CASE 13343 Published on 03.04.2016

An exceptional form of high-grade duodenal obstruction

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, M.D.

"Luigi Sacco" University Hospital,
Radiology Department;
Via G.B. Grassi 74
20157 Milan, Italy;
Email:mtonolini@sirm.org
Patient

79 years, male

Categories
Area of Interest Small bowel ; Imaging Technique CT
Clinical History
Elderly man with diabetes, hypertension, past history of bowel obstruction from adhesions requiring surgery (3 years earlier), and recent (3 months ago) transurethral resection of muscle-invasive bladder urothelial carcinoma.
Currently suffering from vomiting, inability to eat, 10kg weight loss in the past month.
No significant abnormalities of routine laboratory assays.
Imaging Findings
Initially, multiphasic multidetector CT including focused reconstructions (Fig. 1) confirmed overdistended stomach and duodenal bulb with fluid and alimentary stasis. The strictured descending duodenum did not show abnormal mural changes; pancreatic changes and extrinsic masses were excluded. Additionally, unspecific bilateral thickening of the perirenal bridging septa and anterior pararenal fasciae, subtle infiltrative bands in the periduodenal fat were noted.
Upper digestive endoscopy revealed extrinsical compression of the second duodenum without suspicious mucosal changes.
To reach a definite diagnosis and relieve symptoms, laparotomic surgery was performed. Retroperitoneal exploration identified a spiculated, infiltrative lymphangitic tissue surrounding the duodenal stricture: biopsies revealed neoplastic infiltration consistent with known urothelial carcinoma. Palliative gastro-enteroanastomosis was performed.
Following an uneventful postoperative course, follow-up CT (Fig. 2) detected appearance of ascites, moderate increase of the bilateral thickening of retroperitoneal fasciae, progressive infiltration of the left paraaortic and periduodenal retroperitoneal fat. Chemotherapy was ultimately avoided.
Discussion
Duodenal obstruction (DO) manifests with nausea, vomiting and weight loss from gastric overdistension. Causes include contiguous invasion from gallbladder or pancreatic malignancies, rare extrinsic compression by adenopathies, and duodenal infectious, inflammatory or neoplastic processes. Compared to upper gastrointestinal studies, multidetector CT with multiplanar reconstructions not only confirms obstruction, but depicts the duodenal wall and the presence and extent of extraluminal disease: therefore CT generally represents a helpful, crucial adjunct to endoscopy in diagnosing the underlying process [1-4].
Neoplastic lymphangitis involving the duodenum and surrounding retroperitoneum has been mostly described in association with lung, stomach and pancreatic tumours [5, 6]. Few exceptional case reports of DO in patients with urinary bladder cancer exist, with a dismal prognosis [7-9]. Most usually, transitional bladder carcinoma metastasizes to the pelvic, internal and external iliac lymph nodes, may reach the common iliac and periaortic nodes, and eventually spreads through haematogenous dissemination to the liver, lungs and bone [10, 11].
Endoscopically, neoplastic duodenal lymphangitis appears as suspected extrinsic compression or circumferential luminal stricture with negative mucosal biopsies. Endoscopic ultrasound may depict hypoechoic wall thickening with lost deep wall layers. As in this case, CT shows collapsed duodenum associated with more or less subtle stranding of the adjacent retroperitoneal fat; involvement of the anterior pararenal fat and thickened fasciae and perirenal bridging septa are usually present [7-9].
The main differential diagnosis is idiopathic or medication-induced retroperitoneal fibrosis (RF) which mostly or primarily involves the periaortic region, and may sometimes cause duodenal encasement. RF generally appears as well-demarcated or sheet-like soft-tissue mass with characteristic low T1 and variable T2 MRI signal intensity, occasionally as fat infiltration [8, 12].
Alternative conditions to be considered include: acute peptic disease typically involves the bulb rather than the descending duodenum; duodenitis (including Crohn’s disease) has a characteristic but unspecific CT appearance (stratified mural thickening with submucosal oedema and mucosal hyperenhancement) plus periduodenal fat inflammation and hypervascularity; acute pancreatitis may sometimes cause focal or diffuse duodenal thickening, luminal narrowing and inflammation of the pancreatic groove or peripancreatic fat [1-4].
High-grade DO suggests a malignant process, particularly when adjacent organ invasion, vascular encasement, lymphadenopathy or distant metastases are present. Primary adenocarcinoma and duodenal lymphoma may appear as polypoid masses or irregular strictures with solid mural thickening and luminal deformity. Finally, duodenal metastases may also cause segmental wall thickening with lost mural stratification, periserosal fat stranding and enlarged lymph nodes [1-4].
Differential Diagnosis List
Duodenal obstruction from retroperitoneal neoplastic lymphangitis
Retroperitoneal fibrosis
Peptic ulcer
Duodenitis e.g. from toxic ingestion
Crohn’s disease of the duodenum
Duodenal involvement in acute pancreatitis
Submucosal haemorrhage
Duodenal adenocarcinoma
Lymphoma
Duodenal metastases
Extrinsic invasion from pancreatic/gallbladder cancer
Periduodenal adenopathies
Final Diagnosis
Duodenal obstruction from retroperitoneal neoplastic lymphangitis
Case information
URL: https://www.eurorad.org/case/13343
DOI: 10.1594/EURORAD/CASE.13343
ISSN: 1563-4086
License