Anemia and jejunal intussusception: An unusual presentation for a metastatic phyllodes breast tumor

INTRODUCTIONPhyllodes tumor of the breast is a rare cause of breast cancer, accounting for less than 0.5% of breast cancers. These tumors are classified as benign, borderline, or malignant, with malignant tumors compromising nearly 25% of cases. Metastases occur in 20% of malignant tumors, lungs, bones, liver and brain being the frequent sites of metastases.PRESENTATION OF CASEWe present a case of a metastatic phyllodes tumor to the small bowel causing jejunal intussusception, symptomatic anemia, and small bowel obstruction.DISCUSSIONPatients with phyllodes tumor of the breast can develop disease recurrence even years after initial treatment. Phyllodes tumor metastasizing to the small bowel is extremely rare, with only three known previously described case reports in the literature.CONCLUSIONHigh risk patients, with a past medical history of phyllodes breast cancer, should be monitored closely. Even years after breast cancer treatment, these patients may present with gastrointestinal complaints such as obstruction or bleeding, and therefore metastatic disease to the small bowel should be considered on the differential with subsequent abdominal imaging obtained.     

Metastatic carcinoma of breast simulating Crohn's disease

A 52-year-old female had radical surgery on both breasts in 1971 and 1973 for infiltrating lobular carcinoma of the breast. One year later, multiple metastases simulating Crohn's disease were found radiologically and intraoperatively in the colon and small bowel. The pathological examination revealed multiple areas of linitis plastica type carcinoma in the colon and small bowel. Review of the breast slides showed that the original breast carcinoma was morphologically identical to the metastatic lesions. The literature is reviewed and arguments are presented to attest that signet-ring-cell carcinoma of the breast is a distinct entity, which not too infrequently metastasizes to the gastrointestinal tract.     

Multiple stenoses of the small intestine by metastatic spread from breast cancer

We present a patient who had a left mastectomy for breast cancer and 3 years later developed intestinal obstruction due to metastatic spread to the small bowel. The small bowel follow through showed multiple stenoses of the small intestine leading to a variety of differential diagnostic considerations as metastatic spread from breast cancer to the small intestine has not been convincingly documented so far.     

Case report of metastatic breast cancer mimicking ileal Crohn's disease

IntroductionLobular breast cancer (LBC) has an increased risk of gastrointestinal (GI) spread compared with ductal breast carcinoma. Breast cancer commonly metastasises to bone, lung, liver, central nervous system and rarely to the gastrointestinal tract. As the prognosis for breast cancer continues to improve with modern medical practice it is important to be aware of the various clinical presentations and the appropriate management of breast cancer metastases.Case presentationWe describe a case of a 60-year-old woman who presented with symptoms of bowel obstruction 30 months after undergoing mastectomy and adjuvant chemotherapy for LBC. A Computer Tomography (CT) scan showed terminal ileal thickening suggestive of Crohn's disease but histopathology revealed metastatic lobular carcinoma. Surgical resection to relieve her small bowel obstruction confirmed LBC.Clinical discussionThis case illustrates an unusual presentation of metastatic breast cancer causing small bowel obstruction with radiological features mimicking Crohn's disease.ConclusionPatients with breast cancer can present with intestinal obstruction due to metastatic spread to the small intestine; this may resemble Crohn's disease clinically and radiologically.     

A case report of small bowel obstruction from previously undiagnosed lobular breast carcinoma: First in Australian literature

IntroductionThis case report is the first in the Australian literature of a patient, without prior diagnosis, presenting with a bowel obstruction secondary to lobular breast cancer. This highlights a relatively rare cause of bowel obstruction, but also the importance of breast self-examination as a compliment to the current BreastScreen Australia program.Presentation of caseA 67-year-old female presented to the Emergency Department with a 48-h history of sharp, constant epigastric pain, vomiting and constipation. The patient proceeded to emergency laparotomy for presumed large bowel obstruction, which revealed a stricture in the distal terminal ileum causing a distal small bowel obstruction. A right hemicolectomy was performed. Histopathology revealed the terminal ileum stricture to be metastatic lobular breast carcinoma. Clinical examination of the patient’s right breast revealed a lesion suggestive of the primary malignancy despite a normal ultrasound and mammogram in 2014. After failing to progress, a CT scan was performed which revealed progressive small and large bowel distension. A repeat laparotomy was performed revealing dilated large bowel without obstructing pathology and an intact anastomosis. A loop ileostomy was performed. Following a further febrile episode, the patient decided to withdraw care and the patient passed away three weeks into her admission from suspected intra-abdominal sepsis.DiscussionBreast cancer is becoming the third most common cancer amongst Australian women with a significant burden of disease and mortality.ConclusionDespite the rare presentation, this case reminds the medical community and general population of the importance of breast self-examination and the BreastScreen Australia program.     

Small bowel obstruction due to metastatic lobular carcinoma of the breast

Although breast cancer most frequently metastasizes to the bone, lung, pleura, liver, adrenal glands and brain, it can also affect other organs such as the small bowel and ovaries, especially if the type of cancer is infiltrating and lobular. We present a case of metastases to the small bowel and ovaries from pleomorphic type infiltrating lobular breast carcinoma presenting as intestinal obstruction. Barium transit study revealed a stenosis in the jejunum and another in the terminal ileum at the ileocecal valve area. A flat formation in the area of the ileocecal valve was observed on endoscopy but the results of biopsy were negative, a fairly frequent finding due to the absence of infiltration of the intestinal mucosa. Pathological and immunohistochemical study of the intestinal and ovarian surgical specimens confirmed the diagnosis of metastases from lobular carcinoma of the breast, which was corroborated by breast biopsy.     

Small bowel malignancies: A review of 29 patients at a single centre

OBJECTIVE: We analysed the incidence, clinical presentation and outcome of small bowel malignancies treated in the department. PATIENTS AND METHODS: From July 1993 to December 2001, 29 patients with small bowel malignancies were operated upon. The median age was 60 years (30-87 years), and there were 11 males and 18 females. The more frequently used diagnostic investigations included barium contrast studies, and CT scanning. RESULTS: The most frequent complaint was abdominal pain, though other symptoms like abdominal mass, weight loss and change in bowel habit may also be present. Intestinal obstruction necessitated emergency operation in some cases. One case was treated as Crohn's stricture and two others, as irritable bowel syndrome for nearly 6 months before referral was made for surgery. Fifteen cases were secondaries to the small bowel, and fourteen were primary small bowel malignancies. The secondaries were metastases from colorectal cancers (8), gynaecological cancers (5), breast (1) and transitional cell carcinomas (1). Of the 14 primary small bowel malignancies, there were 8 lymphomas, 4 adenocarcinomas and 2 neuroendocrine tumours. Eleven of these patients were alive at mean follow-up of 25 months (1-97 months) and 2 were lost to follow-up. Only one of the secondary small bowel malignancies was alive at the time of review. CONCLUSION: Small bowel malignancy is a rate entity with pre-operative diagnosis remaining difficult. Early surgical intervention with a high index of suspicion is required to improve survival.     

Novel use of an air‐filled breast prosthesis to allow radiotherapy to recurrent colonic cancer

Aim The authors present the novel and successful use of an air‐filled breast prosthesis for extra pelvic exclusion of small bowel to facilitate adjuvant radiotherapy following resection of recurrent adenocarcinoma of the ascending bowel. The therapeutic use of radiotherapy in colon cancer can cause acute or chronic radiation enteropathy. Mobile small bowel can be sequestered in ‘dead space’ or by adhesions exposing it to adjuvant radiotherapy. A variety of pelvic partitioning methods have been described to exclude bowel from radiation fields using both native and prosthetic materials. Method In this case a 68 year old presented with ascending colon adenocarcinoma invading the peritoneum and underwent en bloc peritoneal resection. Thirty‐seven months later surveillance CT identified a local recurrence. Subsequent resection resulted in a large iliacus muscle defect which would sequester small bowel loops thus exposing the patient to radiation enteropathy. The lateral position of the defect precluded the use of traditional pelvic partitioning methods which would be unlikely to remain in place long enough to allow radiotherapy. A lightweight air‐filled breast prosthesis (Allergan 133 FV 750 cms) secured in place with an omentoplasty was used to fill the defect. Results Following well tolerated radiotherapy the prosthesis was deflated under ultrasound guidance and removed via a 7‐cm transverse incision above the right iliac crest. The patient is disease free 18 months later with no evidence of treatment related morbidity. Conclusion The use of a malleable air‐filled prosthesis for pelvic partitioning allows specific tailoring of the prosthesis size and shape for individual patient defects. It is also lightweight enough to be secured in place using an omentoplasty to prevent movement related prosthesis migration. In the absence of adequate omentum a mesh sling may be considered to allow fixation. In this case the anatomy of the prosthesis position allowed for its removal without the need for repeat laparotomy. Pre‐operative deflation of the air‐filled prosthesis under ultrasound guidance also reduces the size of the incision required for removal. This technique may be valuable to prevent collateral small bowel irradiation following resection of renal or retroperitoneal malignancy.     

The identification and clinical implications of human breast milk mitogen

There are constituents of human breast milk that make it superior to cow's milk for the nutrition, health and development of human infants. We have discovered a new activity in breast milk. We have found in human breast milk a nitrogen that stimulates DNA synthesis and induces division in cells grown in culture. This mitogenic activity is concentration dependent, and also depends on time since lactation. No similar mitogenic activity is found in commercially available formulas or cows milk 1 wk after birthing. The human milk mitogen might be involved in the growth and development of cells in the neonate. It may be important in preventing necrotizing entercolitis and peptic ulceration of the newborn. It might also be used in the treatment of infants following massive small bowel resection.     

Massive lower gastro-intestinal bleeding due to small bowel diverticula. A report of two cases

Gastro-intestinal bleeding from the small bowel is a rare entity. It is difficult to determine the source of bleeding because of the unavailability of routine small bowel endoscopy. The most common reasons for bleeding from the small bowel are tumours, arteriovenous malformations and inflammatory bowel diseases. Diverticula of the small bowel are very uncommon. We present two cases of gastro-intestinal bleeding due to small bowel diverticula. Both of them were diagnosed on laparotomy. One had a short segment of small bowel, with six diverticula, which was resected. The second case had a long segment of small bowel with multiple diverticula. This patient was treated by isolating and excising the bleeding diverticulum. Haemodynamically unstable lower gastro-intestinal bleeding mandates exploratory laparotomy. Mesenteric angiography and Tc 99 labelled erythrocyte scintigraphy can detect the bleeding site. Intra-operative endoscopy can be performed safely via an enterotomy and can localize the bleeding site.     

Massive Lower Gastro-Intestinal Bleeding Due to Small Bowel Diverticula. A Report of Two Cases

Gastro-intestinal bleeding from the small bowel is a rare entity. It is difficult to determine the source of bleeding because of the unavailability of routine small bowel endoscopy. The most common reasons for bleeding from the small bowel are tumours, arteriovenous malformations and inflammatory bowel diseases. Diverticula of the small bowel are very uncommon. We present two cases of gastro-intestinal bleeding due to small bowel diverticula. Both of them were diagnosed on laparotomy. One had a short segment of small bowel, with six diverticula, which was resected. The second case had a long segment of small bowel with multiple diverticula. This patient was treated by isolating and excising the bleeding diverticulum. Haemodynamically unstable lower gastro-intestinal bleeding mandates exploratory laparotomy. Mesenteric angiography and Tc 99 labelled erythrocyte scintigraphy can detect the bleeding site. Intra-oper-ative endoscopy can be performed safely via an enterotomy and can localize the bleeding site.     

小肠扭转的发病机制及早期诊断探讨（附43例报道）

目的总结成人小肠扭转的病因、发病机制及早期诊断经验。方法对2009年10月至2012年10月期间摩洛哥赛达特省哈桑二世医院收治的43例小肠扭转患者的临床资料进行回顾性分析。结果本组43例小肠扭转患者中自发性小肠扭转11例,继发性小肠扭转32例,术后腹腔粘连为主要继发原因,有19例（59．4％）。临床表现：早期持续剧烈腹痛40例,频繁呕吐29例,肠型或腹部包块28例。43例小肠扭转均手术,其中22例术前B超确诊。术中见肠坏死16例。治愈37例,死亡6例。结论小肠扭转以继发性为主,术后腹腔粘连是小肠扭转的主要原因;小肠扭转与肠梗阻可互为因果;早期小肠扭转具有腹痛剧烈、呕吐早、症状体征不符等特点,早期诊断以临床为主,B超和CT具有辅助诊断价值;该病起病急,进展快,宜早期手术介入。     

Neonatal laparoscopic Ladd's procedure can safely be performed even if the bowel shows signs of ischemia

In this we describe two cases of neonatal malrotation with volvulus treated laparoscopically in our institution.CASE 1: A term baby girl was presented on day 3 of life with malrotation and volvulus. On inspection laparoscopically,the cecum was lying in a subhepatic position to the left of the midline. The small bowel was lying on the right, and there was a 180-degree rotation of the bowel. The rotated bowel was viable and of good color.The bowel was derotated, Ladd's bands divided, and the mesentery broadened. She was up to full feeds by postoperative day 2 and was discharged home on the 3rd day postsurgery.CASE 2: A baby boy presented with malrotation and volvulus on day 11 of life. At laparoscopy, there was freechyle in the peritoneal cavity and a midgut volvulus with an ischemic appearing bowel (with the exception of stomach duodenum and descending colon). The bowel was derotated, the ischemic bowel was returned to a healthy color, and Ladd's bands were divided and the root of the mesentery broadened. On post-operative day 2, he was commenced on feeds (expressed breast milk), and by post-operative 4, the baby was tolerating fullfeeds.CONCLUSION: In our unit, we have performed two laparoscopic Ladd's procedures. Neither of these children have had any complications and, on follow-up, are clinically well with excellent cosmetic results. We feel that laparoscopic treatment of malrotation with volvulus is a feasible procedure and should be performed where the expertise and equipment are available.     

OBTURATION OF THE SMALL BOWEL

Obturation of the small bowel is an uncommon but important cause of small bowel obstruction. There are a great number of substances that may impact at the narrow portions of the small bowel. More than one object may be present in the alimentary tract and should be actively sought. Certain groups of patients are more likely to suffer from the condition. We present two cases of small bowel obstruction due to obturation and review the relevant literature.     

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     

Aberrant Mesoappendix Vasculature: A Unique Cause of Partial Small Bowel Obstruction

Small bowel obstructions are most frequently caused by hernias or adhesive bands. However, there have been several rare reported cases of mechanical small bowel obstructions caused by loops of bowel or vascular bands. We describe a case of a 30-year-old woman with a clinical presentation suggestive of appendicitis. Laparoscopic evaluation showed an aberrant vessel looping around the small bowel extending from the lateral anterior abdominal wall to the mesoappendix, resulting in a partial small bowel obstruction. We review the literature relating to bowel obstructions resulting from bowel knots and vascular bands. To our knowledge, this is the first reported case of a small bowel obstruction caused by an aberrant intraabdominal vessel.     

Necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a neonatal surgical emergency with potentially devastating consequences. Pre-term infants of very low birth weight are most at risk with several genetic and environmental risk factors identified. The local microbial environment plays a key role in early life to help reduce the risk of NEC. Breast milk has also shown to be protective. The disease is characterized by infection, inflammation and ischaemia of the bowel that can extend from a small segment to most of its length. The diagnosis is made based on clinical, biochemical and radiological features with perforation the most widely accepted indication for surgery. When conservative management fails, a laparotomy is indicated with the aim of resecting necrotic bowel and preserving intestinal length. Complications include strictures, stoma morbidity, short-bowel syndrome and poor neurodevelopmental outcomes. Preventative strategies include the use of probiotics and encouraging the use of breast milk.     

对大肠癌术后早期炎性肠梗阻诊治的探讨

目的：探讨大肠癌术后早期炎性肠梗阻的特点及治疗方法；方法：分析10例大肠癌术后出现早期炎性肠梗阻的临床表现并进行综合保守治疗；结果：10例患者保守治疗全部成功；结论：术后早期炎性肠梗阻是一种非细菌性炎性肠梗阻，以发生在术后早期，腹胀、呕吐明显，腹痛轻或无为主要临床特点，治疗应采用保守治疗。     

Prediction of small bowel viability using Doppler ultrasound. Clinical and experimental evaluation.

The operative determination of small bowel viability following strangulation obstruction or mesenteric vascular occlusion remains a problem. In the canine model, Doppler ultrasound was used to predict intestinal viability in segments of small bowel subjected to mesenteric venous occlusion. This was compared with small bowel electromyography and the short- and long-term clinical courses. If flow was consistently heard on the antimesenteric border, the bowel remained viable, had return of slow waves on electromyography, and did not develop strictures during a six-month follow-up period. Four clinical cases are presented where Doppler ultrasound was utilized to supplement the usual methods of determining small bowel viability. Doppler ultrasound is a rapid, noninvasive method of determining small bowel viability.     

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.