Adenocarcinoma and lymphoma of the small intestine. Distribution and etiologic associations.

Malignant small-bowel tumors in 171 patients over 64 years included 68 with adenocarcinomas, 41 with primary lymphomas, 50 with carcinoids, and 12 with sarcomas. The distribution of the carcinomas showed approximately 80% preponderance in the duodenum and proximal jejunum. A similar distribution in the upper small bowel in small-bowel carcinomas induced in Fischer and Sprague-Dawley rats by azoxymethane (90-160 mg/kg) suggests defense mechanisms within ileal mucosa. The clinical series from 1958 to 1976 included two Crohn's carcinomas (jejunum, defunctioned ileum), two jejunal cancers (lymphoma, carcinoma) associated with celiac disease, two duodenal carcinomas arising in villous adenomas, and one jejunal lymphoma following exposure to irradiation. Multiple primary malignancies were found in 20 to 25% of enteric cancers. Hemorrhage was more common with carcinoma than lymphoma, but lymphomas predominated considering perforation or a palpable mass. Both carcinoma and lymphoma had 75 to 80% resectability rates and 14 to 15% five-year postoperative survival rates. The prognosis was least poor for carcinoma of the jejunum, one third of patients with "curative" resections surviving five years.     

Enteric and rectal duplications and duplication cysts in the adult

Alimentary tract duplication and duplication cysts are rare congenital malformations. The ileum is the most frequently affected site. However, alimentary tract duplication and duplication cysts can occur at any point along the gastrointestinal tract. Early diagnosis and prompt surgical treatment is the best way to prevent associated morbidity. This article presents the cases of three patients admitted to Gulhane Military Medical Academy with signs of acute abdomen, intra-abdominal mass and chronic abdominal pain. These patients were found to have enteric duplication, duplication cyst and/or retro-rectal cyst. The literature on alimentary tract duplications is reviewed.     

Experience with gastro-intestinal duplications in childhood

BACKGROUND: Intestinal duplications are rare congenital malformations. The different locations and sizes of these duplications require a specific diagnostic and surgical approach. This study reviews our paediatric patients with intestinal duplications in order to analyse the influence of prenatal sonography and laparoscopy on the clinical course. PATIENTS AND METHODS: Thirteen duplications of the alimentary tract in 12 patients have been treated over a 10-year period from 1989 to 1999. Six of our patients were diagnosed prenatally by ultrasound and were free of symptoms until surgery, except for one patient who had meconium-ileus owing to cystic fibrosis. In another five patients, the diagnosis was made on the basis of symptoms with signs of obstruction. In one child, the duplication was found incidentally during an operation for an anorectal malformation. The location of the 13 duplications was the stomach in three cases, the duodenum in one case, the jejunum in two cases, the ileum in six cases and the rectum in one case. Laparotomy was performed in ten patients. Two cases were treated by laparoscopic-assisted resection. CONCLUSION: Early diagnosis and treatment of uncomplicated intestinal duplications by means of prenatal sonographic screening and laparoscopic-assisted resection, respectively, are desirable in this congenital malformation. Resection of the duplication with or without minimal resection of the adjacent normal intestine should be mandatory.     

Primary tumors of the small intestine

From 1950 through 1984, 48 cases of primary tumors of the small bowel were treated at the First Surgical Clinic of the University, La Sapienza, of Rome. Forty-three were malignant and five were benign tumors: 13 in the duodenum, 16 in the jejunum and 19 in the ileum. Abdominal pain, weight loss and obstruction were the most common complaints at admission. Radiographic studies of the gastrointestinal tract were diagnostic in 48% of patients. Four benign tumors were leiomyoma of the jejunum or ileum, the other benign tumor was a Brunner's adenomatosis of the duodenal bulb. The tumors were adenocarcinomatous in 29% of the cases and 50% of them were located in the duodenum. The five-year survival of patients with adenocarcinoma was 11%. The fourteen lymphomas were distributed evenly throughout the small bowel: 40% of the patients with lymphoma were alive after five years. Malignant smooth muscle tumors were found in the jejunum and ileum, in these cases the five-year survival rate was 50%. All the carcinoid tumors were in the ileum. The best five-year survival rate, 66%, was seen in patients with this type of tumor. In the malignant group, the five-year survival rate after curative resections was 25% in patients with positive nodes and 75% in those without nodal involvement.     

Alimentary tract duplications in children.

This report reviews the experience with 78 alimentary tract duplications found in 64 patients over a 40 year period at the Children's Hospital of Pittsburgh. Ten patients had the duplication discovered at autopsy. Multiple duplications were found in 15% of patients. The symptoms and physical findings of a duplication varied with location, size and mucosal pattern. About one-fifth of the duplications contained ectopic mucosa, usually gastric. Two-thirds of the patients were diagnosed prior to one year of age. Vertebral anomalies, as a clue to the presence of the lesion, were present in 15% of the patients. The most common indications for surgery included a mediastinal or abdominal mass, intestinal obstruction, and gastrointestinal bleeding. The results of surgery were favorable, with a mortality of 20%. Surgical complications accounted for six deaths, while four children died of severe associated anomalies. Three others died without surgical treatment, but with symptoms from the duplication.     

Three faces of midgut duplication

This is an analysis of three unusual cases of gastrointestinal duplications seen over a two year period. They were all males aged eight and 48 hours, and 4 1/2 years. Two had cystic duplications; in one of them it was associated with a partially fixed cecum resulting in a volvulus, while in the second the duplication occurred in association with duodenal atresia and jejunal deletion. The third patient had a tubular malformation involving distal jejunum, whole of the ileum, and right side of the colon as far as its transverse level. It was also associated with duodenal stenosis and rectal atresia. Two cystic duplications had muscular coats separate from the normal bowel permitting complete excision. Clinical presentation and pathological anatomy are briefly considered and aspects of management are discussed.     

Intestinal duplication in the adult. A case report of colonic duplication and a review of the literature

Alimentary tract duplications are uncommon congenital anomalies that are usually present during the first decade of life. However, a smaller number of cases may remain unsuspected until adulthood. They are most common in the ileum but can occur anywhere along the alimentary tract. Duplications may be cystic or tubular in appearance and characteristically arise from the mesenteric aspect of the intestine. Abdominal pain, nausea and/or vomiting, palpable mass, weight loss, and bleeding are the most common symptoms. This paper reports the case of a 24-year-old male with a cystic duplication of the ascending colon not correctly diagnosed prior to operation. When faced with such an abdominal cystic lesion, differential diagnoses versus duplication cyst, mesenteric cyst, choledochal cyst, giant diverticulum, and cystic tumour of the pancreas should be considered. Ultrasound and computerized tomography are good tools for diagnosis and for delineating the relationship between the cyst and peripheral structures. Surgery provides treatment and allows a final pathological diagnosis. Removal of the cyst could be considered satisfactory but resection of the duplication and the adjacent bowel is recommended because of the possibility of malignant degeneration and the risk of gastrointestinal ulceration and haemorrhage due to ectopic gastric mucosa.     

Triplication of small bowel with perforated peptic ulcer: Report of a rarity with literature review

Triplication of small bowel is an extremely rare variant of enteric duplication with only one previously reported case in a neonate. Most enteric duplications are presented in neonates as intestinal obstruction. Herein we present a case of 3‐year‐old girl with acute abdomen due to perforation of triplicated ileum aiming to highlight the characteristic presenting features, the diagnostic difficulties and challenges of surgical intervention for this condition.     

Laparoscopic resection of gastric duplication: successful treatment of a rare entity

Alimentary tract duplications are rare congenital malformations that may be found anywhere from mouth to anus. They usually share a common smooth muscle wall and blood supply with the adjacent bowel. Some duplications are asymptomatic but most cause problems in early childhood. Gastric duplications account for 2% to 7% of all gastrointestinal duplications. The management of gastric duplication is essentially surgical. The treatment of choice is the complete excision of the gastric duplication without violation of the gastric lumen whenever possible. The authors report an unusual case of gastroesophageal junction duplication completely removed by laparoscopy. To our knowledge, this is the first case of gastric duplication successfully treated by laparoscopy in English literature. Laparoscopic resection may be added to the surgical armamentarium in the treatment of alimentary tract duplications.     

Gastrointestinal adaptation following small bowel bypass for obesity.

Small intestinal morphologic and biochemical changes were studied following jejuno-ileal bypass for obesity after body weight stabilization had occurred. Four patients underwent biopsy of in-continuity and bypassed jejunal and ileal segments of the small intestine 11 to 22 months after the bypass operation. Microscopically, marked mucosal villus hypertrophy of the in-continuity bowel was observed, especially in the ileum. Bypassed jejunal mucosa underwent atrophy compared with pre-bypass jejunum, whereas bypassed ileum appeared similar microscopically to pre-bypass ileum. The specific activities of mucosal disaccharidase enzymes (maltase, sucrase, lactase and trehalase) in units per mg protein remained similar to pre-bypass levels in segments of the in-continuity jejunum and the bypassed jejunum and ileum. On the other hand, elevated mucosal disaccharidase levels were measured in biopsy specimens of the in-continuity ileum. Total enzyme activity per unit length of intestine, however, was estimated to be elevated in both in-continuity jejunum and ileum secondary to mucosal villus hypertrophy. These data indicate that following small bowel bypass: (1) the in-continuity ileum undergoes greater biochemical and morphologic adaptation than the jejunum; and (2) intraluminal nutrients and chyme appear to be essential to maximal intestinal adaptation.     

Small bowel morphology and epithelial proliferation in intravenously alimented rabbits.

Intravenous (IV) alimentation of experimental animals has been associated with an attenuation of the small bowel mucosa. To determine whether alterations in epithelial renewal accompany the morphological changes, we studied cell proliferation as well as the light and electron microscopic appearance of the small bowel in intravenously and orally alimented rabbits. After 10 days of either IV or oral alimentation, 3H-thymidine was given intravenously to all animals to label proliferating cells, and 1 hour later sections of duodenum, upper jejunum, and distal ileum were taken for autoradiography and light and electron microscopy. IV alimentation was accompanied by significant reductions in epithelial cell proliferation and mucosal thickness in the proximal small bowel. The density of goblet cells was greater in the duodenum and jejunum, but less in the ileum, of intravenously alimented rabbits than in corresponding areas of the oral controls. Furthermore, ultrastructural changes in the villous absorptive cells of intravenously alimented rabbits, such as lengthened microvilli and increased numbers of multivesicular bodies, suggested that epithelial migration also may be slowed during IV alimentation.     

Gastric duplication cyst (gdc) associated with ectopic pancreas: Case report and review of the literature

IntroductionDuplication of the alimentary tract is a relatively rare congenital anomaly. It can affect any part of the gastrointestinal tract, with ileum being the most common site. These malformations are believed to be congenital, formed before the differentiation of epithelial lining, and therefore named for the organ with which they are associated. Duplication cysts of the stomach represent four percent of all alimentary tract duplications.Case reportHere, we report a rare case of symptomatic duplication cyst of stomach associated with ectopic pancreas presenting in adult.DiscussionGastrointestinal duplication is a relatively rare anomaly that may occur at any level from oral cavity to rectum with ileum being the most common site. Duplication cysts of the stomach are quite rare, and most of them have been reported in children. Duplication cysts of ileum are usually located on the mesenteric border, whereas the usual location for gastric duplication cysts is along the greater curvature. The duplication cyst is entirely separated from the adjacent bowel but shares a common wall. Complete removal is the treatment choice to avoid the risk of possible complications such as obstruction, torsion, perforation, hemorrhage, and malignancy. A non-communicating GDC is classically treated by complete excision of the cyst and resection of the shared wall between stomach and the duplication cyst.ConclusionThis unusual developmental anomaly should be included in the differential diagnosis of cystic masses of the gastrointestinal tract, and the possibility of malignancy should also be considered, so as be treated surgically by complete resection.     

Primary malignant tumors of the small intestine. A clinical report

The clinical records and pathologic patterns of all the cases of primary small bowel malignancies, treated in the last 15 years, were reviewed. There were 12 patients: 8 men and 4 women ranged from 41 to 86 years old. Carcinoma was the most common (82%) followed by carcinoid and lymphoma (9%). The distribution of the malignancies showed preponderance in the proximal jejunum and duodenum. Multiple primary malignancies were found in 17% of enteric cancers. The most common presentation was pain (75%) followed by weight loss (58%), palpable mass, anemia and gastrointestinal bleeding (25%), obstruction (17%). Barium studies of the duodenum and of the small bowel, duodenal endoscopy were the most useful diagnostic tools but a correct preoperative diagnosis was made in only 42% of the patients. Curative resection was attempted in 67% of the cases. The prognosis is poor.     

成人小肠胃黏膜异位致消化道出血11例

目的 探讨小肠胃黏膜异位并发消化道出血的临床诊断与治疗。方法对我院24年间收治的11例小肠胃黏膜异位并发消化道出血的病例资料进行回顾性分析。结果11例患者发病中位年龄29岁。其中9例发病有腹痛。常规内镜检查均无阳性发现；6例于手术前行放射性^99m锝核扫描均有放射性示踪剂吸收和浓集；1例肠系膜钡餐示末段回肠重复畸形；1例选择性肠系膜血管造影发现近端空肠出血。本组病例均行病变部位小肠段切除，术后病理报告均为胃黏膜异位症，其中病变位于空肠者5例，回肠者6例。11例病灶与肠憩室、肠壁炎性肿块、肠重复畸形并存。11例术后均痊愈出院。结论放射性^99锝扫描对小肠胃黏膜异位症术前诊断有重要意义；手术治疗有效。     

Aortoenteric fistula. Incidence, presentation recognition, and management.

Twenty-two patients developed one or more aortoenteric fistulae following aortic reconstruction with a dacron graft. Endoscopy was performed on 11 of these patients on 17 occasions and a preoperative diagnosis was made in eight patients. Fistulous communication was most common between the aorta and duodenum (60%), and a further 30% penetrated into the jejunum and ileum. The mean period from operation to time of diagnosis was 36 months and the mean length of bleeding was 25 days, allowing ample time for preoperative evaluation. Surgery was performed on 21 of the 22 patients with an overall mortality of 77%. The best surgical results were obtained with graft resection, closure of the aorta, and maintenance of circulation by an axillofemoral graft.     

Enteric duplications presenting as antenatally detected abdominal cysts: is delayed resection appropriate?

Purpose: The aim of this study was to evaluate delayed elective resection of antenatally detected enteric duplication cysts.Methods: A retrospective casenote study of intraabdominal cysts detected antenatally between January 1991 and January 2002 found 37 fetuses with cysts. Twelve were enteric duplications. Two were duodenal, 1 was an 85-cm tubular jejunoileal duplication, and 9 were ileocecal. Asymptomatic cysts were followed with serial ultrasound scars and resected electively over 14 months.Results: Three neonates had small bowel obstruction demanding laparotomy: 1 of the 2 infants with duodenal duplication cysts, 1 infant with an ileocecal duplication, and the infant with the tubular duplication. One with an ileocecal duplication became symptomatic at 2 months and underwent a laparotomy. Seven had their duplications resected electively between 6 weeks and 14 months, and the other is still being followed. Four of the 7 asymptomatic duplications electively resected contained gastric mucosa.Conclusions: Intraabdominal enteric duplication cysts are increasingly likely to be detected antenatally. The majority are likely to remain asymptomatic for several months at least, after which a resection can be planned. The prevalence of gastric mucosa suggests that they should not be left indefinitely. Laparoscopically assisted resection of ileocecal duplications is safe and effective.     

Oral arginine reduces gut mucosal injury caused by lipopolysaccharide endotoxemia in rat

BACKGROUND: The objective of this study was to evaluate the effects of lipopolysaccharide (LPS) endotoxemia and enteral arginine (ARG) supplementation on intestinal structural changes, enterocyte proliferation, and apoptosis in rat. METHODS: Male Sprague-Dawley rats, weighing 250-280 g, were divided into three experimental groups: control rats, LPS rats treated with lipopolysaccharide given ip at a dose of 10 mg/kg every 24 h (two injections), and LPS-ARG rats treated with enteral arginine given in drinking water (2%) 72 h before and following injection of LPS. Intestinal structural changes, enterocyte proliferation, and enterocyte apoptosis were determined on day 3 following the first LPS injection. RESULTS: LPS rats demonstrated a significant decrease in bowel weight in duodenum, mucosal weight in duodenum, jejunum, and ileum, mucosal DNA and protein in jejunum and ileum, and villus height in jejunum and ileum compared to control animals. LPS rats also had a significantly lower cell proliferation index in jejunum and ileum and a higher apoptotic index in jejunum and ileum compared to control rats. LPS-ARG animals demonstrated greater duodenal bowel weight, duodenal and ileal mucosal weight, ileal mucosal DNA and protein, ileal villus height, and jejunal and ileal cell proliferation index compared to LPS animals. CONCLUSIONS: LPS endotoxemia impairs the integrity of the gastrointestinal mucosa in rat. Decreased cell proliferation and increased apoptosis may be considered the main mechanisms responsible for the decreased cell mass. Enteral arginine administration decreases the mucosal injury caused by lipopolysaccharide.     

Perforated tubular duodenal duplication in a 79 year old woman: Case report and review of the literature

INTRODUCTIONEnteric duplications are rare congenital anomalies of the digestive tract that can occur anywhere along its length, with the majority being found in the small intestine. The duodenum is the least common site. Almost all symptomatic duodenal duplications present early in life with abdominal pain and pancreatitis. To the best of our knowledge this is the first described case of a perforated tubular duodenal duplication in an elderly adult.PRESENTATION OF CASEWe present a case of a perforated tubular duodenal duplication in an elderly woman. She presented with diffuse abdominal pain, fever, and tachycardia. Emergent exploratory laparotomy revealed a perforated duodenal duplication. Excision of the duodenal duplication and primary closure of the defect was performed successfully. The patient recovered well.DISCUSSIONEnteric duplications are poorly understood anomalies of embryonic development. They can be cystic or tubular dorsal enteric remnants lying in communication with the alimentary tract that are distinct from diverticula. A tubular duodenal duplication is exceedingly rare, and this case is made even more notable in that such an anomaly presented with sepsis and occurred in a 79 year old woman. We are unsure why the duplication ruptured. To the best of our knowledge this case represents the first report of a ruptured tubular duodenal duplication in an elderly adult.CONCLUSIONThis is a very rare occurrence and has never been described in an elderly patient before. Excision and primary closure led to a good outcome.     

Involvement of small intestine in familial polyposis coli.

Extracolonic intestinal manifestations of familial polyposis coli have been described in recent years, but the exact frequency is still unknown. To date the more common sites of extracolonic polyposis appear to be stomach and duodenum with true adenomas being somewhat rare in jejunum and ileum. The authors report a further two cases of ileal polyposis in siblings from a family with familial polyposis coli and conclude that this condition cannot be considered as a disease exclusively of the large bowel. They emphasize that examination of the upper gastrointestinal tract and small bowel must be included in the investigation and follow-up of patients with familial polyposis coli.     

A triple duplication of the alimentary tract

Duplications of the alimentary tract occur infrequently, and are usually isolated anomalies. In the infant described below, a complex clinical picture was the result of three distinct duplication in widely separated portions of the alimentary tract (esophagus, duodenum, ileum). Details of the clinical course and technical management of an extremely long ileal duplication form the basis for this report.