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Primary linitis plastica of the jejunum
At the Focal Point
Primary linitis plastica of the jejunum
In January 1999, a 58-year-old male patient was admitted to our institution because of intermittent epigastric pain. He reported a decreased appetite and a weight loss of 10 kg in the antecedent 6 months and several episodes of tarry stool in the prior 3 months. Upper-GI endoscopy conducted at another hospital showed no abnormality 2 months before this admission. On examination, he appeared cachectic and pale. Laboratory examination disclosed anemia, with a Hb level of 7.3 g/dL (normal range for Hb in our institution is 14.017.0 g/dL). Upper-GI endoscopy and colonoscopy were conducted to survey his chronic bleeding, but no bleeding site was found. A small-bowel series revealed an irregular configuration of the mucosal surface, luminal narrowing, and poor distensibility of the proximal jejunum (A). CT showed circumferential wall thickening involving the proximal jejunum, with regional lymphadenopathy and multiple liver metastasis (B, arrows). Push enteroscopy (SIF-200; Olympus Optical Co, Ltd, Tokyo,
Japan) disclosed multiple shallow ulcerations, with thickened folds in the jejunum (C, arrows). There was circumferential luminal narrowing with marked rigidity but no luminal obstruction, allowing a biopsy sample to be collected from the ulcerated area. Pathology demonstrated a poorly differentiated adenocarcinoma with a desmoplastic reaction (D; H&E, original magnification 40). The patient received chemotherapy because of inoperable disease and died in 3 months.
www.giejournal.org
Volume 63, No. 3 : 2006 GASTROINTESTINAL ENDOSCOPY 503
Hsu-Heng Yen, MD, Department of Gastroenterology, ChangHua Christian Medical Center, ChangHua, Taiwan; Yang-Yuan Chen, MD, Department of Gastroenterology, ChangHua Christian Medical Center, ChangHua, Taiwan, Department of Gastroenterology, ChungTai Institute of Health Sciences and Technology, Taichung, Taiwan; Maw-Soan Soon, MD, Department of Gastroenterology, ChangHua Christian Medical Center, ChangHua, Taiwan doi:10.1016/j.gie.2005.09.045
At the Focal Point
Commentary Named by Britton to describe the resemblance of cells entrapped in linen cloth, linitis is a strong connective tissue reaction, usually to signet-ring gastric cancer but also to other cancers (eg, breast) and a variety of causes, including lye ingestion, lues, tuberculosis, and sarcoid. Most commonly, the stomach is affected, but involvement of all parts of the GI tract has been described. This case is unusual because of the jejunal involvement, the absence of signet-ring cells, and the ulcerated mucosa; usually the submucosa is most affected and the mucosa is spared. Lawrence J. Brandt, MD Associate Editor of Focal Points
EUS-assisted intervention to restore continuity of an obstructed ileal pouch–anal anastomosis
A 41-year-old woman was referred for evaluation of an obstructed ileal pouch–anal anastomosis (IPAA). Four months before admission, the patient underwent total proctocolectomy, IPAA, and temporary loop ileostomy for
refractory ulcerative colitis. The patient returned for an ileostomy takedown; however, laparotomy with rediversion was performed 10 days later because of symptoms of bowel obstruction. It was recognized by a barium study that the
504 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 3 : 2006
www.giejournal.org
Primary linitis plastica of the jejunum
In January 1999, a 58-year-old male patient was admitted to our institution because of intermittent epigastric pain. He reported a decreased appetite and a weight loss of 10 kg in the antecedent 6 months and several episodes of tarry stool in the prior 3 months. Upper-GI endoscopy conducted at another hospital showed no abnormality 2 months before this admission. On examination, he appeared cachectic and pale. Laboratory examination disclosed anemia, with a Hb level of 7.3 g/dL (normal range for Hb in our institution is 14.017.0 g/dL). Upper-GI endoscopy and colonoscopy were conducted to survey his chronic bleeding, but no bleeding site was found. A small-bowel series revealed an irregular configuration of the mucosal surface, luminal narrowing, and poor distensibility of the proximal jejunum (A). CT showed circumferential wall thickening involving the proximal jejunum, with regional lymphadenopathy and multiple liver metastasis (B, arrows). Push enteroscopy (SIF-200; Olympus Optical Co, Ltd, Tokyo,
Japan) disclosed multiple shallow ulcerations, with thickened folds in the jejunum (C, arrows). There was circumferential luminal narrowing with marked rigidity but no luminal obstruction, allowing a biopsy sample to be collected from the ulcerated area. Pathology demonstrated a poorly differentiated adenocarcinoma with a desmoplastic reaction (D; H&E, original magnification 40). The patient received chemotherapy because of inoperable disease and died in 3 months.
www.giejournal.org
Volume 63, No. 3 : 2006 GASTROINTESTINAL ENDOSCOPY 503
Hsu-Heng Yen, MD, Department of Gastroenterology, ChangHua Christian Medical Center, ChangHua, Taiwan; Yang-Yuan Chen, MD, Department of Gastroenterology, ChangHua Christian Medical Center, ChangHua, Taiwan, Department of Gastroenterology, ChungTai Institute of Health Sciences and Technology, Taichung, Taiwan; Maw-Soan Soon, MD, Department of Gastroenterology, ChangHua Christian Medical Center, ChangHua, Taiwan doi:10.1016/j.gie.2005.09.045
At the Focal Point
Commentary Named by Britton to describe the resemblance of cells entrapped in linen cloth, linitis is a strong connective tissue reaction, usually to signet-ring gastric cancer but also to other cancers (eg, breast) and a variety of causes, including lye ingestion, lues, tuberculosis, and sarcoid. Most commonly, the stomach is affected, but involvement of all parts of the GI tract has been described. This case is unusual because of the jejunal involvement, the absence of signet-ring cells, and the ulcerated mucosa; usually the submucosa is most affected and the mucosa is spared. Lawrence J. Brandt, MD Associate Editor of Focal Points
EUS-assisted intervention to restore continuity of an obstructed ileal pouch–anal anastomosis
A 41-year-old woman was referred for evaluation of an obstructed ileal pouch–anal anastomosis (IPAA). Four months before admission, the patient underwent total proctocolectomy, IPAA, and temporary loop ileostomy for
refractory ulcerative colitis. The patient returned for an ileostomy takedown; however, laparotomy with rediversion was performed 10 days later because of symptoms of bowel obstruction. It was recognized by a barium study that the
504 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 3 : 2006
www.giejournal.org