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Purpose: The authors compared multidetector-row computed tomography (MDCT) and endoscopic ultrasound (EUS) in the identification of pancreaticoduodenal endocrine tumours (PETs) in patients with multiple endocrine neoplasia type 1 (MEN 1)., Materials and Methods: Fourteen consecutive patients (eight men and six women, aged 26-54 years) with MEN 1 underwent MDCT performed with a 4- (n=5) or 64- (n=9) detector-row system and EUS done with a radial transducer (7.5-20 MHz) within 7-28 days of each other. Prior to MDCT examination, patients were given 750 cc of water and asked to lie down in the right lateral decubitus for 15 min. Multiphase MDCT images were acquired both before and after the injection of nonionic iodinated contrast material (2 cc/kg) at an injection rate of 4 ml/s, with technical parameters and scan delay varying in relation to the system used. Images were all reconstructed at 3-mm intervals for the three phases (arterial, pancreatic and portal) and evaluated on a dedicated workstation., Results: MDCT detected a total of 25 PETs (3-18 mm) in nine patients. Of these lesions, nine were situated within the duodenal wall and 16 in either the pancreatic head (n=3), body (n=7), or tail (n=6). Three additional lesions were detected retrospectively after EUS imaging. Most (18/22, 81%) were hypervascular nodules, and four appeared as either hypoattenuating or cystic lesions. EUS detected a total of 32 PETs (2-18 mm) in 11 patients. Most lesions (29/32, 90%) appeared hypoechoic and were situated in the duodenal wall (n=15) or in either the pancreatic head (n=10), body (n=6) or tail (n=1)., Conclusions: Our preliminary data indicate that MDCT is complementary to EUS in the identification of PETs in MEN-1 patients.

The authors report on their experience with 9 patients with small bowel stromal tumours who underwent surgical treatment over the period 1974-2001. Seven were males and 2 females, with an average age of 63.1 years (range: 49-72 years). Histologically, 4 tumours showed evidence of differentiation towards smooth muscle elements (1 benign and 3 malignant), 4 towards neural elements (all malignant) and 1 lacked differentiation towards either cell type. Five tumours were located in the ileum, 3 in the jejunum and 1 in the duodenum. The main symptoms were abdominal pain and an abdominal mass, and the most sensitive diagnostic technique was abdominal CT scan. In the 8 jejunal or ileal stromal tumours we performed a typical intestinal resection, while undifferentiated duodenal stromal tumours were managed by pancreaticoduodenectomy. The diagnosis was only histological. There was no operative mortality, while 2 postoperative complications (1 pancreatic fistula and 1 myocardial infarction) occurred. The patient with jejunal benign muscular stromal tumour is still alive and in good health 73 months after the operation. Of the 3 patients with malignant muscular ileal stroma tumours, 1 is alive and free from disease 63 months after the operation, while the other 2 died of metastatic disease 39 and 29 months after surgery. Of the 4 patients with malignant neural stromal tumours (2 jejunal and 2 ileal) 1 with jejunal and 1 with ileal tumour were lost to follow-up, while 1 is still alive and in good health 101 months postoperatively; the 4th patient, with jejunal disease, developed liver metastasis 14 months after small bowel resection and died 12 months later. The patient with undifferentiated duodenal stromal tumour died of liver metastases 38 months after pancreaticoduodenectomy. Small bowel stromal tumours are more often than not malignant. The most frequent symptoms are abdominal pain and a palpable mass, but no specific signs have been detected. Abdominal CT scan is the most sensitive diagnostic technique in the evaluation of the location, size, invasion of adjacent organs and metastases. The treatment must be intestinal resection, and prognostic prediction on the basis of histological findings is difficult.

The Authors comment on the difficulty of diagnosing and treating duodenal tumours. The most appropriate indications and extent of resection of these neoplasms are discussed. The Authors report 4 cases of primitive adenocarcinoma of the duodenum treated by pancreaticoduodenectomy (2 cases), segmental resection (1 case) and palliative surgery (1 case) for the presence of omental and lymph-node metastases. Survival was 18 and 14 months in the patients who underwent pancreaticoduodenectomy and 9 months for the patient receiving palliative treatment; the patient who underwent segmental resection is still alive and healthy after 12 months. The Authors point out that adenocarcinoma of the duodenum is an uncommon neoplasm and stress the difficulty encountered in establishing an accurate diagnosis and appropriate surgical management. Better results can be obtained only with an early diagnosis. Chemotherapy and radiotherapy do not significantly improve survival.

The Authors report a rare case of undifferentiated duodenal malignant stromal tumour in a 69-years-old man radically managed by pancreaticoduodenectomy and resection of a liver metastasis. Several preoperative tests were performed (barium meal, endoscopy, ultrasonography and CT scan) but failed to yield a differential diagnosis between a tumour of the pancreatic head and a retroperitoneal neoplasm. The diagnosis was only histological. The tumour was considered to be high-grade due to its large size, high mitotic index, and the presence of necrosis and liver metastasis. Thorough surveillance revealed several hepatic metastases 29 months after resection, and chemotherapy performed at this stage proved completely ineffective. The patient died 38 months after surgery.

The duodenal cancers are very uncommon and the carcinomas arising on a duodenal stump following a B II gastric resection are a real rarity. The Aa. present a case of a patient with a cancer arisen on a duodenal stump 24 years after a gastric resection. The patient was operated with a Whipple D.C.P.

A case of 34-years old woman with adenocarcinoma of the IVth duodenal segment extended to the angle of Treitz, treated with duodenojejunal segmentary resection, is described. Clinical features and diagnostic strategies are reported. Personal observation compared with Literature confirms the difficulty of an early diagnosis. The most appropriate surgical techniques for the treatment of these particularly and uncommon neoplasms often discovered in advanced stage are discussed. The better prognosis of these adenocarcinomas compared with those of the proximal duodenum (Ist and IInd segments) can be supported by embryological differences currently to be investigated.

Introduction: We studied the CT patterns of abdominal carcinoid tumors., Material and Methods: Eight patients with carcinoid tumors were examined with CT. The tumors were in the ileum (2 patients), duodenum (1), colon (1), and mesentery (4). Pathologic confirmation was obtained at surgery in all patients. The symptoms were the carcinoid syndrome in 2 patients, abdominal pain in 4, jaundice in 1 patient and a right lower quadrant mass in 1. All patients were examined with(out) i.v. contrast agent administration; 6 patients received oral contrast material and 2 were submitted to water enema, to enhance visualization of the distal ileum and colon., Results: CT identified the tumor in all patients but correctly defined its site in 7 cases only. CT showed a small mass in the distal common bile duct in 1 case, which postoperative histology diagnosed as a malignant carcinoid tumor of the duodenum. The CT findings of carcinoid tumors were a rounded mesenteric mass displacing bowel loops in 4 cases, an infiltrating colonic tumor in 1 case, an apparently intracholedochal mass in 1, a large necrotic mesenteric mass in 1 case. CT showed lymph node involvement in 2 cases, but no liver metastases were found. A carcinoid tumor was diagnosed in 4 patients based on the typical CT finding of a mesenteric mass with radiating soft-tissue density bands resulting in a stellate pattern. No preoperative diagnosis was possible in some other cases because the CT patterns were aspecific and mimicked those of other lesions, namely of tumor of the distal common bile duct, adenocarcinoma of the right colon, submucosal tumor of the distal ileum, large necrotic mesenteric mass., Conclusions: CT is a useful tool in the detection of carcinoid tumors. The correct diagnosis can be made based on the characteristic CT finding of a rounded mesenteric mass. In our experience, however, carcinoid tumors may present with other CT patterns mimicking those of other tumors.

The recent observation of a case of schwannoma in the second part of the duodenum lead the authors to a literature survey in order to state the present knowledge of this subject. Schwannoma is an ectodermal neoplasm arising from the nerve sheath that envelop axons. In the gastrointestinal tract these tumours can concern cells of the myentericus and submucosus plexus of the intestinal wall. A duodenal location is extremely rare. Gastroduodenal endoscopy, abdominal ultrasonography and CT scan were found as important investigatory tools, but only histological examination of the excised tissue suggests the definitive diagnosis. Therapy consists in the radical excision of the tumour; this is rarely obtained by endoscopic way because of the submucosal neoplastic growth. Then a surgical laparotomic approach is more often required and it allows to perform local excisions through a duodenotomy, partial duodenectomy or ampullectomy and more complex operations, like a cephalic duodenopancreatectomy, in front of extended papillar involvement. The latter was the suitable treatment for radical removing of the juxtapapillar schwannoma reported by the authors; the uneventful postoperative course, the patient's excellent general conditions and nutriture at 12 months confirm the validity of the therapeutic policy.

Duodenum is a rare position for gastrointestinal lipoma which sometimes may lead to severe complications. Authors report the case of a 60-year old woman treated with a transduodenotomic excision through a midline laparotomy. At admission the patient presented epigastric pain for 1 month. Physical examination was negative except for a modest epigastric sensitivity. CT scan showed image with regular features and fat density, and permitted the exact preoperative diagnosis. Final histopathological examination confirmed the diagnosis.

Case report. A case of obstructive jaundice due to a preoperative unrecognized rare periampullary tumor, histologically demonstrated to be a gangliocytic paraganglioma of duodenum associated with Von Recklinghausen's disease, is herein reported. Intraoperative ultrasonography guided identification and evaluation of the obstructing lesion, suggesting in Whipple's procedure the most suitable treatment. The clinical case and ultrasonographic and Color Doppler findings are in detail described.

Leiomyosarcoma of the small bowel is a rare malignant neoplasm, representing only the 8%-22% of duodenal malignancy. Diagnosis is difficult and useful is the TC scan of upper abdomen for the localization, extension and organ origin of the neoplasm. The authors report a clinical case of leiomyosarcoma of III portion of the duodenum, arose with intestinal hemorrhage, treated surgically with duodenocephalopancreatectomy, that nowadays represent the only therapeutic treatment for these tumors.

Seven patients suffering from carcinoma of the lower portion of duodenum were examined by means of CT. Water was used as oral contrast medium. In all patients CT showed parietal thickening in the lesion site, with hyperdense (4 cases) or isodense (3 cases) patterns with respect to adjacent normal walls; irregularities on the inner surface were also demonstrated. CT correctly staged the tumor in 5/7 patients (70%), showing pancreatic infiltration in 5 cases--in 1 case associated with hepatic metastases--, vena caval infiltration in 1 patient, and right anterior pararenal fascia involvement in 1 case. In 2 patients the relationship between duodenal carcinoma and pancreas could not be evaluated. CT is suggested for the patients with suspected neoplastic pathologic conditions of the duodenum thanks to its capabilities of showing extraparietal lesion spread, as well as adjacent organs infiltration, adjacent vessels involvement, and distant metastases.

The authors retrospectively reviewed the radiographic (double-contrast small-bowel enema) examinations of 20 patients with primitive small intestinal lymphomas. The diagnosis was histologically confirmed in all cases. The technique was very sensitive (100%) in detecting small-bowel abnormalities. On the contrary, a definite differential diagnosis was difficult to make (65%), except for 4 cases of lymphoma complicating celiac disease in which the presence of a nodular pattern and of thickened and irregular mucosal folds seemed to be highly specific. The most difficult differential diagnosis was with Crohn's disease. In all the cases with surgical confirmation (17), disease extent exactly corresponded to that suggested by small-bowel enema. Primitive small intestinal lymphoma is not radiologically distinguishable from secondary involvement during systemic lymphoma. From the analysis of radiological abnormalities, the authors observed that, different from previous reports, severe luminal narrowing was frequent, whereas "aneurysmal" dilatations of intestinal loops were never observed. CT was confirmed as the best technique for staging. Clinical implications of double-contrast enema in the diagnosis of primitive small intestinal lymphomas are discussed; radiographic patterns are reviewed.

Starting from four primitive malignant neoplasias of the duodenum observed during the course of the last two years, the Authors briefly outline the clinical aetiopathological and especially the radiological characteristics of duodenal primitive malignant neoplasias. They stress the importance of the radiological investigation for early diagnosis of such disturbances, as can clearly by deduced from illustration of the radiological pictures concerning the four cases, all male patients aged from 55 to 68 years. A localisation in the duodenal bulb, with ulceration, is to be considered very rare; the other localisations were two at the 2nd and one at the 1st duodenal portion.

The authors report a case of duodenal leiomyosarcoma presenting a low degree of histological malignancy. The main anatomoclinical features of the neoplasm are summarized. The authors conclude indicating not aggressive surgical therapy as adequate in such cases. However, a prolonged post-operative follow-up is always necessary, in order to detect recurrences as early as possible.

The authors present 3 cases of duodeno-colic involvement by malignant neoplasms and analyse the main radiological features. Benign and malignant duodenocolic fistulas are discussed and colic lesions caused by an extrinsic process. Guiding radioanatomical criteria are stated namely the alterations in the site of the principal lesion first and, afterwards, the morphological changes or displacement of the bowel.

Three cases of reactive lymphoreticular hyperplasia of the stomach (pseudolymphoma) are reported. The histogenesis and the radio-endoscopic aspects are illustrated and the differential diagnosis with the malignant lymphoma and the early cancer is discussed. In each case the radiological examination has shown a granular aspect in the mucosal circonferential area (moth eaten sign) with erosions and multiple ulcers (in two cases).

The radiological detection of intestinal lipomas is not unusual; however, in-depth studies of their radiological features have never been carried out, so far. Eighteen cases of intestinal lipoma were observed, out of different clinical histories. Through a careful survey of these cases, the authors describe the semiological characteristics of the lipomas, which were studied with radiographic contrast examinations of the small intestine and colon. In most cases the characteristics of the mass and--when present--the even more revealing features of its pedicle allowed the identification of such expansive lesions as lipomas. In some lesions detected by means of conventional methods CT proved extremely useful in diagnosing the nature of the lipomas. Such a diagnosis is extremely useful for it allows extensive surgery to be avoided and replaced with less extensive procedures--e.g. endoscopic removal of the lesion, or no specific treatment at all.

The double contrast radiological technique involving duodenal intubation for the examination of the small intestine is described. The technical difficulties involved are discussed with ample illustration. This forms the basis for suggestions on the main indications for the technique in a correct diagnostic protocol.

In 22 patients who shown filling defects in first and second duodenum, only 2 cases of benign tumors were detected by both radiology and endoscopy; the remaining cases were diagnosed as duodenitis and pseudolesions. In duodenum, the great rarity of benign tumors compared with frequency of pseudolesions doesn't allow evaluation of the accuracy of roentgen examinations. Some principles of differential diagnosis are exposed.

Two uncommon cases of Brunner gland hyperplasia are reported. Both presented clinical symptoms simulating gastrointestinal disease caused by hyperacidity. In conjunction with clinical statistics, diagnosis based on aetiology was only formulated after a double-contrast radiological exam of the g-i tract. After treatment with antiacid and antisecretory drugs, remission of the clinical symptoms was obtained, and regression of the hamartomatous polypoid duodenal neoformation, thus confirming the hypothesis which states that hyperacidic gastric secretion is the main cause of Brunner gland hyperplasia.