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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5540_Библиотеки_им_академика_М_И_Перельмана.pdf
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S. N. Hong
g
* Tips for diagnosis: Similar to adenocarcinomas identied on the gastrointestinal tracts with conventional endoscopy, advanced-stage small-bowel adenocarcinomas can present as protruding, ulcerative, ulceroinltrative, and diffuse
inltrative-type endoscopically on balloon-assisted enteroscopy. Small-bowel adenocarcinoma often present with obstructive symptoms and passage disturbance
caused by luminal narrowing.
7.1.2 Lymphoma
① Diffuse large B-cell lymphoma
(A) Mass-like DLBL with a raised margin and central depression in the proxi-
mal ileum
(B) Circumferential ileal DLBL with a nodular friable surface
(C) Geographic ulceroinltrative DLBL covered with exudates
(D) Nodular-type DLBL mimicking submucosal tumors of variable size with super-
cial aphthous ulcers in the terminal ileum.
ab
ab
7 Atlas ofSmall Bowel Diseases Diagnosed by Balloon-Assisted Enteroscopy
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c
d
② Mucosa-assisted lymphoid tissue (MALT) lymphoma
(A) Low-grade MALT lymphoma with a thickened mucosa and small nodules with
indistinct borders
(B) Low-grade MALT lymphoma with patchy depression of discolored inltration
with indistinct borders.
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S. N. Hong
③ Mantle cell lymphoma.
Diffuse inltrative lesion with erythematous nodular mucosal changes and supercial irregular ulcers in the terminal ileum.
④ Natural killer (NK)/T-cell lymphoma
(A) Large geographic ulcerative lesions with an irregular base and clearly demar-
cated margin
(B) Multiple geographic ulcers in the jejunum surrounded by inhomogeneous
regenerative epithelium and abnormal converging folds.
ab
ab
7 Atlas ofSmall Bowel Diseases Diagnosed by Balloon-Assisted Enteroscopy
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⑤ Peripheral T-cell lymphoma
(A) Luminal encircling ulceroinltrative lesion with a whitish exudate covering an
irregular base in the jejunum
(B) Segmental ulceroinltrative lesion with a nodular elevated margin and irregular
base identied in multiple parts of the small bowel.
⑥ Burkitt lymphoma
Luminal encircling ulceroinltrative mass with dirty and thick exudates covering
an irregular base in the ileum.
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S. N. Hong
⑦ Enteropathy-associated T-cell lymphoma [2]
(A) Diffuse inltrative lesions with indistinct margins covered by whitish granular
and erythematous supercial changes
(B) Atypical supercial ulcerative mass with an irregular base and indistinct margin.
7 Atlas ofSmall Bowel Diseases Diagnosed by Balloon-Assisted Enteroscopy
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* Tips for diagnosis: Lymphomas have different ndings, based on histologic
types and origin (from subepithelial lymphoid tissues and lymphocytes), on balloonassisted enteroscopy. Small bowel tumors often present with nonspecic symptoms
such as abdominal pain, weight loss, gastrointestinal bleeding, bowel obstruction,
or perforation. Intestinal obstruction is common in small bowel adenocarcinoma,
whereas perforation is more common in lymphoma.
7.1.3 Gastrointestinal Stromal Tumor (GIST)
(A) A 1.5-cm jejunal GIST with features of a subepithelial tumor that include a
bridging fold overlying the normal mucosa
(B) A 3-cm round mass overlying the normal mucosa with a small central ulcer
(C) A 3-cm round oval subepithelial tumor covered by the normal mucosa in a
patient with small-bowel bleeding
(D) An exposed vessel in the umbilication on the surface of this lesion
(E) GIST with a hematoma attached on the central ulcer, indicating recent
hemorrhage
(F) Malignant GIST with a deeply depressed ulcer and irregular nodular base.
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S. N. Hong
a
c
b
d
e
* Tip for diagnosis: Small-bowel GISTs present as round and oval subepithelial
tumors with an overlying normal mucosa and bridging folds. Malignant transformation should be considered if a GIST ≥2cm accompanied by umbilication, ulcer, and
nodular surface. GIST with central ulcer or umbilication is associated with a risk of
bleeding. Considering the subepithelial origin of GIST, unnecessary biopsy should
be avoided due to the risk of bleeding.
ab
cd
7 Atlas ofSmall Bowel Diseases Diagnosed by Balloon-Assisted Enteroscopy
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7.1.4 Neuroendocrine Tumor (NET)
(A) An irregular nodular subepithelial tumor with bridging folds in the fourth por-
tion of the duodenum
(B) A small, at elevated yellowish polypoid subepithelial tumor with supercial
erythematous changes in the fourth part of the duodenum
(C) A malignant NET with elevated margins, irregularly shaped central depressions,
and nodular surface in the third portion of the duodenum
(D) A malignant NET with luminal semi-encircling ulcerative inltrative lesion in
the second portion of the duodenum. The base of the depressed lesion was irreg-
ular and had a nodular surface with hyperemia and telangiectasia.
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S. N. Hong
7.1.5 Metastatic Cancer
(A) Metastatic lung cancer: An ulceroinltrative mass with a friable mucosal mar-
gin and whitish thick exudates covering the jejunum
(B) Metastatic lung cancer: An irregular and nodular circumferential protruding
mass with supercial ulcer at the border of the jejunum and the ileum
(C) Metastatic lung cancer: An inltrative luminal protruding mass with a central
ulcer with an irregular border and friable mucosa in the ileum
(D) Metastatic liposarcoma: A subepithelial tumor-like protruding mass with a cen-
tral deep ulcer and inltrative friable margin in the duodenum.
7.1.6 Hamartomatous Polyps ofPeutz-Jeghers Syndrome [3]
(A) Multiple hamartomatous polyps on the jejunum in a patient with Peutz-Jeghers
syndrome
(B) Isp-type 8-mm jejunal hamartomatous polyps in a patient with Peutz-Jeghers
syndrome
(C) Isp-type 12-mm ileal hamartomatous polyps in a patient with Peutz-Jeghers
syndrome
ab
7 Atlas ofSmall Bowel Diseases Diagnosed by Balloon-Assisted Enteroscopy
113
(D) Isp-type 20-mm jejunal hamartomatous polyps in a patient with Peutz-Jeghers
syndrome
(E), (F) Endoscopic mucosal resection for Isp-type 15-mm jejunal hamartomatous
polyps in a patient with Peutz-Jeghers syndrome.
c
e
d
f