Enteritis cystica profunda in Peutz-Jeghers syndrome. Report of a case and review of the literature

Enteritis cystica profunda: Case report and literature review

INTRODUCTION

Enteritis cystica profunda (ECP) is a rare benign disease first described in the colonic epithelium. This pathology is developed as cystic lesions filled with mucinous material delineated by an epithelium of columnar characteristic in the mucosa of the small intestine.

PRESENTATION OF THE CASE

A 61-year-old patient without history of previous surgical procedures was admitted to the emergency room with one day of evolution of abdominal pain associated with anorexia, no bowel movements, multiple emetic episodes, and oral intolerance. A diagnosis of intestinal symptomatic management was performed and then a diagnostic laparoscopy was performed with intestinal resection, and primary anastomosis and the surgical specimen was obtained for histopathological study.

DISCUSSION

ECP is a pathology whose pathophysiology is poorly understood, which is commonly accepted as the development of an ulcerative process with the consequent development of a cyst as a repair method. The final diagnosis is made through an anatomopathological study. The scarce literature suggests that this condition can be managed by surgery in order to resect the affected tissue and provide adequate primary anastomosis.

CONCLUSION

Enteritis cystica profunda is a rare disease associated with pathologies such as Crohn's disease. Surgery is the preferred treatment and obtaining a surgical specimen is mandatory for histopathological analysis.

Peutz-Jeghers Syndrome and the Role of Imaging: Pathophysiology, Diagnosis, and Associated Cancers

Simple Summary

The Peutz-Jeghers Syndrome is a rare autosomal dominant syndrome characterized by mucocutaneous pigmentations, multiple gastrointestinal hamartomatous polyps, and an elevated risk of malignancy. Awareness of various Peutz-Jeghers Syndrome imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide an overview of this condition, associated malignancies, and imaging surveillance protocols.

Abstract

The Peutz-Jeghers Syndrome (PJS) is an autosomal dominant neoplastic syndrome defined by hamartomatous polyps through the gastrointestinal tract, development of characteristic mucocutaneous pigmentations, and an elevated lifetime cancer risk. The majority of cases are due to a mutation in the STK11 gene located at 19p13.3. The estimated incidence of PJS ranges from 1:50,000 to 1:200,000. PJS carries an elevated risk of malignancies including gastrointestinal, breast, lung, and genitourinary (GU) neoplasms. Patients with PJS are at a 15- to 18-fold increased malignancy risk relative to the general population. Radiologists have an integral role in the diagnosis of these patients. Various imaging modalities are used to screen for malignancies and complications associated with PJS. Awareness of various PJS imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide a comprehensive overview of PJS, associated malignancies, and surveillance protocols.

Enteritis cystica profunda with lipoma in the second portion of the duodenum

Enteritis cystica profunda (ECP), a rare and benign condition, is defined as the displacement of the glandular epithelium into the submucosa and more profound layers of the small intestinal wall leading to the formation of mucin-filled cystic spaces. ECP frequently occurs in the ileum or jejunum and is associated with diseases such as Crohn disease and Peutz-Jeghers syndrome. ECP also develops in the absence of known pathology. ECP in the duodenum is very rare and mostly occurs without associated conditions. In this report, we present a rare case of ECP without an associated disease, in the second portion of the duodenum distal to the ampulla of Vater and coexisting with lipoma within the polypoid lesion.

Enteritis Cystica Profunda Presenting as Recurrent Sub Acute Intestinal Obstruction-NOT ALL Cases of IC Strictures are Koch's! A Case Report

A 13-year-old girl presented with recurrent colicky abdominal pain and distension. She was treated for abdominal Koch's for 4 months without any relief. She underwent diagnostic laparoscopy which revealed cicatrized cecum and multiple strictures in ileum. Laparoscopy-assisted (extracorporeal) resection of affected bowel (terminal ileum and cecum) and ileoascending anastomosis were performed. Histopathological examination of the specimen diagnosed it as enteritis cystica profunda. Laparoscopy can be successfully used as a diagnostic and therapeutic modality in cases with doubtful diagnosis.

Pseudoneoplasms of the gastrointestinal tract

CONTEXT

The pathologist plays the leading role in distinguishing pseudoneoplasms from truly neoplastic lesions in the gastrointestinal tract.

OBJECTIVE

This review was conducted to heighten awareness of pseudoneoplasms, to help differentiate among the various types of pseudoneoplasms, and to help distinguish pseudoneoplasms from malignancies.

DATA SOURCES

This review is based on the medical literature on pseudoneoplasms in MEDLINE and the authors' own experiences. Reference lists of retrieved articles were also reviewed to identify additional articles.

CONCLUSIONS

A classification of pseudoneoplasms, according to the mechanism of injury to the gastrointestinal tract, morphologic patterns, and heterotopia, may be useful in providing a diagnostic framework in which ancillary techniques often have a diagnostic role. Several pseudoneoplasms may be closely associated with true neoplasms (eg, malakoplakia, prolapsetype lesions) because of the nonspecific nature of the response of the intestine to injury.

Pathology of the hereditary colorectal carcinoma

Positive familial history (first or second degree relative) for colorectal carcinoma (CRC) can be found in approximately 30% of all newly diagnosed cases, but less than 5% will be due to a defined genetic category of hereditary CRC. Pathologic examination of the biopsy or resection specimen can help in identification of unsuspected cases of certain forms of hereditary CRC due to the characteristic morphologic findings. Additional immunohistochemical and molecular studies can then provide a definitive diagnosis. The most common form of hereditary CRC is Lynch syndrome (hereditary non-polyposis colorectal cancer, HNPCC) which is characterized by proximally located tumors frequently showing mucinous and medullary type histologic features. The syndrome results from a germline mutation in genes for mismatch repair (MMR) proteins leading to insufficient DNA repair and development of tumors characterized by high levels of instability in short tandem repeat DNA sequences (microsatellites) or "microsatellite instability-high" (MSI-H). The presence of intra-epithelial lymphocytes is single most helpful morphologic feature in identification of CRC caused by deficiency in MMR proteins, for which MSI-H status is a good marker but morphologic features and MSI-H do not differentiate tumors caused by germline mutations in one of the MMR genes (Lynch syndrome) from sporadic CRC due to inactivation of MLH-1 through promoter methylation. Hereditary CRC may also arise in various familial polyposis syndromes which include familial adenomatous polyposis (FAP), attenuated FAP and other multiple adenomas syndromes as well as various hamartomatous polyposis syndromes. All of these rare conditions have characteristic clinical presentation and histopathologic features of polyps and most of them have defined genetic abnormality. Furthermore, due to the germline nature of mutations in these syndromes, various extracolonic manifestations may be the first sign of the disease and knowledge of such associations can greatly improve the quality of care for these patients. The role of pathologist is to recognize these characteristics and initiate appropriate follow up with clinicians and genetic counselors.

Peutz-Jeghers syndrome in a 14-year-old boy: case report and review of the literature

Peutz-Jeghers syndrome (PSJ) is a relatively rare but well-recognized condition, with a prevalence of approximately one in 120,000 births in the USA. It is generally inherited as an autosomal dominant trait, although 35% of cases are new mutations. This disorder is characterized by melanocytic macules on the hands, feet, peri-oral skin and oral mucosa, and multiple gastrointestinal hamartomatous polyps. People with PSJ have an increased risk for developing a variety of malignant tumours. The aim of the present study was to report one case of PSJ in a 14-year-old boy with mucocutaneous pigmentation associated with duodenal hamartomatous polyps.

A novel STK11 germline mutation in two siblings with Peutz-Jeghers syndrome complicated by primary gastric cancer

Patients with Peutz-Jeghers syndrome (PJS) are known to be at risk of gastric cancer (GC), and the STK11 gene is a susceptibility gene for PJS. However, as no cases of PJS with GC in which a STK11 germline mutation has been identified have ever been reported and other susceptibility genes have also been suggested to be involved in PJS, the relation between STK11 germline mutations and GC in PJS is still unknown. In this study, we used sequencing analysis to investigate the STK11, CDH1, and TP53 loci for a germline mutation in two siblings with PJS with primary GC. A novel type of the STK11 germline mutation, c.890delG, encoding a truncated protein (p.Arg297fsX38) was identified, but no germline mutations of the CDH1 and TP53 genes were detected. No inactivation of the wild-type allele by somatic mutation or chromosomal deletion or hypermethylation at the 5'-CpG site of STK11 was detected in the GC. This is the first report of a STK11 germline mutation in a PJS patient with GC and should contribute to establishing correlations between the STK11 germline mutations and GC in PJS patients.

Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is an unusual polyposis syndrome that has enjoyed a rich and somewhat confusing history. Mucocutaneous pigmentation and diffuse gastrointestinal hamartomas are the hallmark features of this autosomal dominant inherited condition. Peutz-Jeghers syndrome is now also recognized as a cancer predisposition syndrome. In this review, we highlight the historical aspects of PJS polyposis with special emphasis on its extraintestinal manifestations, particularly genital tract tumors. A PJS management scheme for clinicians is included.

Enteritis cystica profunda causing ileoileal intussusception in a child

Enteritis cystica profunda (ECP) is an exceedingly rare lesion of the small intestine. It has identical histopathologic features as colitis cystica profunda, which is mainly a disease of adults and a rare benign lesion of the distal colon and rectum of uncertain cause. Only 12 cases of ECP with only one pediatric case, have been reported in English-language medical literature. Here the authors present the second pediatric case of ECP with the literature review and discussion of the etiology.

Colitis cystica profunda: imaging diagnosis and conservative treatment: report of two cases

Rectally localized colitis cystica profunda can simulate mucosecretory carcinoma.

PURPOSE AND METHODS

Because endoscopic examination and barium enema do not clarify the diagnosis, other diagnostic imaging methods such as transrectal ultrasonography, computerized tomography, or magnetic resonance imaging are needed.

RESULTS

Transrectal ultrasonography identifies multiple cysts in the rectal submucosa, with areas of echorefringent fibrosis between cysts, and confirms the absence of lymph node involvement or invasion of the muscular layer. Findings with computerized tomography and magnetic resonance imaging have not previously been described for colitis cystica profunda. With computerized tomography, the lesion appears as a noninfiltrating entity in the submucosa, with loss of perirectal layers of fatty tissue and thickening of the levator ani muscle. With nuclear magnetic imaging, nodulations produce intense signals that increase in T2, illustrating the mucoprotein content of the cysts. The presence in surgical biopsy material of large, whole cysts confirms the diagnosis.

CONCLUSION

Reeducation of bowel habits aimed at avoiding straining and a high-fiber diet together with bulk laxatives can lead to complete remission of lesions in 6 to 18 months.

Enterocolitis cystica profunda lesions in a patient with unclassified ulcerative enterocolitis

Enteritis cystica profunda and diffuse colitis cystica profunda are exceedingly rare conditions. We report here the first case in which these two entities are associated in one patient. This 48-year-old woman presented initially with a solitary ulcer of the rectum and developed later deep ileal and colonic ulcerations with intervening normal mucosa, polypoid masses, and a dense fibrosis of the bowel wall. Colon and ileum specimens demonstrated submucosal mucous cysts and occasionally herniation of mucosal epithelium into the submucosa, which led to the diagnosis of enteritis and colitis cystica profunda. The exact nature of the underlying ileocolonic disease, which necessitated colectomy and extensive ileal resection, remained undetermined although an aggravating role of iterative surgical procedures is possible. Enteritis cystica profunda and diffuse colitis cystica profunda therefore seem to share a common pathogeny and have to be considered as lesions complicating an underlying disease rather than specific and autonomic diseases.

Proctitis cystica profunda in paraplegics. Report of three cases

Proctitis cystica profunda is a benign disease of the rectal mucosa that can be mistaken for rectal carcinoma both grossly and microscopically. Symptoms may consist of blood or mucus in the stool, diarrhea, tenesmus, or rectal pain. The disease has never been reported in a paraplegic population before, but the proposed etiology makes this group seem to be at high risk. We report three cases in our paraplegic population and discuss the nature of the disease as well as its treatment.

Peutz-Jeghers syndrome: a clinicopathologic survey of the "Harrisburg family" with a 49-year follow-up

Of the original Peutz-Jeghers families reported by Jeghers, the "Harrisburg Family" has now been followed for 49 yr. Their 12 affected family members comprise the largest Peutz-Jeghers kindred reported. The course of this family illustrates that Peutz-Jeghers syndrome is not a benign disease. One family member developed a duodenal carcinoma in a hamartoma with adenomatous changes; this progression in the duodenum has not previously been reported. Ten patients underwent 75 polypectomies. One patient developed short bowel syndrome. Three patients died in young adulthood. The development of gastrointestinal malignancy in 2 of 12 affected patients suggests that Peutz-Jeghers syndrome may be a premalignant condition. Consequently, even asymptomatic gastric, duodenal, and colonic polyps should be removed endoscopically. If surgical intervention is necessary, intraoperative endoscopy with polypectomy may prevent the development of a short bowel syndrome. Colonoscopic screening of patients and their family members may be beneficial and surveillance for extraintestinal malignancy appears to be warranted.