Abdominal pain and anemia under study

Clinical History

Abdominal pain. Anemia under study.Previous gastroscopy and colonoscopy normal.

Imaging Findings

Images 1a, 1b, 1c and 1d: Abdominal ultrasonography. Performed in the emergency room, it did not show any focal hepatic lesions or dilatation of the biliary tree. The gallbladder appeared without any lithiasis, and the pancreatic area was normal.There was a “pseudokidney sign” in the adjacent area to the pancreatic tail, which was suggestive of a digestive tract structure with mural thickening.Images 2a and 2b: Upper gastrointestinal barium tract study.There was a small sliding hiatal hernia with spontaneous reflux, the stomach presented good peristaltic activity, and the duodenal bulb was of a normal morphology.A marked morphologic alteration of the third duodenal portion was identified, adjacent to the duodenojejunal angle. This area, 70 mm. in length, presented a rigid and irregular appearance, but caused no difficulty to the contrast flow.There was a mass effect over the adjacent small bowel loops with separation of the jejunal loops on the left flank and an extrinsic compression over the great curvature of the gastric body, and the inferior margin of the transverse colon.There were signs of exoendoenteric involvement with probable mesenteric alteration and ulceration of the lesion.Images 3a, 3b, 3c and 3d: Helical computed tomography after intravenous contrast administration. It showed an irregular mass located in the third duodenal portion, which contacts with the great curvature of the gastric body, the pancreatic body and the duodenojejunal angle. The appearance of the mass was very bizarre with mural thickening, causing displacement of the adjacent structures.

Discussion

Primary adenocarcinoma of the duodenum, excluding that of the ampulla of Vater, is an uncommon condition. It represents about 0.35% of all malignant neoplasms of the gastrointestinal tract and 33%-45% of malignant neoplasms of the small intestine (reference 1).Within the duodenum carcinoma may present clinically with ulceration and bleeding, obstruction, perforation, or jaundice. The usual classification divides carcinoma of the duodenum into suprapapillary, peripapillary and infrapapillary neoplasms.Duodenal carcinoma develops in the descending segment, including the ampulla of Vater, in about 80% of the cases, therefore duodenal carcinoma of the transverse segment is extremely rare. Tumors below the ampulla usually cause ulceration, bleeding and obstruction.The roentgen features are similar to those seen in the colon or esophagus: a constricting lesion of varying length, associated with and eccentric and irregular channel and with overhanging edges. The mucosa in the region of the lesion is ulcerated, and partial obstruction is common (reference 2)The ultrasonographic appearance of duodenal carcinoma has been described in a few studies. The tumor has been observed to be a round or polypoid mass with internal hyperechogenicity and a hypoechoic periphery, although hypoechoic or isoechoic main lesions have also been described. Ultrasonographically, a duodenal tumor is thought to be detected by the so called “pseudokidney sign”. Careful observation of both the relationship of the lesion to the surrounding structures and continuity to the normal duodenal wall may be helpful for proper localization and diagnosis, although duodenal fiberscopy with biopsy is essential to confirm the diagnosis. Ultrasonography is also useful for evaluating vascular involvement.Till now the capability of sonography to identify acquired disease of the duodenum has received little attention. Ultrasonography can be used to detect lesions of the transverse segment of the duodenum as the first imaging procedure (references 1,3).The evaluation of the morphologic features of duodenal tumors is very well performed by means of computed tomography, it is a sensitive, but non specific, method for predicting that a tumor is malignant (exophytic or intramural mass, central necrosis, ulceration), allowing also an evaluation of extraparietal lesion spread, adjacent organs infiltration and adjacent vessels involvement, by performing a correct stage of the tumoral lesion (references 4,5).Because the area of the ligament of Treitz is a common site of metastatic carcinoma, lesions here carry a high suspicion of being metastatic, but in these cases, usually the presence of abdominal carcinomatosis would be obvious clinically, and small bowel examination demonstrates findings indicative of multiple large metastatic masses.Lymphosarcoma often presents local dilatation of the bowel lumen despite the infiltrating nature of the tumor process.

Differential Diagnosis List

Final Diagnosis

Duodenal adenocarcinoma

URL:	https://eurorad.org/case/3198
DOI:	10.1594/EURORAD/CASE.3198
ISSN:	1563-4086