|Year : 2021 | Volume
| Issue : 2 | Page : 146-148
Leiomyoma of ileum causing intestinal obstruction: A rare presentation
Abhay Vilas Deshmukh, Vihanka Devchand Vaidya, Vitaladevuni Balasubramanyam Shivkumar, Nitin M Gangane
Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Submission||11-May-2021|
|Date of Decision||09-Jul-2021|
|Date of Acceptance||11-Jul-2021|
|Date of Web Publication||16-Aug-2021|
Vitaladevuni Balasubramanyam Shivkumar
Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Leiomyoma is a benign mesenchymal neoplasms arising from smooth muscles which accounts for 20%–30% of all benign gastrointestinal tumours. The occurrence of leiomyoma in ileum is rare. Very few cases of intestinal obstruction due to intestinal leiomyoma have been documented till date as per our knowledge. Here, we report a case of leiomyoma of ileum causing intestinal obstruction in a young woman who presented with pain in abdomen since 7 days. Intraoperative findings showed presence of 15 cm × 14 cm × 12 cm mesenteric tumour encircling the ileum. Microscopically, the benign spindled tumour cells were arranged in whorled pattern. Immunohistochemistry showed positivity for smooth muscle actin and negativity for CD117. One should always consider this rare entity in differential diagnosis of patients presenting with intestinal obstruction.
Keywords: Acute abdomen, benign tumour, leiomyoma, small intestine
|How to cite this article:|
Deshmukh AV, Vaidya VD, Shivkumar VB, Gangane NM. Leiomyoma of ileum causing intestinal obstruction: A rare presentation. Saudi J Health Sci 2021;10:146-8
| Introduction|| |
Benign neoplasms of small intestine are rare and accounts for 1%–6% of all gastrointestinal neoplasms. Leiomyoma is a benign mesenchymal neoplasm arising from smooth muscle which accounts for 20%–30% of all benign gastrointestinal tumours. Amongst small intestine, jejunum is the most frequent location for leiomyoma, followed by ileum and duodenum. These lesions are usually asymptomatic and thus remain silent for years. They are often found as an incidental findings; but can enlarge in size and present as an emergency. Literature shows few cases of leiomyoma arising from small intestine which presented as an emergency.,, Here, we report a case of an leiomyoma of ileum causing intestinal obstruction in a young woman.
| Case Report|| |
A 27-year-old woman presented to surgery outpatient department at Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, a tertiary care hospital in rural Central India with complaints of pain in abdomen since 7 days and vomiting on and off since 2 days. The pain was present over central abdomen and vomiting was non-projectile, non-bile stained and contained food particles. She denied any history of fever, chills and malena. Previous history of hospitalization was absent. She was average built. On physical examination, she was afebrile, normotensive and slightly tachycardic. Systemic examination revealed rebound tenderness over central abdomen. Laboratory investigations showed haemoglobin of 11.4 gm%, reactive neutrophilia (polymorphonuclear neutrophils: 81%) with a total leucocyte count of 12.5 × 109 cells/L. Rest haematological and routine biochemical tests were normal.
Magnetic resonance imaging of abdomen showed heterogeneously enhancing altered signal intensity lesion of approximate size 14 cm × 13.6 cm × 8.2 cm (CC × TR × AP) appearing hypointense on T1W, heterogenously hyperintense on T2W and showed heterogenous post contrast enhancement on contrast study, more on the right side, extending to lower abdomen. The lesion was abutting abdominal wall anteriorly, lumbar vertebrae, right psoas muscle, aorta and bilateral common iliac vessels posteriorly, sigmoid colon, uterus and urinary bladder inferiorly and displacing bowel loops laterally [Figure 1]. The exploratory laparotomy was performed. On opening abdomen, surgeons found presence of 15 cm × 14 cm × 12 cm mesenteric tumour. It was encircling the ileum and was present at 45 cm away from dudenojejunal junction. The tumour was resected and mesenteric vessels were secured. End to end ileoileal anastomosis was done and the abdomen was closed in multilayer fashion. The patient did well postoperatively and she was discharged form hospital 2 days after surgery.
|Figure 1: Magnetic resonance imaging abdomen showing lesion (white arrow) in lower abdomen. The lesion appears hypointense on T1W (a), shows heterogenous post contrast enhancement on contrast study (b) and heterogenously hyperintense on T2W (c)|
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The resected specimen was sent to the surgical pathology section for examination. Grossly, solid mass measuring 15 cm × 11 cm × 10 cm in size with attached part of intestine measuring 14 cm in length was received. External surface was well encapsulated. Cut surface showed presence of grey white whorled areas arising from wall of intestine along with haemorrhagic area at one pole [Figure 2]. Microscopically, H and E stained sections showed presence of spindle cells arranged in whorled pattern [Figure 3]a and [Figure 3]b. Individual tumour cells had blunt ended pale staining nuclei. No necrosis as well as mitosis were noted [Figure 3]b. Immunohistochemistry was done using a formalin-fixed and paraffin embedded tissue blocks. The tumour cells showed strong, diffuse positive staining for Smooth Muscle Actin (1A4) (1:100, Mouse monoclonal antibody, clone: 202M-94, Cell Marque) [Figure 3]c while, it were negative for CD117, c-kit (YR145) (1:100, Rabbit monoclonal Primary antibody, CMC11731050, clone: 117R-14-ASR0, Cell Marque) [Figure 3]d. A diagnosis of leiomyoma of ileum was made.
|Figure 2: Cut surface of tumour mass (green arrow) showing presence of leiomyoma arising from wall of small intestine (red arrow)|
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|Figure 3: (a) Section showing presence of leiomyoma in upper part (red arrow) and normal intestinal glands in lower part (green arrow) (H and E, ×100); (b) Section showing presence of spindle cells arranged in whorled pattern (H and E, ×400); (c) Smooth muscle actin positivity (white arrow) in tumour cells (immunohistochemistry, ×100), (d) CD117 negativity in tumour cells (immunohistochemistry, ×400)|
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| Discussion|| |
Leiomyomas are the most common benign neoplasms of small intestine. It was documented first in literature in 1858. One of the study conducted at Johns Hopkins University Hospital in Baltimore where 11,500 autopsy reports and 45,000 surgical specimen were examined which showed that there was presence of 88 small bowel tumours, out of which only three specimen were diagnosed as leiomyomas.
Leiomyomas can occur at any age, but peak incidence have been documented in fifth decade with male preponderance. The most common location of leiomyoma is jejunum followed by ileum and duodenum., These leiomyomas can be intraluminal, intramural and extramural. The preoperative diagnosis of leiomyoma ileum is often difficult due to lack of exact pathognomonic signs and symptoms. The clinical features are very vague which includes abdominal pain (66%), diarrhoea, palpable abdominal mass (31%), weight loss, bleeding (59%–70%), malena and very rarely acute intestinal obstruction (8%) depending on the location. As the clinical features are similar to common gastrointestinal manifestations, these lesions go unnoticed and present very late in the clinical course. Our patient was a young female presented in third decade of her life.
Grossly, leiomyomas are well circumscribed and nonencapsulated tumours. The capsule is formed by the compression of normal surrounding muscle fibres. These are usually smaller and are firm in consistency. Cut surface shows presence of characteristic sharply circumscribed grey white whorled pattern. Large tumours may show secondary changes like haemorrhage and cystic degeneration. Microscopically, tumour cells resemble normal cells (elongated, spindle shaped) and forms bundles arranged in a concentric pattern with different directions (whorled). Some fibrous connective tissue may be interspread between the muscle bundles. The line will read as shape. [7,8] One of the important differential diagnosis includes gastrointestinal stromal tumour (GIST). Morphologically, GIST can be differentiated form leiomyoma in having marked cellularity and presence of mitosis. Leiomyomas are positive for smooth muscle actin and negative for CD117 and CD34 while vice versa is found in GIST on immunohistochemistry. It is important to distinguish between these two entities as management differs in both.
The treatment of leiomyoma ileum includes surgery. Wide resection should be done to avoid recurrence., The prognosis of leiomyoma is excellent after surgery., Our case presented with typical symptoms of acute abdomen due to a large leiomyoma at an unusual site in abdomen which recovered completely after a surgery.
| Conclusion|| |
Leiomyoma of ileum is a rare entity. It is an unusual cause of intestinal obstruction which requires urgent surgery. Our case was a rare case of huge leiomyoma of ileum in a young woman who presented with vague abdominal pain. Therefore, surgeons should always consider this rare entity in differential diagnosis of patients presenting with intestinal obstruction.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]