Jawaid Younus, Huw Jenkins.
Small bowel neoplasm - a diagnostic dilemma.
Pak J Med Sci Jan ;18(3):250-3.

Abstract: Although uncommon, small bowel tumors often present as a diagnostic dilemma for the clinicians. This important clinical entity requires various diagnostic steps and quite often these steps have to be repeated to reach a firm diagnosis. We present here our experience with three such cases and a brief review of the literature regarding the presentation and the diagnostic steps found helpful in arriving at a diagnosis.

Case Report: A 37 years old female was evaluated at the hospital with recent history of menorrhagia. She presented with a two week history of post-prandial nausea and vomiting. About four days prior to admission she developed 6-8 watery stools without any blood or mucous, but with cramps and urgency. Physical examination was unremarkable. Investigation showed Hemoglobin (Hb) 115 g/l with microcytosis. She was investigated with a chest X-Ray; abdominal X-Ray, abdominal CT scan and stool examination which were all non-contributory. An endoscopic examination of colon and at least twenty cms of distal ileum was normal. A biopsy of cecum was reported as showing microscopic colitis. Subsequently, with improvement in her symptoms, the patient was discharged home on Pentasa, (5-amino salicylic acid) ferrous gluconate and Provera(Medroxyprogesterone acetate). An upper GI follow-through was obtained as an outpatient which showed thickened valvulae conniventes, most marked in ileum. Three months later due to persistence of abdominal pain, enteroclysis was performed. Except for somewhat narrowed lumen of terminal ileum, no other abnormalities were noticed. Anti-reticulin and anti-mycelial antibodies along with an anti-nuclear antibody (ANA) were found to be negative. Lower abdominal crampy pain, vomiting and diarrhea prompted another in-hospital evaluation. Upper GI endoscopy and small bowel biopsy were both normal. CT scan of abdomen and pelvis showed ascites and thickened small bowel loops. Small bowel follow-through revealed mucosal irregularities with wall thickening. A surgical opinion suggested exploration laparotomy, three feet of the mid-jejunum was removed. Pathological evaluation of the specimen showed a jejunal Leiomyosarcoma.

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