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 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  Acknowledgements
 ::  References
 ::  Article Figures

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ARTICLE
Year : 1979  |  Volume : 25  |  Issue : 2  |  Page : 106-108

Leiomyoma of the duodenum : A case report


1 Department of Surgery, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012, India
2 Department of Radiology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012, India
3 Department of Pathology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012, India

Correspondence Address:
A B Samsi
Department of Surgery, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012
India
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Source of Support: None, Conflict of Interest: None


PMID: 501670

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 :: Abstract 

A case of leiomyoma of the duodenum which presented a diagnostic problem is reported. The literature regarding leiomnyoma of the duodenum is reviewed



How to cite this article:
Samsi A B, Pandya A P, Kamdar M S, Kulkarni V R, Kooka D M, Sant SM. Leiomyoma of the duodenum : A case report. J Postgrad Med 1979;25:106-8

How to cite this URL:
Samsi A B, Pandya A P, Kamdar M S, Kulkarni V R, Kooka D M, Sant SM. Leiomyoma of the duodenum : A case report. J Postgrad Med [serial online] 1979 [cited 2019 Dec 13];25:106-8. Available from: http://www.jpgmonline.com/text.asp?1979/25/2/106/42119



 :: Introduction Top


Leiomyoma of the duodenum is an un­common condition. In 1956, River et al [4] made a comprehensive review of all the available literature (except Mayo Clinic series) on benign neoplasms of the small intestine. Of the 1399 cases reviewed only 32 cases of leiomyoma of the duo­denum were reported.

The following is a case report of an in­teresting case of leiomyoma of the duo­denum which presented a diagnostic pro­blem both prior to and during the opera­tion.


 :: Case report Top


A 28 year old Muslim male presented with persistent upper abdominal pain and occasional vomiting of 4 years' duration. There were no aggravating or relieving factors, Medical treat­ment taken elsewhere had failed to relieve his symptoms.

On examination, there was a 10 cm, x 10 cm. non-tender, firm, deeply situated intra-abdomi­nal mass in the epigastric region and extending into the right hypochondrium. It had an irregu­lar surface, ill-defined margins and gave an impression of being mobile during respiration. The rest of the local and general examination was unrewarding.

Four months prior to examination, the patient had been explored in a peripheral hospital through an 8 cm long right mid-paramedian in­cision. A firm mass, thought to be a pancreatic tumour was seen in the region of the head of the pancreas and duodenum. The mass was con­sidered inoperable and hence only a biopsy of the mass was performed which was reported to be normal pancreatic tissue.

The clinical diagnosis rested amongst the following:

(i) Deep seated pancreatic mass,

(ii) Re­troperitoneal mass

(iii) Hydatid cyst arising from the inferior aspect of liver.

The results of the laboratory investigation were as follows: Hemoglobin was 12.5 gm 's Total W.B.C. count was 10,600/cmm., with an eosinophil count of 16%; urine, stool, routine serum chemistry, liver function tests, and serum amylase estimation (done during an episode of pain) showed no abnormality. Casoni's test could not be done due to non-availability of the antigen.

Plain X-ray of the abdomen revealed a soft tissue mass in the epigastrium with elevation of the medial aspect of the right hemidiaphragm. Barium meal and LV. urogram done elsewhere were reported to be within normal limits. A transfemoral aortogram and coeliac arteriogram were performed which showed large common hepatic and gastro-duodenal arteries. Both the posterior and anterior, superior pancreatico­duodenal arteries were hypertrophied and dis­placed and gave off nwre.ous large irregular branches towards the right, supplying a richly vascularized lobulated mass, 8 cm x 11.5 cm in size, situated in the region of the duodenal `C' loop/head of the pancreas. (See [Figure 1] & [Figure 2] on page 108A). From the vascular pattern, an angiographic diagnosis of leiomyoma or leiomyo­sarcoma of the duodenum was made. Barium meal studies were repeated and hypotonic duodenography performed. These showed a large impression on the medial aspect of the descending duodenum interpreted as extrinsic pressure by a mass in the head of the pancreas. (See [Figure 3] on page 108A). Therefore, a revised radiological diagnosis of cystadenoma/cystadeno­carcinoma of the head of the pancreas was made and an exploratory laparotomy was performed.

A nodular bluish mass with variegated con­sistency was found in the region of the duodenal loop/head of the pancreas. An unsuccessful attempt was made to aspirate the soft area and hence a diagnosis of a solid tumour of the pancreas was made. The mass was mobile and there were no metastases in the liver. A classi­cal Whipple's operation was performed. The post-operative period was uneventful. The ,patient was discharged from the hospital after about 3 weeks.

Cut section of the mass showed solid, cystic and haemorrhagic areas. On cutting open the duodenum, a 1 cm x 2 cm ulcer with firm, irregular margins and necrotic floor was seen in the peri-ampullary region. (A re-evaluation of the Barium studies suggested the presence of an ulcer).

Histopathologically, the lesion proved to be a leiomyoma of the duodenum. (See [Figure 4] on page 108A).

The patient has been coming regularly for follow-up examination for the last 6 months. He is generally asymptomatic except for occa­sional foul smelling frothy stools which could be controlled by oral pancreatic enzymes.


 :: Discussion Top


In 1956, River, et al [4] reviewed the literature and studied 1399 cases of benign tumours of the small intestines. Of these 198 (14%) were located in the duodenum of which only 32 (2.1'%) were leiomyomas.

Olson et al [2] reviewed the surgical pathology records of Mayo Clinic from 1911-1942 and came across 77 small bowel tumours of which 22 (28%) were leiomy­omas, 9 (11%) of them being situated in the duodenum.

In a study of 100 cases of tumours of small intestine, Schmutzer and 'Holleran' found only 2 (2%) cases of leiomyoma of the duodenum.

In 1971, Aubrey et al [1] reported 7 cases of small bowel tumours, their diagnostic features and their management. Of these, 2 cases were of leiomyoma of jejunum and the rest were malignant tumours.

The 179 cases of leiomyoma of small in­testine reviewed by River, et al [4] present­ed with a variety of symptoms which could be grouped under the following two categories:

(i) Symptoms due to the presence of a mass.

(ii) Symptoms due to compression or obstruction.

Other uncommon symptoms include in­testinal haemorrhage, diarrhoea, loss of weight and appetite, dysuria and oliguria. Our case falls into the first group.

In the above mentioned series of 1399 cases a correct preoperative diagnosis was made in only 81 cases (about 6%). Most of these were jejunal or ilea]. No men­tion has been made in the literature of a duodenal leiomyoma having been diagnos­ed pre-operatively. It is apparent from the above data that a correct pre-opera­tive diagnosis is very difficult in most cases since the condition is very rare and there are no specific symptoms or signs which could be attributed to the lesion. We also experienced the same. How­ever, in our case the diagnosis could be suspected with the help of arteriography and barium, studies. Thus the possibility of such a lesion being present should al­ways be borne in mind which may be con­firmed by angiography. [3]

In this particular case, the duration of 4 years, a relatively well preserved patient, absence of hepatomegaly and ascites and a history of previous explora­tion with biopsy revealing normal pan­creatic tissue, strongly suggested a rela­tively benign pathology. Radical surgery was performed because the prognosis would be very good in view of the sus­pected benign lesion.


 :: Acknowledgements Top


We thank the Dean, K.E.M. Hospital, Bombay, for permitting us to reproduce the hospital records and publish this case report[5].

 
 :: References Top

1.Aubrey, D. A.., Blumgart, L. H., Davies, G. T. and Gravelle, I. H.: Occult small bowel tumours: Their diagnostic features and management. Brit. J. Surg., 58: 678-684, 1971.  Back to cited text no. 1    
2.Olson, J. D., Dockerty, M. B. and Gray, H. K.: Benign tumours of small bowell. Ann. Surg., 134: 195-204, 1951.  Back to cited text no. 2    
3.Ramer, M., Mitty, H. A. and Baron, M. G.: Angiography in leiomyomatous neoplasms of the small bowel. Amer. J. Roentgenol., 113: 263-268, 1971.  Back to cited text no. 3    
4.River, I., Silverstein, J. and Tope, J. W.: Benign neoplasms of the small intestine­ a critical comprehensive review with report of 20 new cases. Int. Abst. Surg., 102: 1-38, 1956. appearing in Surg. Gynec. & Obst., January 1956.  Back to cited text no. 4    
5.Schmutzer, K. J., Holleran, W. Nl. and Regan, J. F.: Tumours of small bowel. Amer, J. Sin-g., 108: 270-276, 196.1.  Back to cited text no. 5    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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