Small bowel neoplasm a diagnostic dilemma

Although uncommon, small bowel tumors often present as a diagnostic dilemma for the clinicians. This important clinical entity requires various diagnostic steps and quite often these steps have to be repeated to reach a firm diagnosis. We present here our experience with three such cases and a brief review of the literature regarding the presentation and the diagnostic steps found helpful in arriving at a diagnosis. A 37 years old female was evaluated at the hospital with recent history of menorrhagia. She presented with a two week history of post-prandial nausea and vomiting. About four days prior to admission she developed 6-8 watery stools without any blood or mucous, but with cramps and urgency. Physical examination was unremarkable. Investigation showed Hemoglobin [Hb] 115 g/l with microcytosis. She was investigated with a chest X-Ray; abdominal X-Ray, abdominal CT scan and stool examination which were all non-contributory. An endoscopic examination of colon and at least twenty cms of distal ileum was normal. A biopsy of cecum was reported as showing microscopic colitis. Subsequently, with improvement in her symptoms, the patient was discharged home on Pentasa, [5-amino salicylic acid] ferrous gluconate and Provera[Medroxyprogesterone acetate]. An upper GI follow-through was obtained as an outpatient which showed thickened valvulae conniventes, most marked in ileum. Three months later due to persistence of abdominal pain, enteroclysis was performed. Except for somewhat narrowed lumen of terminal ileum, no other abnormalities were noticed. Anti-reticulin and anti-mycelial antibodies along with an anti-nuclear antibody [ANA] were found to be negative. Lower abdominal crampy pain, vomiting and diarrhea prompted another in-hospital evaluation. Upper GI endoscopy and small bowel biopsy were both normal. CT scan of abdomen and pelvis showed ascites and thickened small bowel loops. Small bowel follow-through revealed mucosal irregularities with wall thickening. A surgical opinion suggested exploration laparotomy, three feet of the mid-jejunum was removed. Pathological evaluation of the specimen showed a jejunal Leiomyosarcoma

review: Pathogenesis of vitiligo

Vitiligo is a disease of unknown etiology characterized by depigmentation of the skin secondary to the local destruction of melanocytes. In this review of the pathogenesis of vitiligo, information has been assimilated from clinical studies, histologic features, genetic studies, tissue culture experiments, animal models and therapeutic studies in an attempt to enhance our understanding of its pathogenesis. It is clear that there is no single hypothesis to unify all the observations. Postulated mechanisms of the neuro-chemical theory, self-destructive and immune theories seem to act cooperatively. The extent of the role played by each may vary from one patient to the other. It appears that most patients produce an anti-melanocyte antibody. However, a significant number of patients produce other autoantibodies and have ocular problems. There are very important lacunae in the present understanding of the pathogenesis of vitiligo. We anticipate that the new techniques of molecular biology will significantly enhance the understanding of this ancient disease