Pneumatosis cystoides intestinalis associated with gastric outlet obstruction; A case report

INTRODUCTION AND IMPORTANCE

Pneumatosis cystoides intestinalis (PCI) is defined as the presence of air-filled cysts in the bowel wall. The overall incidence of pneumatosis cystoides intestinalis in the general population is very rare.

PRESENTATION OF CASE

This is a 44-year-old male patient who presented with epigastric abdominal pain and repeated vomiting of one-month duration. The patient was emaciated; vital signs were within normal limits. The abdomen was grossly distended. Laboratory tests, radiologic imaging, and upper gastrointestinal endoscopy were performed. The diagnosis of gastric outlet obstruction (GOO) secondary to peptic ulcer disease cicatrization along with the coincidental finding of PCI with hepato-diaphragmatic interposition of the small bowel (Chilaiditi sign) was made. Truncal vagotomy, gastrojejunostomy, and Braun jejunojejunostomy was performed. Adhesionolysis and repositioning of the ileum back into its' normal infracolic location was also done.

CLINICAL DISCUSSION

The causes of PCIs are multifactorial; however, the exact etiology is not well known. PCIs have a wide range of non-specific presenting symptoms such as bloody stools, diarrhea or constipation, vomiting, abdominal pain, flatulence, and weight loss. The diagnosis of PCI is made based on endoscopy and radiographic evaluation of the alimentary tract. The appropriate therapy depends on the underlying etiology and the presence of complications.

CONCLUSION

In the absence of complication, PCI can be managed conservatively. However, in the presence of an indication for surgery, PCI related with bowel interposition in the hepato-diaphragmatic space; concomitant repositioning and adhesion release may help to alleviate the symptoms and prevent further complication of PCI.

Giant retroperitoneal well differentiated liposarcoma: A case report and literature review

INTRODUCTION AND IMPORTANCE

The most prevalent type of primary retroperitoneal tumors is soft tissue sarcoma (STS). Liposarcoma accounts for 40 % of retroperitoneal tumors (Mack, 1995). Retroperitoneal liposarcoma accounts for 12 % to 40 % of all liposarcomas (Vijay and Ram, 2015). They typically present with advanced disease and often carry a poor prognosis. Because of their rarity and anatomic location, these malignant tumors can cause a diagnostic dilemma and present several therapeutic challenges (Vijay and Ram, 2015).

CASE PRESENTATION

A 48-year-old male patient presented to our gastrointestinal oncology clinic with a 2-year history of abdominal discomfort, weight loss and steadily growing abdominal swelling. A soft, rubbery lobulated mass with a positive "slippage sign" was palpable over all the quadrants of the abdomen. CT scan conclusion was retroperitoneal lipoma with internal enhancing nodular components. During laparotomy, a fatty mass measuring 55*60*22 cm and weighing 14 kg was excised. Histopathologic report showed a well differentiated liposarcoma (WDLS).

CLINICAL DISCUSSION

Giant retroperitoneal liposarcoma (RPL) is exceedingly rare. Liposarcomas have diverse MRI and CT appearances due to the various subtypes. WDLS are difficult to identify from lipomas before surgery. Histopathology is the only way to provide a reliable diagnosis; therefore en block resection is the recommended approach when malignancy cannot be ruled out.

CONCLUSION

Although imaging with ultrasound, CT, and MRI can aid in the diagnosis, differentiating WDLS from lipoma pre-operatively can be difficult, and en block resection is the recommended approach when malignancy cannot be ruled out.

An inflammatory myofibroblastic tumor of the small intestine presenting as jejunojejunal intussusception; A case report

INTRODUCTION AND IMPORTANCE

An inflammatory myofibroblastic tumor (IMT) is an uncommon solid neoplasm of mesenchymal origin. They are usually seen in children and adolescents and commonly affect the lung, but they can nearly arise from every organ. The prevalence of IMT in the small bowel is very rare. The tumors have generally a benign clinical course, with some risk of local recurrence or distant metastasis.

PRESENTATION OF CASE

This is a 55-year-old male patient who presented with intermittent abdominal pain, vomiting of ingested matter and loss of appetite for 2 weeks duration. On physical examination, he had stable vital signs and the abdominal examination was non-revealing. Abdominal CT scan with contrast showed a long segment jejunojejunal intussusception. He underwent en-bloc resection of the mass and end-to-end anastomosis of the jejunum.

CLINICAL DISCUSSION

IMTs have a mesenchymal origin and are grouped into a mixture of fibroinflammatory disorders. They show a variable mix of inflammatory cells with spindle cells. The diagnosis of IMT preoperatively is challenging often mimicking malignant lesions. The diagnosis is often confirmed by histopathology after surgery. Complete excision with a negative margin is the preferred treatment. We report a rare case of jejunal IMT presenting with intussusception.

CONCLUSION

An intestinal IMT is a rare and an underdiagnosed entity, and should be considered in the differential diagnosis of small bowel intussusception. Surgery is still the most favored and effective treatment for intestinal IMT. Complete surgical excision with a negative margin has the least chance of disease recurrence.

Giant lipoma of the colon presenting as a case of adult intussusception: A case series

INTRODUCTION AND IMPORTANCE

Lipoma of the intestine is one of the uncommon benign tumors of the alimentary tract first reported by Bauer in 1957. The peak incidence is usually seen between 50 and 60 years of age and more commonly in females. They are usually either asymptomatic or mildly symptomatic. The occurrence of symptoms is mostly related to the diameter of the lesion.

PRESENTATION OF CASE

We present a single center consecutive case of three patients who had giant colonic lipomas presented with colonic intussusception. Two of the cases presented for the first time with an emergency condition: acute intestinal obstruction. The mode of presentation, diagnosis, and management outcome of colonic lipoma was assessed.

DISCUSSION

Symptomatic lipoma may present with non-specific abdominal pain, change in bowel habits, intussusception, and hemorrhage. The clinical diagnosis is usually challenging, given the non-specificity of symptoms of the disease. Computed tomography is considered to be a diagnostic modality of choice in recognizing the presence of lipoma. However, a definitive diagnosis of lipoma is usually obtained after a histopathologic examination of the resected specimen. The management of colonic lipoma depends on the size of the lesion and the presence or absence of symptoms.

CONCLUSION

Colonic lipoma is a rare benign tumor that occurs in the elderly, frequently misdiagnosed as a malignant tumor. Despite the rarity of the disease, lipoma should be considered in the differential diagnosis of large bowel tumors and adult intussusception.

A rare case of huge intra-abdominal cystic lymphangioma arising from rectovesical pouch; a case report

INTRODUCTION AND IMPORTANCE

Lymphangiomas are benign maldevelopment of the lymphatic vessels; they classically occur in the head and neck region. They are usually seen in newborn and pediatric age groups, especially below two years of age, and rarely occur in adults.

PRESENTATION OF CASE

A 27-year-old male patient presented with progressive abdominal swelling of two-year duration. He had also difficulty breathing from the mass effect of a huge intra-abdominal mass. He was emaciated; vital signs were in the normal range, except for tachypnea. His abdomen was hugely distended, tense, dull to percussion, and the umbilicus was everted. CT scan revealed a multiseptated cystic mass. He underwent complete surgical excision with ligation of the cyst peduncle. The diagnosis of cystic lymphangioma was confirmed after a histopathologic examination.

CLINICAL DISCUSSION

Lymphangiomas have an incidence rate of one in every 20,000 to 250,000 populations. The clinical presentation of abdominal cystic lymphangioma is non-specific and is related to the size, and location of the tumor. The preoperative diagnosis of abdominal cystic lymphangioma is often challenging and leads to misdiagnosis. The management of abdominal cystic lymphangioma depends on the mode of presentation and location of the tumor. It has good prognosis after complete surgical resection of the tumor.

CONCLUSION

Abdominal cystic lymphangioma arising from the rectovesical pouch is a very rare condition. The best management is complete surgical resection to prevent a recurrence. Despite, the rarity of the disease in adults they should be considered as a differential diagnosis in cystic abdominal tumors.

Unusual presentation of GIST associated with type 1 neurofibromatosis: A case report

INTRODUCTION AND IMPORTANCE

Type 1 neurofibromatosis (NF1) is an autosomal dominant disorder caused by NF1 gene mutation, which is associated with several types of tumors. GIST is an intestinal stromal tumor arising from interstitial cells of Cajal in the intestine. GIST is one of the neoplasms seen in NF1 and usually affects elderly individuals with a median age around 60-65 years but rarely occur in children, adolescent and young adults.

CASE PRESENTATION

An 18-year-old male patient presented to our hospital with abdominal swelling of one-year duration. He also has multiple skin nodules and café au lait spots all over his body. Objectively, the abdomen is grossly distended; with a palpable non-tender mobile mass above the umbilicus measuring 20 × 15 cm. CT imaging of the abdomen and histologic examination of the skin lesion was done. The diagnosis of GIST was made and surgical resection followed by adjuvant therapy with imatinib was given.

CLINICAL DISCUSSION

Patients who have a gene mutation in NF 1 have a high probability (7 %) of developing GIST and mostly occur in the small intestine, whereas our finding was solitary GIST localized to the stomach. NF 1-associated GISTs are very rare and account for <5 % of all GISTs. The standard therapy for GIST is surgical resection of the tumor. Targeted therapy with tyrosine kinase inhibitors is an effective adjuvant therapy in patients harboring KIT/PDGFRA mutation.

CONCLUSION

The incidence of GIST is higher in NF1 patients than in the general population. The definitive diagnosis of GISTs preoperatively is usually challenging and is usually confirmed by immunohistochemistry. NF1-associated GISTs are mainly treated with surgery and have limited response to tyrosine kinase inhibitors.