Unveiling the Unlikely: Extraskeletal Ewing Sarcoma Masquerading as Gastrointestinal Bleeding.

While Ewing sarcoma is traditionally a malignant tumor of bone, it may uncommonly present extra-skeletally, leading to an array of puzzling presentations depending on the tissue involved. Here, we describe the case of a 66-year-old man who presented to the primary care office for evaluation of intermittent melena. He ultimately underwent capsule endoscopy and developed a secondary small bowel obstruction, unveiling his neoplasm. The tumor was then resected and managed with surveillance only, and the patient remains without evidence of disease after four years of follow-up.

The Role of Capsule Endoscopy in the Diagnosis and Management of Small Bowel Tumors: A Narrative Review.

Small bowel tumors (SBT) are relatively rare, but have had a steadily increasing incidence in the last few decades. Small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy are the main endoscopic techniques for the study of the small bowel, the latter additionally providing sampling and therapeutic options, and hence acting complementary to SBCE in the diagnostic work-up. Although a single diagnostic modality is often insufficient in the setting of SBTs, SBCE is a fundamental tool to drive further management towards a definitive diagnosis. The aim of this paper is to provide a concise narrative review of the role of SBCE in the diagnosis and management of SBTs.

Unusual presentation of jejunal adenocarcinoma and ovarian metastasis

It is rare to find a small bowel tumour presenting as intestinal obstruction. This type of cancer is an extremely unusual condition often misdiagnosed until late stages. We report the case of a patient with persistent vomiting secondary to an obstructing jejunal adenocarcinoma not related to intestinal bowel disease. After resection and chemotherapy treatment a huge mass was detected in the left ovary. The anatomopathological findings confirmed a metastatic cancer consequent to the jejunal adenocarcinoma previously resected. This case illustrates a successful outcome of a jejunal adenocarcinoma with very poor prognosis after a extremely unusual ovarian metastasis. It is highly important to suspect other causes than intestinal bowel disease when doing a differential diagnosis in a young patient presenting with clinical symptoms of intestinal obstruction. (AU)

Symptoms Contributing to the Diagnosis of Small Bowel Tumors.

INTRODUCTION: Small bowel tumors (SBTs) are difficult to diagnose because of limited opportunities and technical difficulties in evaluating the small bowel. Asymptomatic conditions or nonspecific symptoms make SBT diagnosis more challenging. In Asia, SBTs are reported to be more frequently malignant lymphoma (ML), adenocarcinoma, and gastrointestinal stromal tumor (GIST). In this study, we examined 66 patients diagnosed with SBTs and determined their clinical characteristics. METHODS: This retrospective study was conducted from January 2013 to July 2020 at Kurume University Hospital. The modalities used to detect SBTs were computed tomography (CT), positron emission tomography, magnetic resonance imaging, and ultrasonography. Endoscopy was also performed in some cases to confirm SBT diagnosis. The study included 66 patients. The medical data collected included presenting symptoms, tumor location, underlying condition, diagnostic modalities, pathologic diagnosis, and treatment. RESULTS: ML and adenocarcinoma were the most common tumors (22.7%), followed by GIST (21.2%) and metastatic SBT (18.2%). Symptoms that led to SBT detection were abdominal pain (44.5%), asymptomatic conditions (28.8%), hematochezia (12.1%), and anemia (10.6%). CT was the most used modality to detect SBTs. Nineteen patients were asymptomatic, and SBTs were incidentally detected in them. GISTs and benign tumors were more often asymptomatic than other malignant tumors. CONCLUSION: Abdominal pain was the main symptom for SBTs in particular adenocarcinoma, ML, and metastatic SBT. In addition, GIST, which was highly prevalent in Asia, had fewer symptoms. An understanding of these characteristics may be helpful in the clinical practice of SBTs.

Computed tomography enteroclysis combined with double-balloon endoscopy is beneficial to the diagnosis of small bowel submucosal tumors.

AIM: To compare the effectiveness and diagnostic accuracy of computed tomography enteroclysis (CTE), double-balloon endoscopy (DBE), and CTE with DBE (CTE/DBE) for detecting submucosal tumors (SMTs) in the small intestine. METHODS: The clinical data of 42 patients with pathologically confirmed small bowel SMTs seen at Renmin Hospital of Wuhan University between March 2012 and October 2020 were retrospectively analyzed. The value of CTE and DBE for detecting small bowel SMTs was then compared. RESULTS: No remarkable difference was found with regard to the sensitivity, positive and negative predictive values, as well as diagnostic accuracy rate between DBE and CTE, but the specificity of CTE was significantly higher than that of DBE (50.0% versus 25.0%, P = 0.001). Additionally, CTE/DBE also presented a higher sensitivity than CTE (97.4% versus 84.2%, P = 0.031). However, CTE/DBE and CTE were not greatly different in the positive predictive values and diagnostic accuracy rates. CONCLUSION: These findings suggest that CTE was better at detecting small bowel SMTs than DBE. Additionally, the combination of CTE and DBE is more beneficial for detecting SMTs in the small intestine.

Multiple Small Bowel Gastrointestinal Stromal Tumors Associated with Neurofibromatosis Type 1 that Were Not Detected by Endoscopy: A Case Report.

We treated a 39-year-old Japanese man who was admitted for an abdominal mass. He had had neurofibroma-like skin lesions since childhood. Computed tomography and endoscopic ultrasound results were consistent with a tumor in the small intestine. Although the tumor was undetectable by single-balloon endoscopy, the patient's background and imaging results led us to suspect a gastrointestinal stromal tumor (GIST). He also met the diagnostic criteria for neurofibroma type 1 (NF1). We performed a surgical removal of the tumor, and the biopsy results led to a definitive diagnosis of GIST. Small bowel GISTs should be considered in cases of NF1.

Computed tomographic findings may be useful for differentiating small intestinal adenocarcinomas, lymphomas, and spindle cell sarcomas in dogs.

An improved understanding of the CT characteristics for histologically confirmed primary intestinal tumors would be helpful for guiding prognosis and treatment plans in affected dogs. This retrospective, multi-center, analytical study aimed to evaluate the CT characteristics for the differentiation of adenocarcinoma, lymphoma, and spindle cell sarcoma (SCS) in dogs. Thirty-seven dogs who underwent contrast CT and histopathological examinations were included (adenocarcinomas, n = 11; lymphomas, n = 12; SCS, n = 14). Quantitative and qualitative CT parameters, including tumor morphology, contrast enhancement pattern, Hounsfield unit (HU) value, and presence or absence of intraabdominal lymphadenopathy, were evaluated for each included small intestine tumor CT case. Adenocarcinomas tended to show endophytic growth, intestinal obstruction, and a heterogeneous enhancement pattern. Lymphomas tended to show exophytic growth, contrast enhancement of the intestinal tumor mucosal layer, a homogeneous enhancement pattern, and the presence of lymphadenopathies in the abdominal cavity. SCSs tended to show lobulated growth, a large cystic portion within the tumor, a heterogeneous enhancement pattern, a large size with fat stranding sign, and lower HU values in postcontrast images. Cut-off values of the minimum diameter/fifth lumbar vertebral mid-body height (≥5.80; area under the curve [AUC] = 0.97, P < 0.001) and minimum HU value/HU value of the aorta (≤0.26; AUC = 0.96, P < 0.001) were derived to discriminate SCS from the two other tumor types. In conclusion, contrast CT characteristics may be useful in differentiating small intestinal adenocarcinomas, lymphomas, and SCSs in dogs.

Primary Dedifferentiated Duodenal Liposarcoma With Gastric Outlet Obstruction: A Rare Small Bowel Tumor.

Liposarcoma is the most prevalent malignant soft tissue tumor and is primarily found in extremities and retroperitoneum, but its occurrence within abdominal viscera is rare. Most of these cases have been reported in the esophagus and stomach. Among liposarcomas of the gastrointestinal tract, primary duodenal liposarcomas are exceptionally rare, with only five documented cases in the literature. We describe a case of a 66-year-old female presenting with syncope, melena, and anemia. Computed tomography (CT) showed soft tissue mass involving the superior wall of the duodenum and hypo-enhancing hepatic mass. An endoscopy was performed, which revealed a duodenal mass causing gastric outlet obstruction and significant bleeding. Therefore, laparotomy was performed with extensive lysis of adhesions and gastrojejunostomy.

Advances in the diagnosis of primary solid small bowel tumors by contrast-enhanced multislice spiral CT / 中国辐射卫生

@#Primary small bowel tumors have low incidence and contain predominantly solid components, and the lesions are similar and difficult to be detected and distinguished with multislice spiral CT (MSCT) plain scans. In this article we describe contrast-enhanced MSCT technique and imaging characteristics for solid small bowel tumors or small bowel tumors containing predominantly solid components, including the type and use of contrast agents. In contrast-enhanced MSCT, small bowel imaging with CT has the advantages of determining the true extent of intestinal wall lesions, the possible extent of wall penetration, the degree of mesenteric involvement, and distant metastases, as well as easiness to detect and identify the blood supply vessels of small bowel tumors and assessment of the corresponding complications. Contrast-enhanced MSCT has become the best noninvasive imaging technique for the diagnosis, evaluation, and staging of solid small bowel tumors or small bowel tumors containing predominantly solid components. CT texture analysis (CTTA) is a new research hotspot and can be useful for the correct diagnosis of primary small bowel tumors containing predominantly solid components.

Small bowel intussusception caused by a serrated adenoma: a case report.

The case was a 17-year-old young woman with a one-year history of recurrent abdominal pain and discomfort. B-scan ultrasonography identified intussusception and contrast-enhanced computed tomography of the pelvis revealed volvulus. A laparoscopic procedure was planned to identify the reason for the intussusception and obstruction. Intraoperatively, the intussusception was found to be caused by a cauliflower-shaped polypoid tumor measuring approximately 4 × 3 cm. Postoperative pathological examination identified the tumor to be a traditional serrated adenoma of the small intestine, which is rare and has atypical clinical manifestations. If unexplained abdominal pain or gastrointestinal bleeding occurs and an abdominal mass cannot be accurately located, laparoscopic or open surgery should be performed immediately. Early surgery is the most effective and reliable way of securing a prompt diagnosis and a favorable prognosis.

Totally laparoscopic resection using delta-shaped anastomosis of jejunal leiomyosarcoma with intussusception at the angle of Treitz: a case report.

BACKGROUND: A leiomyosarcoma of the gastrointestinal tract is extremely rare. We report a case of jejunal leiomyosarcoma with intestinal intussusception at the angle of Treitz that was successfully treated with laparoscopic resection followed by intracorporeal reconstruction using a delta-shaped anastomosis. CASE PRESENTATION: A 54-year-old man was referred to our hospital due to fatigue and loss of appetite. Blood tests showed anemia. Enteroscopy and subsequent enterography using meglumine sodium amidotrizoate showed easily hemorrhagic tumor (10 cm in diameter) in the jejunum just beyond the angle of Treitz. Contrast-enhanced computed tomography revealed jejunojejunal intussusception. Histopathological examination of a biopsy specimen revealed a leiomyosarcoma. Laparoscopic resection of the tumor without reduction of the intussusception was performed. The resected line of the proximal intestine was very close to the ligament of Treitz in the present case. Intracorporeal jejunojejunostomy was completed using a delta-shaped anastomosis, wherein anastomosis was performed between the posterior walls of the proximal and distal jejunums after minimal mobilization around the ligament of Treitz. The patient's postoperative course was uneventful, and he was discharged at 10 days postoperatively. No recurrence has been observed within 2 years after surgery. CONCLUSIONS: We present a case in which a totally laparoscopic surgery for leiomyosarcoma located at the angle of Treitz with jejunojejunal intussusception was performed successfully.

Inverted Meckel's diverticulum diagnosed using capsule endoscopy: A case report.

BACKGROUND: Meckel's diverticulum is a common asymptomatic congenital gastrointestinal anomaly. However, its presentation as an inverted Meckel's diverticulum is a rare complication, of which few cases have been reported in the literature. CASE SUMMARY: Here, we report the case of a 33-year-old man with iron deficiency anemia without manifestation of gastrointestinal bleeding. An upper gastrointestinal endoscopy and total colonoscopy were performed, but no abnormalities were found within the observed area. Finally, a capsule endoscopy was performed and offered us a clue to subsequently confirm the diagnosis of inverted Meckel's diverticulum via computed tomography scan. Laparoscopic intestinal resection surgery was performed. The final pathology report described a Meckel's diverticulum. CONCLUSION: Since inverted Meckel's diverticulum is an uncommon disease and its clinical presentation is not specific, it may go undetected by capsule endoscopy. Successful diagnosis and treatment of this disease requires a high index of clinical suspicion.

B-Lymphoblastic Lymphoma of the Small Bowel: An Extremely Rare Occurrence.

B-lymphoblastic lymphoma is a neoplasm of immature B cells and is characterized by aggressive behavior and disease progression. Common sites of involvement are skin, lymph nodes, bone, soft tissues, breast, and the mediastinum. Gastrointestinal lesions are rarely encountered and therefore not fully described. We herein report the case of a 28-year-old male, who presented with abdominal pain and CT scan showed a tumor involving the small bowel and its mesentery. He underwent emergency laparotomy and enterectomy. Histopathology report revealed B-lymphoblastic lymphoma affecting the small bowel and the adjacent mesentery. This is the first documented case of a small bowel tumor diagnosed as B-lymphoblastic lymphoma in published literature.

Intussusception induced by gastrointestinal metastasis of malignant melanoma: A case report.

INTRODUCTION: Malignant melanoma sometimes metastasizes to small intestine, and could cause various clinical symptoms, including intussusception. Among the acute abdomen cohort in Japan, it is quite rare to encounter this entity. PRESENTATION OF CASE: A 68-year-old male patient was admitted to our hospital with chief complaints of abdominal pain and vomiting.　He underwent tumor resection for malignant melanoma of the primary lesion at left foot base, local recurrence and brain metastasis during the last five years. At admission, abdominal X-ray demonstrated small bowel obstruction. An ileus tube was inserted, and contrast media enema study showed crab-like shadow defect was observed in the advanced part. Enhanced computed tomography showed intussusception in the proximal jejunum caused by a tumor of 5 cm in diameter in the advanced part. No other intestinal lesion was found. Diagnosis of intussusception caused by solitary metastasis of malignant melanoma was made. Laparoscopic partial resection of the small intestine was performed. Postoperative course was uneventful, and patient was followed in outpatient clinic without further treatment with any recurrence of disease for one years. DISCUSSION: Malignant melanoma tends to metastases to the small intestine simultaneously and multiply. It bothers surgeons to decide range of small intestinal resection at emergency surgery. In the present study, preoperative examination allowed the adequate range of intestinal resection including location and number of metastases before operation. CONCLUSION: When an acute abdomen caused by intestinal metastasis of malignant melanoma was consulted, surgeon should make effort to identify location and number of metastatic lesion, preoperatively.

A case of small bowel adenocarcinoma that caused intestinal obstruction after administration of patency capsule.

An 80-year-old man was admitted to our hospital with iron deficiency anemia and exertional chest pain. Coronary artery angiography showed 90% stenosis in the middle left anterior descending branch; abdominal computed tomography (CT) showed enlarged mesenteric lymph nodes. Although his past medical history and results of imaging studies did not suggest intestinal stenosis, assessment of intestinal patency with the PillCam® patency capsule (tag-less PC) was performed. Thirty-three hours after administration, excretion of tag-less PC was not confirmed; an abdominal contrast-enhanced CT showed arrest of tag-less PC in the small bowel and thickening of the bowel wall, suggesting a small bowel tumor. Four days after administration of tag-less PC, he developed abdominal pain and vomiting. Intestinal obstruction was diagnosed by abdominal radiograph. A diagnosis of small bowel tumor with intestinal obstruction was made, and surgical resection was performed. The tumor was histologically an adenocarcinoma. It is necessary to carefully evaluate gastrointestinal patency before small intestine endoscopy especially in elderly people with reduced cardiopulmonary function and many underlying diseases.

Intestinal Obstruction of Uncommon Cause and Point-of-Care Ultrasonography - Where Do We Stand?

Malignant neoplasms of the small bowel, especially from the jejunum, are among the rarest types of cancer. Given its location, a delayed diagnosis is frequent and sometimes only made in an emergency context. The authors present a case of intestinal obstruction, where ultrasonography was pivotal in establishing a diagnosis. Point-of-care ultrasonography seems to be particularly sensitive in assessing emergency patients with abdominal pain, allowing effective orientation and saving human and technical resources.

As neoplasias malignas do intestino delgado, particularmente as do jejuno, estão entre os tipos de tumores mais raros. Devido à sua localização, é frequente existir um atraso no diagnóstico e muitas vezes apenas em contexto de emergência a situação é solucionada. Os autores apresentam um caso de obstrução intestinal, onde a ecografia realizada por gastrenterologista foi fundamental no estabelecimento diagnóstico. A ecografia point-of-care parece ser muito sensível no diagnóstico em urgência, nomeadamente em doentes com dor abdominal, permitindo orientação adequada e poupando recursos humanos e técnicos.

Clinical analysis of 180 cases of primary small intestinal tumor / 中华消化杂志

Objective To improve the knowledge and early diagnostic rate of primary small intestinal tumor.Methods From August 2012 to August 2017,hospitalized patients with pathological diagnosis of primary small intestinal tumor (excluding duodenal neoplasm) from Peking Union Medical College Hospital were retrospectively enrolled.The data of clinical manifestations,laboratory examinations,imaging,endoscopy examination,pathological findings and treatment were collected and analyzed.Results A total of 180 patients with primary small intestinal tumor were enrolled.The common clinical manifestations included abdominal pain (76 cases,42.2 ％),gastrointestinal bleeding (64 cases,35.6％),and abdominal distension (30 cases,16.7％),and 22 (12.2％) patients had no overt clinical symptoms.The sensitivity of carbohydrate antigen 19-9 (CA19-9) in the diagnosis of small bowel adenocarcinoma was 57.1％ (12/21).The diagnostic rates of computed tomography enterodysis (CTE),positron-emission computed tomography (PET)/computed tomography (CT),and abdominopelvic enhanced CT were 96.5％ (83/86),100.0％ (29/29),and 91.5％ (43/47),respectively.The diagnostic small intestinal tumor patients of barium radiography (14 cases),abdominopelvic magnetic resonance imaging (MRI) (eight cases),small bowel endoscopy (18 cases) and capsule endoscopy (eight cases) were seven,six,fifteen and six cases,respectively.Among 180 patients,14 (7.8％) patients were considered gynecological tumors by imaging examination before surgery,seven (3.9％) patients underwent emergency operation because of intestinal obstruction,four (2.2％) patients underwent emergency surgery due to gastrointestinal bleeding,and four (2.2％) patients underwent emergency surgery because of intestinal perforation.Histopathological type included gastrointestinal stromal tumor (117 cases,65.0％),lymphoma (25 cases,13.9％) and adenocarcinomas (21 cases,11.7％).Except seven patients with intestinal lymphoma who received chemotherapy,the rest 173 patients underwent surgical resection.Conclusions Primary small bowel tumor has no specific clinical manifestations.It should be alert on patients without positive findings by regular gastroendoscopy and colonendoscopy examination but with symptoms of abdominal pain,gastrointestinal bleeding and intestinal obstruction.CTE should be the first choice for patients with symptoms but unclear diagnosis.

Clinicopathologic features, surgical treatments, and outcomes of small bowel tumors: A retrospective study in China.

BACKGROUND: Small bowel tumors are relatively rare. Accumulation of data regarding their clinical presentation, pathologic features, prognostic factors, treatment modalities, and outcome has been an issue. We summarize the clinicopathologic features and evaluate the long-term outcome of patients with small bowel tumors who underwent surgery. METHODS: This is a retrospective study of medical records of 456 patients with small bowel tumors treated surgically at a Cancer Hospital between 1999 and 2016. RESULTS: The study included 275 males (60.3%) and 181 females (39.7%). Small bowel tumors were difficult to diagnose because of non-specific symptoms. The most common symptoms were alimentary symptoms (56.8%) and abdominal pain (37.3%). Final histopathology revealed 241 adenocarcinomas (52.9%), 153 gastrointestinal stromal tumors (GISTs; 33.6%), 16 neuroendocrine tumors (NETs; 3.5%), and 46 other types of tumors (10.1%). The 456 surgeries performed included 153 pancreaticoduodenectomies, 241 limited duodenum resections, 60 palliative bypass surgeries, and 2 abdominal explorations. The 5-year overall survival and progression-free survival rates for patients with small bowel tumor were 57.2% and 44.6%, respectively. Adenocarcinomas resulted in the worst overall survival compared to GISTs or NETs, and tumors with duodenal location resulted in a worse survival compared to those with non-duodenal location. CONCLUSION: Surgery is the mainstay of treatment for small bowel tumors. Adenocarcinomas and duodenal involvement seem to contribute to poor outcomes.

Obscure Gastrointestinal Bleeding Due to a Small Intestinal Gastrointestinal Stromal Tumor in a Young Adult.

The source of most cases of gastrointestinal bleeding is the upper gastrointestinal tract. Since bleeding from the small intestine is very rare and difficult to diagnose, time is required to identify the source. Among small intestine bleeds, vascular abnormalities account for 70-80%, followed by small intestine tumors that account for 5-10%. The reported peak age of the onset of small intestinal tumors is about 50 years. Furthermore, rare small bowel tumors account for only 1-2% of all gastrointestinal tumors. We describe a 29-year-old man who presented with obscure anemia due to gastrointestinal bleeding and underwent laparotomy. Surgical findings revealed a well-circumscribed lesion measuring 45 × 40 mm in the jejunum that initially appeared similar to diverticulosis with an abscess. However, the postoperative pathological diagnosis was a gastrointestinal stromal tumor with extramural growth.

Neurofibroma del mesenterio en un paciente sin enfermedad de Von Recklinghausen / Mesenteric neurofibroma seen in a patient without Von Recklinghausen´disease

Los neurofibromas son tumores benignos del sistema nervioso que pueden ser solitarios o múltiples: la neurofibromatosis o enfermedad de Von Recklinghausen. Estos tumores en general son de consistencia blanda, frecuentes a nivel de partes blandas, su localización en el aparato digestivo es infrecuente y no son encapsulados. El objetivo del presente trabajo fue presentar el caso de una paciente con neurofibroma mesentérico sin enfermedad de Von Recklinghausen. Se presenta el caso de una paciente de 41 años que fue ingresada por dolor abdominal y una tumoración palpable en la región entre flanco e hipocondrio izquierdo. En los estudios imaginológicos realizados se informó como quiste del mesenterio, lo que fue confirmado en el acto quirúrgico. Se realizó exéresis de la tumoración informada por Anatomía Patológica como neurofibroma secundariamente enquistado benigno. El neurofibroma mesentérico es una tumoración que puede verse en pacientes sin enfermedad de Von Recklinghausen.

Neurofibromas are benign tumors of the nervous system that can be solitary or multiple, the neurofibromatosis or Recklinghausen's disease. In general, these tumors are soft, non-encapsulated, more frequent in soft parts of the body and infrequent in the digestive system. The objective of the present paper was to present a female patient with mesenteric neurofibroma and without Von Recklinghausen disease. Here is a 41 years-old female patient who was admitted to the hospital because she suffered abdominal pain and a palpable tumor at the region between left flank and hypochondrium. The imaging studies revealed a mesenteric cyst, which was confirmed in surgery. The tumor was classified as a benign cyst neurofibroma by pathological anatomy and finally removed. The mesenteric neurofibroma is a tumor that can be found in patients without Von Recklinghausen disease.