Leiomyoma of the duodenum : A case reportAB Samsi1, AP Pandya1, MS Kamdar1, VR Kulkarni1, DM Kooka2, Suman M Sant3
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
A case of leiomyoma of the duodenum which presented a diagnostic problem is reported. The literature regarding leiomnyoma of the duodenum is reviewed
Leiomyoma of the duodenum is an uncommon condition. In 1956, River et al  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.
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.
In 1956, River, et al  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  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  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  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. 
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.
We thank the Dean, K.E.M. Hospital, Bombay, for permitting us to reproduce the hospital records and publish this case report.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]