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

Asymptomatic Ileal Schwannoma presenting as a Mesenteric Tumour: Case report and review of literature

A schwannoma is a benign tumour which arises from the schwann cells of the central or peripheral nervous system. Common sites include the head and limbs; it is rare that this tumour arises from the gastrointestinal tract's neural plexus. It is even rarer to find the ileum as the site of origin. We report a patient who presented with a central abdominal mass which was preoperatively diagnosed as a mesenteric tumour. However, immunohistochemistry of the surgically-removed specimen proved it to be a benign ileal schwannoma.

Adenomyoma of the jejunum

Adenomyoma of the small intestine is an extremely rare condition characterized by abnormal glandular structures surrounded by smooth muscle. We report a case of adenomyoma of the jejunum. The patient was a 61-year-old female with cancer of the sigmoid colon and multiple liver cysts, who was sent to the operation room for exploratory laparotomy and sigmoidectomy. At surgery, a polypoid lesion was incidentally found in the lower jejunum, which was resected. On histologic examination, the morphologic features were typical of adenomyoma. However, new histopathological and immunohistochemistry features are described here, providing evidence that adenomyoma of the jejunum is a form of intestinal epithelial hamartoma.

Brunner's gland hyperplasia: treatment of severe diffuse nodular hyperplasia mimicking a malignancy on pancreatic-duodenal area

Brunner's gland hyperplasia is a benign tumor of the duodenum and it is rarely associated with clinical symptoms. We report on a 64-yr-old man with Brunner's gland hyperplasia who had undergone a duodenocephalo-pancreatectomy. The reason is that he presented upper gastrointestinal obstructive symptoms and the esophagogastroduodenoscopic finding revealed the lesion to be an infiltrating type mass on the second portion of the duodenum with luminal narrowing. An abdominal computed tomography showed a 2.5 cm-sized mass in the duodenal second portion with a suspicious pancreatic invasion and 7 mm-sized lymph node around the duodenum. Duodenocephalopancreatectomy was successfully performed. Histological examination revealed a Brunner's gland hyperplasia. The final diagnosis was the coexistence of Brunner's gland hyperplasia and pancreatic heterotopia with a pancreatic head invasion. The literature on Brunner's gland hyperplasia is reviewed.

Ileal schwannoma developing into ileocolic intussusception

Intussusception is rare in adults. We describe a 47-year-old man with ileal schwannoma that led to ileocolic intussusception. Abdominal ultrasonography, abdominal CT scan and barium enema confirmed an ileal tumor. Colonoscopy revealed a peduncular submucosal tumor (SMT) 75 mm long with an ulcerated apex at the ascending colon. The provisional diagnosis was a gastrointestinal stromal tumor of the terminal ileum. Ileocecal resection was carried out and the tumor was histologically diagnosed as schwannoma. Abdominal pain resolved postoperatively. This case reminds us that ileal schwannoma should be included in the differential diagnosis of intussusception caused by an SMT in the intestine.

A shift in the diagnostics of the small intestine tumors

Primary, secondary, benign or malignant tumorous diseases of the small intestine are rare. They are very often diagnosed by accident or as a cause of acute abdomen. This work should answer the question, whether there is a method of making the diagnosis earlier when the disease is limited and easy to cure.

METHODOLOGY

A retrospective study comprising 96 patients having undergone surgery for a small intestine tumor in our hospital from 1996 to 2005 is presented. An analysis of first symptoms, diagnostic methods and number of patients admitted during the years was made. In the year 1998 we changed our philosophy in trying to directly detect the small intestine pathology and not making the diagnosis by the exclusion only. Intestinal ultrasound was performed on the Ultramark 3000 HDI device with autofocussable convex 5 MHz and linear 7.5 MHz probes or nowadays ATL 5000 HDI, 7-12 MHz linear probe. No contrast enhancement was used. Abdominal CT engaged Somatom Plus appliance by Siemens, single detector with our conventional abdominal CT protocol. Enteroclysis was done with Micropaque suspension diluted 1:1 with HP-7000 300 ml with its application rate of 75 ml/min followed by HP-7000 solution 2000 ml, application rate of 120 ml/min.

RESULTS

We treated surgically 96 patients with the small intestine tumor. A shift in the diagnostic algorithm was noticed in the bowel ultrasound now taking the lead. An enlarged portion of patients diagnosed by means of capsule endoscopy was also seen. An increase of surgically treated patients after 1998 was recorded and the majority of them could be offered an elective laparoscopic surgery in contrast to before 1998 when the majority of them had undergone surgery for an acute abdomen.

CONCLUSION

The small bowel ultrasound can be recommended as the first choice method. All patients with even very moderate abdominal symptoms ought to be examined for the small intestine pathology. As a result one can get higher rate of elective surgery, if possible laparoscopic and higher number of R0 resections accompanied by longer survival.

Myoepithelial hamartoma causing small-bowel intussusception: a case report and literature review

We report an unusual case of a 5-month-old girl who suffered an ileo-ileal intussusception that was not reduced by hydrostatic reduction. Surgical treatment revealed that the leading point was a tumor 1.5 cm in diameter. Myoepithelial hamartoma was diagnosed histopathologically. The literature indicates that MEH rarely causes small-bowel intussusception in childhood.

CT enteroclysis: technique and clinical applications

CT enteroclysis (CTE) has been gradually evolving with technical developments of spiral and multidetector row CT technology. It has nowadays become a well-defined imaging modality for the evaluation of various small bowel disorders. Volume challenge of 2L of enteral contrast agent administrated to the small bowel via a nasojejunal catheter ensures luminal distension, the prerequisite for the detection of mural abnormalities, also facilitating the accurate visualization of intraluminal lesions. CT acquisition is centered on small bowel loops, reconstructed in thin axial slices and completed by multiplanar views. Image analysis is essentially done in cine-mode on work-stations. CTE is of particular diagnostic value in intermediate or advanced stages of Cohn's disease, including the depiction of extraintestinal complications. It has become the imaging modality of choice for the localization and characterization of small bowel tumors. The cause and degree of low-grade small bowel obstruction is more readily analyzed with the technique of CTE than conventional CT. Limitations of CTE concern the assessment of pure intestinal motility disorders, superficial mucosal lesions and arteriovenous malformations of the small bowel, which are not consistently visualized. CTE should be selectively used to answer specific questions of the small bowel. It essentially contributes to the diagnostic quality of modern small bowel imaging, and therefore deserves an established, well-defined place among the other available techniques.

Neoplasias do intestino delgado: experiência de cinco anos

OBJETIVO: Analisar a experiência do Serviço de Cirurgia Geral - HC/UFPE com os tumores do intestino delgado, na tentativa de colaborar com a definição de metas para o manejo dessas lesões. MÉTODO: Constitui-se este estudo em uma análise retrospectiva de12 pacientes portadores de neoplasias intestinais atendidos no SCG-HC/UFPE, no período de cinco anos (1994-1999). Sete eram do sexo masculino (58%). A média de idade à admissão foi de 52 anos. A principal queixa referida foi dor abdominal (83%), seguida por sangramento digestivo e perda ponderal (42%). Massa abdominal palpável foi evidenciada em 50% dos casos. Sete (58%) apresentavam lesões malignas. Dentre as neoplasias benignas, quatro eram leiomiomas. Uma paciente, portadora de síndrome de Peutz-Jeghers, apresentou um hamartoma. Dez foram submetidos a tratamento operatório. Em seis, enterectomia com enteroanastomose foi empregada. Três foram operados em caráter de urgência (um por perfuração intestinal, um por enterorragia maciça e um por obstrução intestinal). RESULTADOS: A mortalidade relacionada à operação foi de 17%. Todos os pacientes que evoluíram para óbito apresentavam neoplasias malignas avançadas e perda ponderal superior a15% de seu peso. CONCLUSÕES: Tumores do intestino delgado são lesões incomuns, mesmo em serviços de referência. Um alto grau de suspeição deve ser mantido visando o diagnóstico precoce.

Hypotonic duodenograms of postbulbar duodenal lesions: pictorial essay

General features are described and examples are provided of the radiological manifestations of postbulbar duodenal lesions, particularly the findings on hypotonic duodenograms. Hypotonic duodenography does not always reveal the characteristic findings of postbulbar duodenal lesions, but it helps to evaluate luminal stenosis and diagnose disease entities even in lesions that show non-specific findings. Radiologists should be familiar with the radiological findings of postbulbar duodenal lesions and know which kinds of lesions can affect the postbulbar duodenum. This is important in making a differential diagnosis and in preventing delays in diagnosis.

Imaging of primary small intestinal tumours by enteroclysis and CT with pathological correlation

Preoperative diagnosis of primary small intestinal neoplasms can be a challenge for both clinicians and radiologists. As a result of their infrequent occurrence, they invariably present difficult problems in diagnosis and management. These problems are reflected mainly in the delayed treatment and a very poor prognosis for such malignant tumours. Their morphological changes, however, shown in enteroclysis and CT, correlate almost perfectly with the lesions identified in the gross pathological specimens. This ability to accurately image a small intestinal neoplasm, independently of its size, anatomical localization and growing tendency, represents a major improvement in the diagnosis and management of these neoplasms. This paper, based on a large series of patients with primary small intestinal neoplasms, focuses on the recognition of their detailed radiological appearances when evaluated by enteroclysis and CT.

Adult enteric intussusception: additional observations on enteroclysis

Enteroclysis patterns encountered in four patients with adult intestinal intussusception of different etiology--including a leiomyoma, a Peutz-Jeghers hamartoma, a metastatic colon carcinoma, and adhesions--were analyzed and compared to surgical and pathological findings. Emphasis was given not only to radiological signs indicative of impaired circulation but also to the preoperative evaluation of the stimulating cause. A "stretched spring" pattern, corresponding to increased distance between large and thick concentric rings, was found to conform to a stage of strangulation with exudation, whereas sharply demarcated fine rings in close proximity were suggestive of the absence of vascular impairment. The morphology of the underlying lesion was also shown to conform to the dynamic appearance of the intussusception. Benign submucosal, intraluminal tumors led to a long, rather permanent intussusception, with the tumor being the leading point; whereas intussusception associated with annular malignancies or adhesions was shorter and transient or partial, as fixation was present. The cause of the intussusception was correctly identified preoperatively in each case; the vascular compromise involved was also indicated, and the correlation between radiological appearances and morphology at pathology specimens was excellent.