Presentation
Patient with known ileal Crohn's disease, referring worsening of her symptomatology (abdominal pain, diarrhea, weight loss)
Patient Data
There is an hypoechoic mass within the wall of the terminal ileum. In the video, we see the luminal contents moving through and the lesion protruding from the wall.
The lesion shows marked vascularization and early intense enhancement after contrast injection.
There is no sign of inflamatory bowel disease.
The CT confirms the existence of an hypervascular tumor in the terminal ileum, near to the ileocecal valve.
Case Discussion
When a hipoecoic and hipervascular small bowel wall mass is found, the differential diagnosis must include:
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Gastrointestinal Stromal Tumor (GIST)
- It is the most common mesenchymal tumor of the gastrointestinal tract, being the small bowel its second preferred location.
- Exophytic growth is more common, although endoluminal growing tumors can also be seen.
- With CEUS, it will appear as an hypoechoic wall mass with mild to intense contrast enhancement.
- CT shows soft tissue attenuation with areas of central necrosis when it gets bigger, resulting in an heterogeneous appearance and enhacement. However, small GIST can appear as a more homogeneous tumor, just like in our case.
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Neuroendocrine tumor
- The small bowel and especially the terminal ileum is the most common location of this type of gastrointestinal tumors.
- In this case, endoluminal growth is more common and calcifications can be present in 70% of the patients, more frequently than GIST.
- It can be quite similar to GIST in imaging, appearing as an hiperenhancing mass within the bowel wall, hipoecoic with US and hiperdense in CT.
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Endometrioma
- In women of reproductive age with symptoms matching the menstruation cycle, an endometrioma must be considered. This endometriotic implants can appear practically anywhere, including the bowel wall.
- With CEUS, endometriomas are seen as hypoechoic masses with avid enhancement. In CT they appear as hypervascular nodular masses.
In this case, the tumor was finally removed, being histopathologically characterized as a neuroendocrine tumor.
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