Leiomyoma of the small bowel - a rare cause of massive gastrointestinal bleeding: A case report and literature review

Naif Al Awad

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CASE REPORT

Year : 2000 | Volume : 6 | Issue : 2 | Page : 92-94

Leiomyoma of the small bowel - a rare cause of massive gastrointestinal bleeding: A case report and literature review

Naif Al Awad
Department of Surgery, King Faisal University, Dammam, Saudi Arabia

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Date of Submission	16-Feb-1999
Date of Acceptance	10-Oct-1999

How to cite this article:
Al Awad N. Leiomyoma of the small bowel - a rare cause of massive gastrointestinal bleeding: A case report and literature review. Saudi J Gastroenterol 2000;6:92-4

How to cite this URL:
Al Awad N. Leiomyoma of the small bowel - a rare cause of massive gastrointestinal bleeding: A case report and literature review. Saudi J Gastroenterol [serial online] 2000 [cited 2022 Jan 17];6:92-4. Available from: https://www.saudijgastro.com/text.asp?2000/6/2/92/33486

Massive small bowel bleeding remains a diagnostic challenge. Various diagnostic modalities singly, or in combination, yield variable results. Despite advances in the diagnostic methodology, a large percentage of cases are undiagnosed. Small bowel enteroscopy, a newly introduced diagnostic tool, can diagnose only about 50% of cases of small bowel tumors[1]. With improved techniques and equipment the diagnostic rate has gone up to 64%[2]. This still leaves a large population of patients without any preoperative diagnosis. Benign tumors are the commonest cause of massive bleeding from the small bowel. Although rare, leiomyoma is the commonest of small bowel benign tumors but can cause diagnostic difficulty in routine evaluation of the source of bleeding. In this report, a case of leiomyoma of small intestine presenting with massive rectal bleeding is described. The literature is reviewed with particular reference of the emerging role of enteroclysis, push enteroscopy and laparoscopy.

Case Report

M.K a 29-year-old Egyptian male was referred to the King Fahd Hospital of the University with previous history of massive rectal bleeding, mild abdominal pain and deep seated ano-rectal discomfort, all of which occurred 15 days earlier when he had been admitted in another hospital. There was no vomiting or constipation. However, he was lethargic and had headache. His rectal bleeding persisted for 2 days and necessitated blood transfusion. There was no history of drug intake. He had been treated for schistosomiasis 15 years back. On examination in our hospital he was well built, pale but anicteric. Abdomen was lax and not tender without organomegaly. Bowel sounds were normal. Digital rectal examination was inconclusive; there was no blood on the finger. His current hematocrit was 23.7%, hemoglobin 7.5%, and platelets 184 x 103. Coagulation profile, liver and renal function tests were within normal limits. Stool examinations for occult blood and parasitic infestation were negative. Carcino-embryonic antigen and alpha-fetoprotein were within normal limits. Esophagogastroduodenoscopy was normal. Ultrasonogram detected a vague mass in the pelvis but exact details were obscure. A barium enema showed extrinsic compression on the rectosigmoid with intact mucosal pattern. A contrast- enhanced CT scan showed an irregular soft tissue mass, about 8 x 4 cm, in the pelvis [Figure - 1]. The appearance of the mass was suggestive of a colon tumor. Colonoscopy up to 60cm revealed no pathology and mucosal biopsies were normal. A diagnostic laparoscopy was performed 12 days after admission. A large hemorrhagic mass arising from and adherent to the small bowel and wedged into the pelvis was seen. Attempts to mobilize it through laparoscope resulted in brisk bleeding and the mass could not be freed from the pelvis. The procedure was therefore abandoned and an exploratory laparotomy through a low midline incision was performed. A 6 x 5 x 3.5cm tumor arising from the jejunum was excised using GIA-90 stapler and bowel continuity was restored. The histopathologic diagnosis was leiomyoma of the jejunum. The patient made an uneventful recovery and remained asymptomatic at one year of follow-up.

Discussion

Leiomyomas of the gastrointestinal tract, although rare, are the most common benign nonepithelial tumors of the small intestine. They usually present with massive bleeding per rectum. Preoperative diagnosis is difficult to make owing to the absence of specific clinical symptoms and difficulties in radiologic evaluation of small bowel. Furthermore, the rarity of the condition does not allow any one surgeon or center to gain sufficient expertise. In a large review of 5,190 patients with significant gastrointestinal hemorrhage, tumor of small intestine was the cause in only 14 cases[3]. Klinvimol et al[4] reviewed 1,489 patients of gastrointestinal hemorrhage and found only one leiomyoma out of 10 cases where the bleeding had originated in the small bowel. The preliminary work-up in these cases includes upper and lower gastrointestinal contrast series, oesophagogastroduodenoscopy and colonoscopy. These conventional diagnostic tools usually fail to identify the bleeding, and the small bowel becomes implicated by exclusion. Enteroclysis, a double contrast study of the small bowel with the contrast instilled directly into the small bowel, has been recommended for patients with suspected small bowel pathology. The diagnostic yield has been claimed to be 10% in patients with obscure gastrointestinal bleeding[5]. Six such studies performed in 4 out of 13 patients failed to show any lesion in the hands of other authors(l). Using barium infusion techniques, Gourtsoyiannis et al[6] identified, preoperatively, a lesion in 11 of 18 benign small intestinal tumors. In their experience, enteroclysis provides effective preoperative evaluation of patients with suspected small bowel lesions. Ultrasonography and CAT scan with or without contrast are of little help since the features are nonspecific. Although Gupta et al[7] had described imaging features of leiomyosarcoma of the stomach in infants, no such features have been described for leiomyomas of small intestine. Invasive procedures such as selective mesenteric angiography can reveal the bleeding source in 57% of cases[8] , but are best reserved for cases which are actively bleeding, since the radiologic diagnosis depends upon extravasated contrast, although, the same authors have been able to demonstrate other angiographic features in non bleeders. Technetium99m-red blood cell scintigraphy has an advantage over angiography[9]. It can be performed even in the presence of intraluminal barium. Nuclear isotopic studies have been extensively used in patients with suspected bleeding from the Meckel's diverticulum. Nuclear scintigraphy is recommended as a follow up study in patients where enteroclysis has failed to demonstrate any lesions[9]_.

Currently 'push-enteroscopy' of small bowel is gaining popularity as a diagnostic tool for detecting small bowel pathology as a source of bleeding. These procedures are time consuming[10] and the yield rate is only 25% in the lesions of the distal small bowel[8]. Moreover, they provide only direct viewing of mucosal lesions and are blind to extramucosal pathology. Explorative laparotomy may be essential for removing any doubts regarding diagnosis[11]. It is especially true if there has been some identification of pathology by other preoperative investigations. Zak and Galtsev[12] have gone on record that in some cases only laparotomy can succeed in localizing the tumor. The laparotomy can be conveniently coupled with enteroscopy to enrich the yield. Sonde-enteroscopy[13] and probe radio enterography[3] have been found to be less traumatic and more fruitful, but again can be used only intraoperatively. Recently, laparoscopy is being used more frequently as a diagnostic tool. The indications have varied from acute or chronic abdominal pain to intestinal obstruction. Laparoscopy not only provides a visualization of the entire gut but also is a means to obtain tissue or provide cure by removing the offending lesion. Over the years the safety and ease of laparoscopy has made it a popular diagnostic tool provided it is understood that it cannot diagnose intraluminal pathology with certainty. In our experience with this case, the dilemma of identifying the source of small bowel bleeding was adequately solved by laparoscopy. Refinements in the armamentarium and availability of `needle scopes' further enhance the suitability of this procedure as a diagnostic tool. These procedures can conveniently be undertaken in the emergency room or the operating room just before laparotomy, and, thereafter, the incision can be suitably placed. It is concluded that leiomyoma of small bowel is a very rare cause of gastrointestinal bleeding, and its preoperative diagnosis can be difficult. Laparoscopy as a tool of diagnosis of obscure, extramucosal bleeding lesions of the small bowel is a safe method. Laparoscopy should be considered by the surgeon faced with this challenging diagnostic problem.

References

1.	Lewis BS, Kornbluth A, Waye JD: Small bowel tumorsyield of enteroscopy. Gut 1991;32:763-5.
2.	Chong J. Tagle M, Brkin JS, Reiner DK: Small bowel push type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol 1994;89:21413-6.
3.	Kurygin AA, Baranchuk VN, Smirnov AD: Features and diagnosis of tumors of the small intestine complicated by hemorrhage. Khirurgiia 1991;4:43-5.
4.	Klinvimol T, Ho YH, Parry BR, Gob HS: Small bowel causes of per rectal hemorrhage. Ann Acad Med, Singapore 1994;23:866-8.
5.	Rex DK, Lappas JC, Maglinte DDT: Enteroclysis in the evaluation of suspected small intestinal bleeding. Gastroenterology 1989;97:58-60.
6.	Gourtsoyiannis HC, Bays D, Papaioannou N, Theothokas J, Barouxis G, Karabelas T: Benign tumors of the small intestine: preoperative evaluation with a barium infusion technique. Eur J Radiol 1993;16:115-25.
7.	Gupta AK, Berry M, Mitra DK. Gastrointestinal smooth muscle tumors in children-Report of three cases. Paediatr Radiol 1994;24:498-9.
8.	Tillotson CL, Geller SC, Kantrowitz L, Eckstein MR, Waltman AC: Small bowel haemorrhage: angiographic localization and intervention. Gastrointest Radiol 1988;13:207-11.
9.	Rehm PK, Atkins FB, Ziessman HA: Positive technetium99m-red blood cell gastrointestinal bleeding scan after barium small-bowel study. J Nucl Med 1996;37:643-5.
10.	Lewis BS, Waye JD. Chronic gastrointestinal bleeding of obscure origin-role of small bowel enteroscopy. Gastroenterology 1988;94:1117-20. [PUBMED]
11.	Piemonte F, D'Avino V, Barone G, et al. Leiomyoma of the small intestines-a rare cause of emergency abdominal surgery. Minerva Chir (Italian) 1996:51:989-91.
12.	Zak VI, Galtsev AP: Bleeding non epithelial gastrointestinal neoplasms (Russian): Klin Med (Mosk) 1993;71:46-8.
13.	Lopez MV, Cooley JS, Petros JG, Sullivan, JG Care DR: Complete intraoperative small bowel endoscopy in the evaluation of occult gastrointestinal bleeding using Sondeenteroscope. Arch Surg 1996;131:272-7.