Presentation
Dull epigastric pain with occasional vomiting and 3 kg weight loss in last two months. Normal upper and lower GI endoscopy.
Patient Data
Two hypoechoic solid nodules measuring 32 x 34 mm and 19 x 34 mm are seen in the left upper quadrant, anterior to the left kidney. These have some internal and peripheral vascularity on color Doppler ultrasound examination. One of the adjacent small bowel loops has mildly thick walls measuring up to 7 mm.
Mural thickening of one of the proximal jejunal loops without any significant proximal bowel obstruction, in the left hypochondrium. This mural thickening is associated with a few confluent isodense, soft tissue density masses inseparable from the proximal jejunum, with the largest one measuring 4 cm. These masses show mild heterogeneous enhancement on the post-contrast study and have some internal hypodense/necrotic areas. Morphology of the remaining bowel is unremarkable. A small focal benign-looking focal lesion measuring 19 x 20 mm (isodense in the non-contrast and delayed phases and enhancing in the arterial and venous phases) is seen in segment V of the liver which is likely a hemangioma. No other focal hepatic pathology is seen. Spleen, pancreas, adrenals and kidneys are normal. No ascites, pneumoperitoneum or significant para-aortic lymphadenopathy is seen. Bulky uterus showing multiple heterogeneously enhancing rounded myometrial masses, likely fibroids.
Histopathology of the resected jejunum showed moderate-poorly differentiated adenocarcinoma.
Case Discussion
Mural thickening of one of the proximal jejunal loops with a few confluent heterogeneously enhancing nodules inseparable from the jejunum in the left hypochondrium. A few possible differentials are small bowel malignancy, small bowel lymphoma and gastrointestinal stromal tumor (GIST).
The patient underwent diagnostic laparoscopy which showed a proximal jejunal mass encasing the superior mesenteric vessels. Debulking surgery with resection of the proximal jejunum followed by the duodenojejunostomy was done. Later on after the histopathological confirmation of small bowel adenocarcinoma, the patient was referred to the medical oncology for further management.
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