout the duodenum and proximal jejunum. The lesions had smooth borders and did not show any retraction at the base. Other typical radiologic patterns of intestinal amyloidosis described in the literature were not observed in the present case. Differential diagnosis from multiple polyposis and diffuse lymphoproliferative neoplastic diseases is discussed.

Cronkhite-Canada syndrome: radiologic features

We report 6 cases of Cronkhite-Canada syndrome, analyze the patterns of involvement, and review the literature on this entity. There were 4 women and 2 men, with an average age of 58 years. The stomach was diseased diffusely in 5 and focally (distally) in 1. Small bowel polyps were detected in 4 patients. Patterns of involvement were classified as (a) innumerable small polyps carpeting large areas, (b) scattered varying-size polyps, and (c) sparse involvement with few small polyps. There was concordance of patterns between the stomach and colon in 5 of the 6 patients.