Small bowel tumors

Clinicopathological Features of Small Bowel Tumors Diagnosed by Video Capsule Endoscopy and Balloon-Assisted Enteroscopy: A Single Center Experience

Background/Aims

Small bowel malignancies often present a diagnostic challenge due to their relative rarity and nonspecific clinical symptoms. However, technical developments in endoscopic instruments, including video capsule endoscopy (VCE) and enteroscopy, have allowed for the visualization of the entire small bowel. This study aimed to investigate the clinicopathological features of small bowel malignant tumors diagnosed by VCE and double-balloon enteroscopy (DBE) in a single tertiary center.

Methods

We retrospectively analyzed VCE and DBE findings from Korea University Guro Hospital from January 2010 through September 2018.

Results

A total of 510 VCE and 126 DBE examinations were performed in 438 patients. Small bowel malignancies were diagnosed in 28 patients (15 males; mean age, 61.0 years; range, 42 to 81 years). Among them, 8 had lymphoma, 8 had primary adenocarcinoma, 7 had gastrointestinal stromal tumor (GIST) and 5 had metastatic cancer. Abdominal pain and obstructive symptoms were the most common findings in metastatic cancers (4/5, 80%). On the other hand, obscure gastrointestinal bleeding was the most common symptom of GIST (6/7, 85.7%) and adenocarcinoma (3/8, 37.5%).

Conclusions

Approximately 6% of the patients who underwent either VCE or DBE were diagnosed with small bowel malignancy. These findings demonstrated the different clinical characteristics among small bowel malignancies and merit further study.

Capillary hemangioma arising from the lesser omentum in an adult: A case report

RATIONALE

Although capillary hemangiomas, common lesions involving the proliferation of small capillary vessels and a single layer of endothelial cells, can arise in any organ, they are rarely reported in the greater or lesser omentum. Here in, we report a case of capillary hemangioma arising from the lesser omentum in an adult with interesting diagnostic imaging findings, including changes in tumor size over time on computed tomography (CT), that was resected using laparoscopic surgery. To our knowledge, this is the first English report to describe a capillary hemangioma arising from the lesser omentum.

PATIENT CONCERNS

A 63-year-old Japanese man received hemodialysis for chronic renal failure due to diabetic nephropathy, and a small, gradually enlarging tissue mass was found near the lesser curvature of the stomach on plain CT performed annually, without any associated complaints. Diagnostic imaging revealed an 18 × 15-mm tumor with a homogenous, highly enhanced effect in the early phase that was attenuated but prolonged in the delayed phase. Magnetic resonance imaging showed a mass with low signal intensity on T1-weighted imaging and relatively high signal intensity on T2-weighted imaging.

DIAGNOSIS

The patient was diagnosed with capillary hemangioma arising from the lesser omentum according to the pathological and immunohistological findings.

INTERVENTIONS

The patient underwent laparoscopy for excision of the tumor from the lesser omentum.

OUTCOMES

At the 1 year follow-up, the patient had no recurrence of the tumor.

LESSONS

We describe the first case worldwide of capillary hemangioma that was a true vascular tumor arising from the lesser omentum. Although capillary hemangioma arising from the lesser omentum is extremely rare, it should be considered in the differential diagnosis of patients presenting with a highly enhanced lesser omental tumor, and laparoscopy can be safely applied for the excision of this tumor.

Small bowel bleeding: a comprehensive review

The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.

A hemangioma of the sigmoid colon mesentery presenting as a retroperitonealtumor: a case report and review

Hemangiomas of the gastrointestinal tract and mesentery are uncommon benign vascular lesions. While spontaneous bleeding is the hallmark of the gastrointestinal tumor variant, clinical signs of mesenteric hemangiomas are mostly unspecific. Despite the increasing imaging quality of computerized tomography (CT), in most cases the final diagnosis is established through surgery and histopathologic analysis of a macrobiopsy.

We present a case report of a 20-year-old female patient who was admitted with progressive abdominal distension and suffered from persistent abdominal pain for 3 months. A large retroperitoneal tumor mass was detected on the CT scan. Due to radiographic signs of an intraabdominal liposarcoma, an explorative laparotomy was performed revealing a large hemangioma originating from the mesosigmoid.

Although rare, gastrointestinal hemangiomas should be kept in mind by oncological visceral surgeons as one differential diagnosis of large intraabdominal tumorous masses, especially in young adults.

Mesenteric vasculature-guided small bowel segmentation on 3-D CT

Due to its importance and possible applications in visualization, tumor detection and preoperative planning, automatic small bowel segmentation is essential for computer-aided diagnosis of small bowel pathology. However, segmenting the small bowel directly on computed tomography (CT) scans is very difficult because of the low image contrast on CT scans and high tortuosity of the small bowel and its close proximity to other abdominal organs. Motivated by the intensity characteristics of abdominal CT images, the anatomic relationship between the mesenteric vasculature and the small bowel, and potential usefulness of the mesenteric vasculature for establishing the path of the small bowel, we propose a novel mesenteric vasculature map-guided method for small bowel segmentation on high-resolution CT angiography scans. The major mesenteric arteries are first segmented using a vessel tracing method based on multi-linear subspace vessel model and Bayesian inference. Second, multi-view, multi-scale vesselness enhancement filters are used to segment small vessels, and vessels directly or indirectly connecting to the superior mesenteric artery are classified as mesenteric vessels. Third, a mesenteric vasculature map is built by linking vessel bifurcation points, and the small bowel is segmented by employing the mesenteric vessel map and fuzzy connectness. The method was evaluated on 11 abdominal CT scans of patients suspected of having carcinoid tumors with manually labeled reference standard. The result, 82.5% volume overlap accuracy compared with the reference standard, shows it is feasible to segment the small bowel on CT scans using the mesenteric vasculature as a roadmap.

Small bowel tumors discovered during double-balloon enteroscopy: analysis of a large prospectively collected single-center database

BACKGROUND

The emergence of capsule endoscopy and double-balloon enteroscopy (DBE) has greatly enhanced the management of small bowel tumors (SBTs). DBE is particularly useful as a diagnostic modality because it allows for direct investigation of the gastrointestinal lumen, yet little data exist regarding its clinical efficacy.

AIM

: To determine the diagnostic yield of DBE in detection of SBTs.

METHODS

We restrospectively reviewed our large prospectively collected DBE database from September 2005 to May 2012. Patients who were diagnosed with SBTs by DBE were included in the study. The diagnostic yield of DBE in detection of SBTs was calculated by frequency analysis.

RESULTS

A total of 1106 patients underwent 1652 DBE procedures. Of these patients, 134 (12.1%) were found to have an SBT. The majority (56.7%) of patients diagnosed with SBT were male, and the average age at the time of diagnosis was 64 years (SD±14 y). Indications for performing DBE included suspected mass lesion in 54.5% (73/134) of SBT patients, obscure gastrointestinal bleeding in 26.9% (36/134), and overt gastrointestinal bleeding in 14.9% (20/134). The most common SBTs identified were: carcinoid (26/134, 19.4%), hamartoma (14/134, 10.4%), inflammatory polyp (11/134, 8.2%), gastrointestinal stromal tumor (10/134, 7.5%), and lymphoma (10/134, 7.5%).

CONCLUSIONS

DBE is a valuable tool in the evaluation of SBTs. The incidence of SBTs in our patient population was significantly higher than the generally accepted incidence for the overall population, but was comparable with other similar studies. Carcinoid tumor was the most common SBT identified, and was most often seen in the ileum.

Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications

Enteroscopy, defined as direct visualization of the small bowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past several years. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies one of which is non-invasive, the video capsule, and a type of invasive technique, the device-assisted enteroscopy. In particular, the device-assisted enteroscopy consists then of three different types of instruments all able to allow, in skilled hands, to display partially or throughout its extension (if necessary) the small intestine. Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocarcinoma or gastrointestinal stromal tumors. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

The role of endoscopic imaging of the small bowel in clinical practice

Enteroscopy, defined as direct visualization of the small bowel (SB) with the use of a fiberoptic or wireless endoscope, has progressed considerably over the past several years. Technological advancements in the field have facilitated endoscopic evaluation of the SB. This comprehensive clinical review summarizes the latest modalities available to aid gastroenterologists in exploring the SB for evaluation of obscure gastrointestinal bleeding, tumors, inflammatory bowel disease, and celiac disease. Previous physical limitations in equipment that made a complete evaluation of the SB difficult have all but disappeared with the advent of capsule endoscopy, balloon-assisted enteroscopy, and spiral enteroscopy.

Capsule endoscopy in small bowel tumors: a multicenter Korean study

BACKGROUND AND AIM

Capsule endoscopy (CE) has proven to be highly effective at detecting small bowel lesions in a variety of clinical conditions, but studies concerning the practical impact of CE on small bowel tumors are still scarce, especially in the Asian population. The aim of this study was to evaluate the diagnostic and therapeutic impact of CE in the field of small bowel tumors.

METHODS

CE records consecutively pooled from the beginning of use of CE in Korea, October 2001 until April 2008, in 14 centers throughout Korea were reviewed. Clinical information and CE video images of small bowel tumors were analyzed.

RESULTS

A total of 1332 cases undergoing CE were reviewed with all clinical indications. Small bowel tumors were diagnosed with CE in 57 (4.3%) of 1332 patients. The tumors were malignant in 33 cases, and included three adenocarcinomas, eight lymphomas, 20 gastrointestinal stromal tumors, and two metastatic cancers. The most frequent indications for CE in malignant tumors were obscure gastrointestinal bleeding, followed by abdominal pain and weight loss. Thirty of 57 tumors were identified exclusively by CE (diagnostic impact = 30/57), and they were smaller in size (mean, range: 14.3 mm, 2-35 mm) compared to the other tumors detected in radiological studies (48.7 mm, 10-110 mm). Seven patients underwent surgical resection (therapeutic impact = 7/57).

CONCLUSION

CE effectively identifies small bowel tumors that are undetectable by conventional radiological studies (diagnostic impact = 52.6%) and can critically change the therapeutic course (therapeutic impact = 12.3%).

Role of double-balloon endoscopy in the diagnosis of small-bowel tumors: the first Japanese multicenter study

BACKGROUND

The early diagnosis of small-bowel tumors (SBT) was a difficult task until the advent of capsule endoscopy (CE) and double-balloon endoscopy (DBE) allowed access to the disease site. However, although CE and DBE have greatly simplified the task, DBE studies have yet to provide sufficient data on the diagnosis and outcome of patients with SBTs.

OBJECTIVE

To determine the efficacy of DBE examination in the detection and diagnosis of SBT.

DESIGN

A retrospective analysis of cross-sectional case series.

SETTING

Seven major medical centers in Japan.

PATIENTS

The first 1035 consecutive DBE cases at these major Japanese centers since the introduction of DBE.

MAIN OUTCOME MEASUREMENTS

The percentage of subjects with SBT and a diagnosis of SBT, their indications for DBE, and diagnostic and therapeutic DBE procedures carried out for SBT.

RESULTS

SBTs were identified in 144 of 1035 subjects (13.9%) who underwent DBE between September 2000 and December 2005. For subjects with SBT, the most common indication for DBE was the suspected presence of a SBT (61/144 [42.4%]). For subjects without SBT, the most common indication was obscure GI bleeding (OGIB) (419/891 [47.0%]). Malignant lymphoma and GI stromal tumor (GIST) were the most frequent (31/144 [21.5%]) and the second-most frequent SBTs (27/144 [18.8%]), respectively, in this database. We also performed 85 biopsies and 45 therapeutic procedures for the evaluation and treatment of SBTs in 144 patients. Although complications were encountered in 5.3% of cases (14/266 sessions), none of these were life threatening in the present study.

CONCLUSION

DBE proved a valuable tool for the detection and diagnosis of SBTs, especially when tumors were suspected. Biopsies and therapeutic procedures were also possible in most of these patients, which directed our management of the disease.

Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability

BACKGROUND

The rapid expansion in use of capsule endoscopy (CE) has led to discussion about training needs and provision. The lesion recognition skills required for CE are ideally suited to computer-based training.

OBJECTIVE

The aim of this study was to prospectively evaluate the educational effectiveness of a computer-based CE training and testing module on trainees with varying experience.

DESIGN

This was a prospective educational evaluation study.

SETTING

Academic endoscopy unit.

PATIENTS

This study involved 28 trainees of varying CE experience (medical students, gastroenterology trainees) and 4 CE experts.

INTERVENTION

Trainees (medical students and gastroenterology trainees) without CE experience completed a 60-question, computer-based test module consisting of 30-second video clips and multiple-choice questions. Without feedback, trainees then completed a comprehensive, menu-driven, computer-based CE training module. The test module was then completed a second time and feedback was given. Expert performance on the test module was benchmarked by 4 CE experts.

MAIN OUTCOME MEASUREMENTS

The first measure was the difference in baseline performance on the test module between trainees and experts (to determine construct validity). The second measure was a change in performance on the test module after training (to determine content validity of the training module).

RESULTS

A significant difference was noted in baseline performance (P < .001) among CE experts (mean 73.8% +/- 8.0%), gastroenterology trainees (49.5% +/- 10.9%), and medical students (29.5% +/- 3.3%). Performance improved significantly (P < .001) in both trainee groups after training (gastroenterology trainees' posttraining score 62.1% +/- 7.7%; medical students' 46.7% +/- 6.8%).

CONCLUSION

Computer-based learning has a potentially significant role in the development of a training syllabus for CE and in CE accreditation.

A rare cause of recurrent gastrointestinal bleeding: mesenteric hemangioma

Lower gastrointestinal hemorrhage accounts for approximately 20% of gastrointestinal hemorrhage. The most common causes of lower gastrointestinal hemorrhage in adults are diverticular disease, inflammatory bowel disease, benign anorectal diseases, intestinal neoplasias, coagulopathies and arterio-venous malformations. Hemangiomas of gastrointestinal tract are rare. Mesenteric hemangiomas are also extremely rare.We present a 25-year-old female who was admitted to the emergency room with recurrent lower gastrointestinal bleeding. An intraluminal bleeding mass inside the small intestinal segment was detected during explorative laparotomy as the cause of the recurrent lower gastrointestinal bleeding. After partial resection of small bowel segment, the histopathologic examination revealed a cavernous hemagioma of mesenteric origin.Although rare, gastrointestinal hemangioma should be thought in differential diagnosis as a cause of recurrent lower gastrointestinal bleeding.

Wireless capsule endoscopy indication as a predictor of study quality

PURPOSE

The aim of the study was to assess whether specific indications are associated with poor visualization during wireless capsule endoscopy (WCE) studies . Four hundred consecutive WCE studies performed at our institute were analyzed retrospectively.

RESULTS

Data was available on cases involving 176 males and 224 females. About 23 capsules failed to exit the stomach (excluded from the study). Poor visualization was reported in 66 (17%) WCE studies. The most common indications were gastrointestinal (GI) blood loss (271 cases; 72%), abdominal pain and/or diarrhea (73 cases; 19%), and suspected inflammatory bowel disease (46 cases; 12%). Of the 271 patients suffering GI bleeding, visualization was reported to be poor in 53 (19%) patients; among those showing other indications, visualization was poor in 13 (11%) patients (P = 0.02). After controlling for secondary indications and age, GI bleeding was associated with a higher rate of poor visualization compared to all other indications (odds ratio 2.6; 95% confidence interval 1.4-6.8).

CONCLUSIONS

Gastrointestinal bleeding as study indication for WCE is associated with a higher rate of poor visualization.