Primary Malignancies of the Small Bowel: A Report of 96 Cases and Review of the Literature

The clinical records and histologic sections of 96 cases of primary small bowel malignancies (excluding lymphomas and periamullary lesions) were reviewed. The location, clinical presentation, pathologic findings, treatment and outcome are compared to the collected published experience, approximately 2400 cases. There were 48 adenocarcinomas, 37 carcinoids, and 11 leiomyosarcomas. Fifty-one men and 45 women ranged from 31 to 83 years old. Eighty-four caused symptoms leading to operative diagnosis; 12 carcinoids were incidental autopsy findings. The most common presentation was pain (33%) followed by weight loss (23%) obstruction (16%), hemorrhage (15%), jaundice (5%), intussusception (3%) and perforation (3%). Masses were felt in 30% of the cases, but were usually dilated bowel or intussusception rather than the tumor per se. Curative resection was attempted in 80 of 84 operatively diagnosed tumors. The 80% mortality among patients followed 5 years is attributed to the late appearance of symptoms and anatomic obstacles to a truly radical operation.     

Gastro-intestinal stromal tumor (GIST): case report

Gastro-intestinal stromal tumors (GISTs), as currently defined, represent the largest category of primary non epithelial neoplasms of the gastrointestinal tract. They arise from mesenchymal cells located in the wall of the organ and show a remarkable variability in their differentiation pathways. For this reason there is relevant degree of confusion in their interpretation. On the basis of immunohistochemical and ultrastructural studies these neoplasms are divided into several categories: leiomyomas, schwannomas and less differentiated tumors referred as GIST. In the small bowel GIST are uncommon. Usually asymptomatic, they could be the cause of surgical emergencies like massive bleeding, obstruction, intussusception or perforation. Generally benign, an higher percentage of malignant cases are described in the small bowel. The Authors report a case of malignant GIST of the small intestine presented with bowel obstruction by ileal invagination. In this case, as usually it happens in malignant GIST, the final diagnosis was obtained by an abdominal surgical exploration.     

Small bowel metastases from renal cell carcinoma: a rare cause of intestinal intussusception

Small bowel metastases from renal cell carcinoma (RCC) are very rare. Clinical presentation includes obstruction, bleeding, intussusception and rarely perforation. We report a case of a 48-year-old female presenting a jejunal intussusception due to intestinal metastasis from RCC. To our knowledge, there are only a few such cases reported in the literature (seven cases). However, if considered in the total summary of reported cases with small bowel metastases from RCC, intussusception is a probable cause.     

Intestinal melanoma: A broad spectrum of clinical presentation

INTRODUCTIONSmall intestine melanomas are rare and the most of them are metastases from primary cutaneous neoplasms.PRESENTATION OF CASEBelow, we report two cases of small intestine metastatic melanoma with very different clinical presentation.DISCUSSIONStill now, primary versus metastatic origin is often unclear. Small bowel melanoma is often asymptomatic. However, clinical picture can be various; it may occurs with non specific symptoms and signs of gastro-intetstinal involvement, like chronic abdominal pain, occult or gross bleeding and weight loss, or with an emergency picture due to intestinal intussusception, obstruction or, rarely, perforation.CONCLUSIONSmall bowel melanoma is rare and the diagnosis done late. Imaging techniques are recommended in order to obtain early diagnosis of gastrointestinal metastases.     

“Twist & Slide” Bowel Obstruction: Two Different Rare Causes of Adult Bowel Obstruction in the Same Patient

A man, age 68, presented with two rare clinical entities of adult bowel obstruction. This case showed a caeco-colic intussusception (due to a caecal malignant lesion) with a small bowel volvulus secondarily. These are rare but potential life-threatening surgical emergencies.     

"Twist & slide" bowel obstruction: two different rare causes of adult bowel obstruction in the same patient

A man, age 68, presented with two rare clinical entities of adult bowel obstruction. This case showed a caecocolic intussusception (due to a caecal malignant lesion) with a small bowel volvulus secondarily. These are rare but potential life-threatening surgical emergencies.     

Small bowel intussusception caused by metastasis from anaplastic thyroid carcinoma: case report and literature review

Symptomatic involvement of the small bowel by metastasis from an extra-abdominal primary malignancy is rare, most commonly resulting from malignant melanoma and lung cancer; very rarely is small bowel involvement as first metastatic site. The Authors report a case of anaplastic thyroid carcinoma with lung metastasis, brain metastasis and an isolated metastasis to the small bowel leading intestinal obstruction due to small bowel intussusception. The Authors review the international literature about frequency, etiopathogenesis, clinical and diagnostic features and therapy of small bowel metastasis by extra-abdominal malignancies, especially by primary anaplastic thyroid carcinoma. Small bowel metastasis from extra-abdominal malignancies are very unusual, especially from anaplastic thyroid carcinoma, and the etiopathogenesis is still unknown. Clinical findings are typical for abdominal urgency, especially by small bowel obstruction from anaplastic thyroid carcinoma. Computed Tomography has an important role in detecting the type of intestinal obstruction despite it is often unable to diagnose an isolated metastasis. Best therapy is surgical resection, that allows the assessment of metastasis and the definitive staging. The prognosis is poor, despite long-term survival has been occasionally reported for isolated small bowel metastasis     

Profile of pediatric abdominal surgical emergencies in a developing country

We aim to determine the profile and determinants of outcome of pediatric abdominal surgical emergencies in southeastern Nigeria. We prospectively analyzed 115 children with abdominal surgical emergencies managed at the University of Nigeria Teaching Hospital, Enugu, Nigeria, from January 2008 to June 2009. The emergencies were typhoid intestinal perforation (TIP) 22 (19.1%), intussusception 20 (17.4%), obstructed hernia 17 (14.8%), neonatal intestinal obstruction 11 (9.6%), appendicitis 11 (9.6%), trauma 8 (6.9%), ruptured omphalocele/gastroschisis 8 (6.9%), Hirschsprung's disease 7 (6.1%), adhesive bowel obstruction 7 (6.1%), and malrotation 4 (3.5%). The mean time to diagnosis was 3.5 days (range, 4 hours to 12 days). Ninety-three cases had an emergency operation, while 22 were managed nonoperatively. After a mean hospital stay of 10.8 days (range, 2-38 days), 35 (37.6%) of the operated patients had one or more postoperative complications. There were 10 (8.7%) deaths. Overall, TIP had a higher postoperative complication rate (P < 0.001), while neonates had a higher mortality (P < 0.001). Delayed presentation and lack of neonatal and pediatric intensive care facilities were daunting challenges. A pediatric abdominal surgical emergency in our setting has high morbidity and mortality. Efforts geared towards improvement in time to diagnosis and perioperative care may result in better outcomes.     

Synchronous Jejunal Metastasis Presenting as Intussusception in a Case of Advanced RCC: a Rare Presentation

Renal cell carcinoma (RCC) may metastasize to almost any organ, but metastasis to the small bowel is very rare. Factors responsible for a resistant behavior of small bowel wall are still not clear. Small bowel metastasis from RCC may cause obstruction, bleeding, and perforation. RCC metastasis to the small bowel presenting as intussusception is extremely rare. Only 20 cases of small bowel intussusceptions caused by metastatic RCC have been reported worldwide. Here, we are reporting this rare case of RCC with simultaneous solitary metastasis in jejunum which presented as intussusceptions and which was treated with simultaneous radical nephrectomy, jejunal resection, and anastomosis.     

Emergency surgery of tumors of the small intestine

Ten cases of serious complications requiring emergency surgery in patients with tumours of the small intestine are presented: 3 cases of peritonitis due to perforation of a fibroleiomyoma, a jejunal adenocarcinoma, and an ileal lymphosarcoma; 3 invaginations (1 ileocolic due to an ileal polyp, and 2 ileoileal due to lymphoma and polypoid metastasis of melanoma; 3 stenosis (ileal owing to metastasis of melanoma, and duodenal and of the duodenojejunal flexure due to histologically unascertained neoplasias); 1 massive enterorrhagia from ileal anaplastic carcinoma. The frequency of such pictures is not negligible when assessed in terms of emergency surgical pathology and compared with other emergency situations arising in patients with tumours. Preoperative diagnosis is difficult even from the clinical history. Tumours of the small intestine appear to give rise to such complications in their initial stages.     

Three cases of small bowel intussusception in relation to a rare lesion: inflammatory fibrous polyps

BACKGROUND/AIMS: Inflammatory fibrous polyps (IFPs), also known as inflammatory pseudotumors, occur rarely in the gastrointestinal tract. IFPs have variable presentations, often presenting as small bowel obstruction due to intussusception or, less commonly, as an incidental finding on radiological examinations or screening colonoscopies. The diagnosis and management of IFPs will be discussed through a review of the literature and a series of cases from our own institution. METHODS: A retrospective analysis of the diagnosis, management and complications of IFPs was performed by a literature review. This was accompanied by a series of 3 cases of IFPs, 2 of which causing intussusception, diagnosed and treated in our own institution. CONCLUSIONS: IFP is a rare disease and has a variable presentation, from asymptomatic to small bowel obstruction due to intussusception. IFPs cannot be differentiated from malignancy without histological examination. Therefore, whether diagnosed incidentally or in the setting of intussusception, the treatment of IFPs is surgical resection of the involved bowel.     

Primary small bowel malignant tumors. Unrecognized until emergent laparotomy

Forty-five consecutive cases of primary small bowel malignant tumors treated at our institution from 1969-1983 were reviewed. Sixty-four per cent of the patients had surgical emergencies. Fourteen patients had intestinal obstruction, 11 had gastrointestinal (GI) hemorrhage, and 4 had perforation of the small bowel. The remaining 16 patients were explored for persistent symptoms, an abnormality on GI series, or a mass lesion on CT scan. Thirty-eight patients underwent resection of the tumor and seven had palliative bypass procedures. This study suggests that a high index of suspicion and early diagnostic evaluation including a small bowel series is necessary to prevent the large number of small bowel tumors presenting as surgical emergencies. In particular, small bowel tumors should be suspected in patients with abdominal pain of unknown etiology, unexplained weight loss, or occult GI bleeding.     

Elective laparoscopy in diagnosis and treatment of recurrent small bowel obstruction

BACKGROUND: To evaluate the feasibility, efficacy, and safety of laparoscopy in diagnosis and treatment of recurrent small bowel obstruction. METHODS: Retrospective analysis of 253 patients who underwent therapeutic laparoscopy for recurrent small bowel obstruction from June 1996 to May 2005 was carried out. Patients with acute small bowel obstruction, bowel obstruction due to tumor, and obstructed inguinal hernias were excluded from analysis. RESULTS: Laparoscopy diagnosed cause of obstruction in all except 3 (1.18%) patients. The etiology included adhesions (38%), incarcerated ventral incisional hernias (32%), Meckel diverticulum (7%), stricture (14%), volvulus (3%), intussusception (4%). One hundred sixty nine patients were managed totally laparoscopically with adhesiolysis. Therapeutic bowel intervention other than adhesiolysis was required in 84 patients, of which 33 procedures were performed totally laparoscopically and remaining 51 procedures were completed with laparoscopically guided target incision. Five patients required conversion to open celiotomy. Iatrogenic enterotomies occurred in 3 patients and small bowel perforation during manipulation occurred in 1 patient. Postoperative procedure-related complications were seen in 44 patients. There was one mortality due to postoperative arrhythmia and cardiac failure. CONCLUSIONS: Laparoscopic diagnosis and treatment of recurrent small bowel obstruction is feasible, safe, and can be performed electively in selected cases.     

Acute surgical emergencies in inflammatory bowel disease

BACKGROUND: Acute surgical emergencies in patients with inflammatory bowel disease may carry a substantial morbidity, but fortunately today, a low mortality. The aim of this review is to delineate the treatment of acute surgical emergencies that occur in patients with ulcerative colitis and Crohn's disease. METHODS: Suitable English language reports were identified using PubMed search. RESULTS: Inflammatory bowel disease can present in numerous ways as an acute surgical emergency. These include toxic colitis, hemorrhage, perforation, intra-abdominal masses or abscesses with sepsis, and intestinal obstruction. Toxic colitis and perforation are best managed with intestinal resection and fecal diversion. Hemorrhage in ulcerative colitis initially requires colectomy with rectal preservation and ileostomy. In Crohn's disease hemorrhage is often focal and localization and segmental resection are performed. Intra-abdominal abscesses should initially be attempted by computed tomography-guided percutaneous drainage followed subsequently by definitive resection. Perianal disease requires abscess drainage with minimal tissue trauma. Intestinal obstruction should be initially managed nonoperatively, with surgery reserved for complete obstruction or intractability. CONCLUSIONS: Acute surgical emergencies in patients with inflammatory bowel disease are rare and can have a high morbidity. With a multidisciplinary approach, morbidity can be reduced and patients can have a rapid return and improved quality of life.     

Acute intestinal intussusceptions in adults: analysis of 20 cases

AIM OF THE STUDY: To report our experience in the management of acute intestinal intussusceptions in adults. PATIENTS AND METHODS: Retrospective study of data of patients older than 15 years who were operated on for acute intestinal intussusceptions from January 1997 to December 2001. RESULTS: Twelve of the patients were males and eight females with an average age of 41 years (range: 16-71). The clinical and radiological findings were suggestive of bowel obstruction (N = 14), peritonitis (N = 5) and appendicular abscess (N = 1). Correct preoperative diagnosis of acute intestinal intussusceptions was established in 6 cases. Type of intussusception was jejunojejunal (N = 1), ileo-ileal (N = 8), ileocolic (N = 1), ileocecocolic (N = 7) and colocolic (N = 3). Necrosis was found in the intussusceptum in 10 cases and a tumor on the lead point in 14 cases (5 benign lesions and 9 malignant ones). For intussusception involving the colon, all patients underwent en bloc resection with immediate anastomosis, while intussusception located on the small bowel were treated by surgical reduction (N = 1), en bloc resection (N = 8) with immediate (N = 7) or delayed (N = 1) anastomosis. The mortality rate was 15%. CONCLUSION: In our experience, intussusceptions in adults is not an uncommon clinical entity but correct diagnosis is often established peroperatively. En bloc resection is recommended because of the frequency of neoplasms and bowel ischemia.     

Multifocal small bowel stromal tumours presenting with peritonitis in an HIV positive patient

INTRODUCTIONThe most common mesenchymal tumour of the gastrointestinal tract is stromal tumours (GISTs). Symptomatic GISTs can present with complications such as haemorrhage, obstruction and perforation. Complete surgical resection with negative margins is the mainstay of treatment but may be imprudent on emergent occasion. Tyrosine-kinase inhibitors (TKIs) have been revolutionary in the treatment of GISTs and have resulted in improved outcomes.PRESENTATION OF CASEA 41 year old HIV positive male presented with an acute history of abdominal pain and obstructive symptoms. Clinical examination revealed sepsis and peritonitis. One of the several small bowel tumours discovered at exploratory laparotomy was necrotic and perforated. The perforated tumour alone was resected and a small bowel internal hernia reduced. The patient made an uneventful recovery and will be considered for TKI therapy with a view to later re-operation.DISCUSSIONGISTs very rarely perforate. The pathophysiology of stromal tumour necrosis is poorly understood. Multifocality and small bowel location are poor prognosticators and may occur in the setting of familial GISTs, specific syndromes and sporadic cases. There is no established association between HIV and GISTs.CONCLUSIONPerforation occurs infrequently in ≤8% of symptomatic cases and poses increased risk of local recurrence. The surgical management of perforation takes precedence in an emergency. The surgeon must however take cognisance of the adherence to ideal oncologic principles where feasible. TKI therapy is invaluable if a re-exploration is to be later considered.     

Small Bowell Malignant Melanoma-Report of Three Cases and Review of Literature

Malignant melanomas have a predilection to metastasize to the small bowel. Three patients with malignant melanoma involving the small bowel are reported. Two patients were operated on for small bowel obstruction and the third for gastrointestinal bleeding with anemia. Two patients remained well 6 month and 2 years, respectively, after surgery. One patient died of metastatic cerebral melanoma 6 months postoperatively.

One should suspect small bowel metastasis in every patient with malignant melanoma in his past medical history, who presents with recent changes in bowel habits, intestinal obstruction or gastrointestinal bleeding. Preoperative assessment can only raise the suspicion, even with advanced imaging methods: capsule endoscopy, enteroscopy, CT or PET-CT. The only therapeutic procedure is surgical resection, offering both short term survival as well as an improvement in the quality of life. Although prognosis is dismal there are factors associated with prolonged survival: complete surgical resection with no residual primary or metastatic tumor, so-called primary small bowel tumors in patients aged more then 60 years, LDH < 200 U/L, lack of tumor spread in mesenteric lymph nodes.     

Surgery for melanoma metastatic to the gastrointestinal tract.

Melanoma frequently disseminates to the gastrointestinal tract, being found post-mortem in 60 per cent of patients with disseminated disease, while during life it is diagnosed in only 4 per cent. During the period 1981-87, 835 melanoma patients were referred and 30 developed complaints caused by gastrointestinal metastatic melanoma. Twenty-three patients were treated surgically. The interval between treatment of the primary melanoma and detection of intestinal involvement was a median of 34 months (range 2-87 months). In four patients recurrence in the gut was the first evidence of dissemination. Major complaints were nausea and vomiting, abdominal pain, signs of anaemia, and blood in the stools. Complications were bleeding (ten cases), ileus due to intussusception (five cases), bowel perforation (four cases) and cholecystitis (one case). The metastases, mainly localized in the small bowel, were removed by relatively simple procedures. Symptoms were reduced in 19 patients. Two patients died after operation: one from sepsis due to suture leakage, the other from pneumonia and a cerebrovascular accident. Of the remaining patients, 16 survived a median of 7.5 (range 0.7-32.0) months. Five patients are still alive 72, 72, 70, 7 and 2 months after the metastasectomy, three of whom are tumour-free. The actuarial 5-year survival of all patients is 19 per cent. These results support surgical intervention for patients with complaints and/or complications attributable to gastrointestinal metastatic melanoma.     

El íleo biliar como causa de abdomen agudo. Importancia del diagnóstico precoz para el tratamiento quirúrgico

Gallstone ileus is an uncommon type of mechanical intestinal obstruction caused by an intraluminal gallstone, and preoperative diagnosis is difficult in the Emergency department. This study is a retrospective analysis of the clinical presentation of 5 patients with gallstone ileus treated between 2000-2010. Clinical features, diagnostic testing, and surgical treatment were analyzed. Five patients were included: 2 cases showed bowel obstruction; 2 patients presented a recurrent gallstone ileus with prior surgical intervention; and one patient presented acute peritonitis due to perforation of an ileal diverticula. In all cases CT confirmed the preoperative diagnosis. In our experience, gallstone ileus may present with clinical features other than intestinal obstruction. In suspicious cases CT may be useful to decrease diagnostic delay, which is associated with more complications.     

Idiopathic adult colo-colonic intussusception: Case report and review of the literature

INTRODUCTIONAcute colonic intussusception occurring in the absence of organic cause is uncommon in adults.PRESENTATION OF CASEWe report acute colonic intussusception in a 46-year-old female; clinical evidence of a palpable mass, abdominal pain and bloody mucoid stools appeared a few hours after hospital admission. Multislice CT-scan confirmed the clinical diagnosis and surgical exploration revealed right colonic obstruction caused by intussusception of the cecum into the ascending colon. Right hemicolectomy was performed and histopathological examination did not reveal any causative pathology.DISCUSSIONIntussusception remains a rare condition in adults, representing 1–5% of bowel obstruction and accounting for 0.003–0.02% of all hospital admissions. Intussusception occurs more frequently in the small (50–80%) than in the large bowel (12–50%). It is estimated that approximately 90% of intussusceptions in adults are secondary to an anatomical or pathological condition, of which more than half are malignant. Idiopathic cases are the exception in adults. The clinical presentation of adult intussusception differs considerably from the classic pediatric presentation of abdominal pain, palpable mass, and blood per rectum, which is rarely seen in adults. A pre-operative CT-scan showed a 10 cm intussuscepted segment of right colon. Surgical resection was considered mandatory because of severe bowel obstruction, and the theoretical possibility of occult malignancy. This approach was vindicated by the presence of widespread ischemic lesions in the wall of the resected bowel, without any obvious lead point.CONCLUSIONThere are few reports in the medical literature of acute colonic intussusception occurring in the absence of organic cause in adults.