A Case of Multiple Gastrointestinal Stromal Tumor of the Jejunum Which Was Diagnosed by Capsule Endoscopy / 대한소화기학회지

More than 90% cases of chronic gastrointestinal bleeding can be diagnosed by upper endoscopy and/or colonoscopy, and therefore, obscure gastrointestinal bleeding has been defined as bleeding of unknown origin that persists after these conventional endoscopic evaluation. Gastrointestinal stromal tumors (GISTs) are rare tumors, but the most common form of mesenchymal tumors of the gastrointestinal tract. Small bowel is the second most common primary site for GISTs, and accounts for 2-10% of chronic bleeding sites. GISTs usually present as a sporadic and solitary tumor, and a minority of the cases of multiple GISTs are discovered as forms of hereditary or idiopathic tumor syndromes. Small bowel tumor has been difficult to diagnose because of absence of accurate and proper diagnostic tools. Recently developed wireless capsule endoscopy helps in the diagnostic work-up of small bowel diseases. We report a case of multiple jejunal GISTs presenting melena in a 39-year-old male, which was diagnosed with wireless capsule endoscopy.

Enfermedad Celiaca y Obstrucción Intestinal por Linfoma de Células T / Celiac disease and intestinal obstruction by T cell lymphoma

Paciente varón de 55 años, raza blanca (ascendencia española), natural y procedente de Ayacucho, que ingresó por una enfermedad de seis meses de evolución, caracterizada por dolor abdominal tipo cólico y baja ponderal de 10 Kg. Había estado hospitalizado seis meses antes y dado de alta con el diagnóstico de síndrome de intestino irritable. Entre sus antecedentes refería intolerancia a la lactosa y artritis reumatoidea. Los exámenes mostraron: Hb:12 g/dl, leucocitos: 5260 cel/mm, abastonados: 11%, albúmina: 2,7 mg/ml y VSG: 33mm/h. El resto de exámenes -incluyendo los marcadores tumorales- fueron normales. El tránsito gastrointestinal mostraba las asas delgadas con fragmentación del bario y dilatación focal moderada de un asa yeyunal distal. La tomografía de tórax, abdomen y pelvis sin alteraciones; Rx tórax normal. La colonoscopia fue normal; el íleon tenía pocos pliegues y pequeñas nodulaciones, las biopsias indicaron "ileitis inespecífica". La endoscopia mostró gastritis y una cicatriz de úlcera duodenal; la mucosa duodenal mostraba áreas con aspecto de mosaico rosado-blanquecino. La biopsia duodenal evidenció acortamiento de vellosidades, infiltrado inflamatorio crónico e incremento de linfocitos intraepiteliales, hallazgos compatibles con los criterios de celiaquía Marsh-tipo 3. Los anticuerpos IgA antiendomisio y antitransglutaminasa tisular estaban incrementados. Durante su hospitalización aumentó el dolor y aparecieron signos de obstrucción. En la laparotomía se encontraron una tumoración yeyunal estenosante y una perforación adyacente. El espécimen mostró un linfoma intestinal de células T. Se ha demostrado que existen más celiacos subclínicos que celiacos con esprue clásico; el conocimiento de esta situación nos debe llevar a tenerla presente por sus complicaciones o asociaciones, una de las cuales es el linfoma primario intestinal.

A male patient, 55 years old, born in Ayacucho, with Spanish ancestors, was hospitalized through emergency referring abdominal pain, and 10 kilograms weight loss. Six months before he was diagnosed as having irritable bowel syndrome. His previous diseases were rheumatoid arthritis and intolerance to lactose. Laboratory results were: Hb 12 gr./dL, white cells 5200 per mm3, albumin 2.7 gr./dL, erythrocyte sedimentation rate 32 mm/hr., and tumor markers were negative. Radiographic study of the small bowel showed barium fragmentation, and a focal dilation in distal jejunum. Chest X-ray and CT scan of thorax, abdomen and pelvis were normal. Colonoscopy was normal for colonic mucosa, but in ileum it showed an irregular mucosa, little nodules and fewer folds than usual. Biopsy from ileum demonstrated unspecific inflammation. Upper endoscopy showed gastritis, a duodenum scar ulcer and an irregular mosaic pattern pink and white. Duodenum biopsy demonstrated short villi, chronic inflammation and an increase in the number of intraepithelial lymphocytes, all these was consistent with celiac disease Marsh 3. Antibodies anti-endomisium and anti-transglutaminase were positive. After some days he developed signs of bowel obstruction and was operated. A tumor was found in jejunum with a bowel perforation. Pathological study showed a small bowel T-cell lymphoma. Fortunately this patient did well, and was sent home to continue treatment on ambulatory basis. Celiac disease is more common than what is thought, and it has been demonstrated that there are more persons with subclinical celiac disease, than those with the typical clinical pattern. It is necessary to be aware of this disease to improve diagnosis in order to avoid late complications as small bowel lymphoma.

GIST Yeyunal con Sangrado Digestivo de Origen Oscuro / Jejunal GIST with obscure gastrointestinal bleeding

Reportamos el caso de una mujer de 84 años con antecedentes de arritmia cardiaca y hemorroides. Tenía múltiples hospitalizaciones y transfusiones por anemia ferropénica sintomática; los estudios endoscópicos solo demostraron divertículos y pequeños pòlipos de colon. Posteriormente fue hospitalizada por presentar heces sanguinolentas de color rojo vinoso; la endoscopia alta indicó gastritis y la colonoscopia mostró pequeñas úlceras colónicas, un pólipo colónico y múltiples divertículos. Meses después, reingresó con hemorragia de origen oscuro; en esa ocasión se demostraron: gastritis, erosiones antrales, pequeños pólipos colónicos y úlceras colónicas en vías de cicatrización; la cápsula endoscópica mostró probable angiodisplasia en yeyuno medio, la enteroscopia anterógrada detectó en yeyuno proximal algunas lesiones eritematosas sin evidencia de sangrado activo. Volvió a ser hospitalizada por melena y dolor abdominal, la endoscopia alta mostró angiodisplasias gástricas y duodenales que fueron tratadas. El último ingreso indicó un tiempo de enfermedad de dos años, el episodio se caracterizó por presentar deposiciones rojo vinosas y anemia. La endoscopia mostró angiodisplasia gástrica, que fue tratada con termocoagulación con argón plasma. En el examen no presentó signos de descompensación hipovolémica. Enfocado como un problema de hemorragia digestiva de origen oscuro se repitieron varios exámenes endoscópicos sin resultados. Resangró estando hospitalizada, se realizó cápsula endoscópica que demostró sangrado agudo en yeyuno, se complementó con nueva enteroscopia anterógrada que mostró lesiones ulceradas de yeyuno, se marcó el área con tinta china y se indicó laparotomía exploratoria. En la intervención quirúrgica se encontró en borde antimesentérico de yeyuno, una tumoración redondeada (6x6x4.5 cm) de crecimiento extraluminal, que comprometía la pared sin adherirse a otras estructuras; se realizó resección del tumor y anastomosis yeyuno-yeyunal. El estudio histológico -con inmunohistoquímica- del espécimen mostró que se trataba de un Tumor Estromal Intestinal (GIST), de riesgo intermedio, patrón histológico fusiforme, con escasas mitosis, dependiente de la capa muscular propia del intestino delgado. En conclusión el presente caso se trata de una mujer con un GIST yeyunal cuya presentación clínica fue una hemorragia de origen oscuro que constituyó un problema diagnóstico y que gracias al advenimiento de los nuevos procedimientos endoscópicos (enteroscopia y cápsula endoscópica) fue localizada y posteriormente extirpada quirúrgicamente.

We report the case of a woman of 84 years with a history of cardiac arrhythmia and hemorrhoids. She had multiple hospitalizations and transfusions for symptomatic iron deficiency anemia, endoscopic studies showed only small diverticula and colon polyps. He was later hospitalized with bloody stools red wines, upper endoscopy and colonoscopy showed gastritis, small colonic ulcers, colonic polyp and multiple diverticula. Readmitted with bleeding of obscure origin, on that occasion showed gastritis, antral erosions, small ulcers, colon polyps and colon ulcers in the process of healing, capsule endoscopy showed angiodysplasia in jejunum, anterograde enteroscopy detected some erythematous lesions in proximal jejunum without evidence of bleeding. Again hospitalized for melena and abdominal pain, upper endoscopy revealed gastric and duodenal angiodysplasia were treated. The last entry indicated a time of two years disease, the current episode with wine-red colored stools, Hb: 8.4 g, for which he received two units of PG. Endoscopy showed gastric angiodysplasia, which was treated with thermocoagulation (argon plasma). In the entrance examination showed no signs of hypovolaemic decompensation. Approached as a problem of obscure gastrointestinal bleeding were repeated several endoscopic examinations without results. She re-bled being hospitalized, capsule endoscopy was performed showing acute bleeding in the jejunum, complemented by new anterograde enteroscopy that showed ulcerated lesions of the jejunum, the area was marked with indian ink. Exploratory laparotomy was indicated. In the surgical intervention it was in edge antimesentérico of yeyuno, a round tumor (6x6 cm) of extraluminal growth, which compromised the wall without sticking to other structure, Resection of the tumor and jejuno-jejunal anastomosis was realized. The histological study with immunohistochemistry showed an Intestinal Stromal Tumor (GIST), intermediate risk, histological pattern fusiform, with scarce mitosis; the lesion was dependent on the muscularis propria of the small intestine. In conclusion, this case involves a woman with a jejunal GIST whose clinical presentation was hemorrhage of unknown origin which was a diagnostic problem and thanks to the advent of new endoscopic procedures (enteroscopy and capsule endoscopy) could locate the place of injury and subsequent surgery.

Small Bowel Carcinoma in Young Patient Detected by Double-balloon Enteroscopy / 대한소화기학회지

A 17-year old female presented with a chief complaint of melena and epigastric pain. She had a family history of colon cancer, her mother having been diagnosed with hereditary nonpolyposis colorectal carcinoma (HNPCC). After close examination including double-balloon enteroscopy, the patient was diagnosed with small bowel carcinoma, in spite of her young age. Here we report this rare case of small bowel carcinoma in a young patient with a family history of HNPCC.

Isolated mesenteric fibromatosis.

Fibromatosis is a rare, locally aggressive but non-metastasising fibrous mass often associated with familial adenomatous polyposis in Gardner's Syndrome (GS). Although sporadic cases occur, unlike in GS, they are predominantly extra-abdominal. We report the case of a 40-year-old lady who underwent laparotomy for a large isolated abdominal mass three years after a Whipple's procedure for adenocarcinoma of the distal common bile duct. A spherical, football sized tumour was found in the jejunal mesentery. Resection of the tumour with jejunum was carried out. No metastasis was detected. This case is peculiar in that mesenteric fibromatosis occurred in a patient with prior history of periampullary carcinoma and without history of familial adenomatous polyposis.

Small Bowel Lymphoma Detected by MiroCam(R) Capsule Endoscope in a Patient with Acquired Immune Deficiency Syndrome / 대한소화기학회지

Human immunodeficiency virus (HIV) infection is a risk factor for developing non-Hodgkin's lymphoma. Most acquired immune deficiency syndrome (AIDS)-related lymphomas are high-grade B cell non-Hodgkin's lymphomas. The use of highly active antiretroviral therapy has reduced the incidence of AIDS-related lymphoma. There have been 7 reports of AIDS-related extra-nodal lymphoma in Korea. We report a case of AIDS-related lymphoma detected by MiroCam(R) capsule endoscopy.

Oxaliplatin/5-fluorouracil/leucovorin [FOLFOX4] regimen as an adjuvant chemotherapy in the treatment of advanced jejunal adenocarcinoma: a report of 2 cases

To present our clinical experience of 5-fluorouracil/leucovorin/oxaliplatin [FOLFOX4] regimen administered as an adjuvant chemotherapy to 2 patients with advanced jejunal adenocarcinoma. Case Presentation and Intervention: A 55-year-old woman presented with recurrent upper abdominal pain, nausea and vomiting. A small bowel series as well as the abdominal computed tomography scan revealed an irregular narrowing lesion at the proximal jejunum. The patient then underwent an exploratory laparotomy and the jejunal adenocarcinoma with localized peritoneal metastasis was found [R0 resection, T3N1M1, stage IV]. Chemotherapy with FOLFOX4 regimen of 12 cycles was initiated after the curative resection. No adverse event was observed during the period of chemotherapy. She has been well without evidence of recurrence for over 20 months postoperatively. The second case was a 77-year-old female presenting with mechanical ileus. Surgical exploration revealed a proximal jejunal adenocarcinoma with regional lymph node involvement [R0 resection, T3N1M0, stage III]. She also received the FOLFOX4 chemotherapy of 12 cycles with an uneventful course. No obvious toxicity developed except for temporary grade I peripheral neuropathy and skin eruption. This patient has survived well and has been free of this disease for over 12 months since the operation. This report showed that adjuvant chemotherapy with FOLFOX4 regimen seems effective and well tolerated in these 2 patients with advanced jejunal adenocarcinoma. Further investigation of a large number of patients with long-term follow-up is needed to confirm these findings

Small intestinal adenocarcinoma in Peutz-Jeghers syndrome.

Peutz-Jeghers syndrome (PJS) is characterized by intestinal hamartomatous polyposis (usually affecting the jejunum) and mucocutaneous melanin spots. Though malignant changes are not common, PJS can predispose to carcinoma in the GI tract and elsewhere. We report a 25-year-old man with PJS who developed small intestinal adenocarcinoma and presented with small bowel obstruction due to jejuno-ileal intussusception.

[ case report of metastatic choriocarcinoma to jejunum with severe lower GI bleeding]

A 33-year-old female presented with intermittent abdominal pain and severe attacks of lower gastrointestinal [GI] bleeding since 2 weeks. She has had history of irregular menses in last 3 months. In the labeled RBC-Scan study, the bleeding site was detected in left upper quadrant [LUQ]. In surgery, a tumor with the diameter of 2x1cm in a 65 cm distance of ligament of Trietz was detected. In pathological assessment jejunal metstatic choriocarcinoma was reported. Generally, choriocarcinoma is very rare among the intestinal metastatic tumors, including less than 5% of these tumors. Its presentation is acute lower GI bleeding and organ rupture, especially splenic rupture. These tumors will respond appropriately to the treatment in initial stages. Chemotherapy is the treatment of choice in these tumors

Jejunal leiomyosarcoma presenting as chronic intra-abdominal abscess.

We report a 35-year-old man with jejunal leiomyosarcoma who presented with chronic intra-abdominal abscess. He underwent drainage of the abscess initially but was re-explored four months later when a mass developed. Total excision of the tumor was done.

Leiomiossarcoma de jejuno / Jejunum's leiomyosarcoma

We describe a case of leiomyosarcoma of the jejunum in which abdominal computed tomography showed an intestinal tumor with a "sui generis" metalic artefact inside, which made us think of a benign disease (foreign body granuloma), because the patient lived in the rural area and he had a manioc flour mill, which is one the basic foods of the majority of the population of the north in Brazil. Because of the aspect of the tumor, we decided on a large scale resection, considering the possibility of a malignant tumor since we don't have frozen sections. This assured us of an adequate treatment for the tumor. This type of pathology should be remembered even though it only accounts for 0,2-2 per cents of the intestinal tract tumors

Dermatofibrosarcoma protuberans of the jejunum.

We report a 55-year-old man with recurrent bleeding from the small intestine. Preoperative investigations suggested it to be a small intestine tumor. The resected specimen was diagnosed at histology as dermatofibrosarcoma protuberans of the small bowel.

Duodeno-jejunal hemangiomatosis.

Diffuse duodeno-jejunal hemangiomatosis in children is a rare cause of bilious vomiting. In the clinical approach to bilious vomiting, tumors of the duodenum come at the end of the differential list--not to mention the rarity of hemangiomatosis. To our knowledge, isolated duodeno-jejunal hemangiomatosis as a cause of bilious vomiting in children is being reported for the first time. We analyse the various imaging modalities available to reach a clinical diagnosis.

Adenocarcinoma de jejuno: aspectos clínicos, diagnósticos e terapêuticos: a propósito de um caso / Adenocarcinoma of the jejunum: clinical, diagnostic and therapeutic aspects: report of one case

O intestino delgado é um órgão difícil de examinar clinicamente e de estudar diagnosticamente. O trânsito intestinal é um exame simples e ainda efetivo para avaliação de algumas patologias do intestino delgado. Os autores apresentam um caso de Adenocarcinoma de jejuno, patologia maligna rara do trato digestivo, estabelecendo considerações sobre os aspectos clínicos, diagnósticos e terapêuticos dessa entidade. Baseados neste caso, nós recomendamos que qualquer paciente com sintomas e sinais sugestivos de tumor de intestino delgado, especialmente sangramento crônico gastrointestinal com investigação diagnóstica negativa, sejam considerados de alta suspeita e reinvestigados agressivamente