Presentation
Severe anaemia (5.5 g/dL); haematochezia; clinical suspicion of lower gastrointestinal bleeding
Patient Data
A plaque-like hypervascular distal ileum lesion.
Multiple hepatic hypervascular foci, the largest of which is in the caudate lobe , with mild washout in the venous phase.
A thickened ileal loop at the left flank with bowel-within-bowel configuration, in which the layers of the intestine are duplicated forming concentric rings depicting the intussuscipiens (outer layer) and intussusceptum ileum (inner layer), displayed by intervening mesenteric fat. Findings specific for ileo-ileal intussusception.
MRI with hepatospecific mdc confirms multiple solid liver nodules, the largest one in the caudate lobe, with hyperintense signal in T2-weighted sequences, hypervascular with mild washout, hypointense compared to hepatic parenchyma in hepatobiliary excretion phase, matching with signal restriction in diffusion-weighted imaging.
Pathology report (italian)
Summary of the pathological report:
Surgical specimen submitted: portion of an ileal distal loop with its meso and an adjacent mesenteric lymph node.
Macroscopic analysis: [...] whitish solid vegetating endoluminal neoformation.
Diagnosis: well-differentiated neuroendocrine tumour (NET) histological grade G2; metastasis in the loco-regional lymph node.
Case Discussion
Neuroendocrine tumours of the small bowel can occur with gastrointestinal bleeding. The most typical location is the distal ileum, they are characterised by precocious vascularisation and, at the time of the diagnosis, they are metastatic in 30 % of cases 1. The primary bowel tumour is usually resected to avoid complications such as bleeding itself, or occlusion, ischaemia or perforation. If metastases are localised only to the liver, treatment (surgical or interventional radiology) has curative purposes 1.
In the current case we also have a collateral finding of ileo-ileal invagination, which is also a very rare cause of bleeding 2.
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