GI Disease Case Studies: CT Enteroclysis MCh Balaji Reddy
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CASE 1

 
2HISTORY
A 51-year-old male patient presented with malaena for 3 days requiring 3 units of blood transfusion.
 
EXAMINATION
He was pale. No palpable mass or areas of tenderness.
 
INVESTIGATIONS
  • CXR normal
  • Ultrasound showed multiple small hypoechoic lesions in liver. Other solid organs normal. Poor assessment of bowel loops.
  • CEA ->1000 ng
  • Altered LFT ' s, serum creatinine and low Hb
 
COLONOSCOPY
Figures 1.1A and B.
 
FINDINGS
Bleeding cecal ulcer, few ulcerations in ascending colon. Hemostasis secured with 1:10,000 adrenaline injection. I-C junction and appendix could not be evaluated. No definite mass seen.
 
CECT ENTEROCLYSIS
Figures 1.2A to G3
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Figure 1.1A: Colonoscopy shows a bleeding ulcer incecum (arrow)
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Figure 1.1B: Hemostasis achieved with injection of adrenaline 1:10,000
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Figure 1.2A: Spurting of IV contrast seen in the lumen of the cecum(arrow)
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Figure 1.2B: Intensely enhancing base of appendix and I-C region (arrow)
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Figure 1.2C: Intensely enhancing appendix
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Figure 1.2D: Soft tissue attenuating mass in the tip of appendix
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Figure 1.2E: Hyperemia of the terminal ileum
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Figure 1.2F: Contrast spurt in cecum (arrow)
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Figure 1.2G: Mass in base of appendix with contrast spurt (asterix)
 
FINDINGS
Multiple non-enhancing liver lesions noted. Intensely enhancing base of appendix and adjacent cecum noted. Non-enhancing soft tissue mass in the tip of appendix. It measures 1.76 cm. Hyperemia of the terminal ileum noted with poor distension. Multiple lymph nodes seen in adjacent mesentery and para-aortic region. The intensity of enhancement of the lesion suggests the bleeding source. Rest of the small bowel loops are normal in caliber and mural enhancement.
 
DIAGNOSIS
Active bleeding sites from appendicular orifice and cecum with appendicular sol-neoplastic.8
 
SURGERY
Findings-growth at base of appendix, large para-aortic nodes, multiple liver secondaries. Right hemicolectomy performed with ileocolic anastomosis.
 
HISTOPATHOLOGY
Figures 1.3A to C
 
FINDINGS
  • Adenocarcinoma (signet ring cell type), appendix, diffusely infiltrating the muscularis propria, subserosa, serosa and mesoappendix. The tumor is infiltrating base of appendix and perforating through cecum. Several tumor emboli in the lymphatics.
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    Figure 1.3A: H and E (10 X): Normal mucosa with diffuse infiltration of tumor cells
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    Figure 1.3B: H and E (20 X): Signet ring cells with intracytoplasmic mucin with eccentric nuclei (arrow)
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    Figure 1.3C: H and E (40 X): Higher magnification of Fig. 1.3B
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  • Cecal ulcer shows infiltration by tumor.
  • Pericecal lymph nodes (3/4) +ve.
  • Stage T4 N1M1
 
DISCUSSION
The indication for surgery in this patient with metastatic disease is repeated malena.
CT enteroclysis has clearly demonstrated the bleeding site from the appendicular orifice, medial wall of the cecum and the appendicular mass. The commonest tumor at this site with this presentation is carcinoid.
Adenocarcinoma appendix is rare, 0.2% of appendectomy specimens are associated with appendiceal adenoma or rupture of appendix.
Age of presentation is similar to colonic adenocarcinoma (40-69 years).
Seventy five percent are symptomatic, with symptoms of acute appendicitis, abdominal mass or intestinal obstruction.
Cases with mixed carcinoid-adenocarcinoma behave as adenocarcinoma.
Mucinous cases typically present with pseudomyxoma peritonei.
 
TREATMENT
Appendectomy if well differentiated and superficial, otherwise right hemicolectomy.