Radiologic and Endoscopic Diagnosis of Duodenal angioma

Acta Radiologica ISSN: 0284-1851 (Print) 1600-0455 (Online) Journal homepage: https://www.tandfonline.com/loi/iard20 Radiologic and Endoscopic Diagnosis of Duodenal angioma Branko Plavšić & B. Jereb-Prović To cite this article: Branko Plavšić & B. Jereb-Prović (1987) Radiologic and Endoscopic Diagnosis of Duodenal angioma, Acta Radiologica, 28:6, 735-738 To link to this article: https://doi.org/10.3109/02841858709177435 Published online: 07 Jan 2010. Submit your article to this journal Article views: 112 Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalinformation?journalcode=iard20

Acra Radiologica 28 (1987) Fasc. 6 FROM THE INSTITUTE OF RADIOLOGY AND THE INSTITUTE OF GASTROENTEROLOGY, SCHOOL OF MEDICINE, UNIVERSITY OF ZAGREB, YU-41000 ZAGREB, YUGOSLAVIA. RADIOLOGIC AND ENDOSCOPIC DIAGNOSIS OF DUODENAL ANGIOMA B. PLAVSIC and B. JEREB-PROVIC Abstract Two patients with lymphangioma and one with hemangioma of the duodenum are described. The radiologic presentation of duodenal angiomas is that of multiple submucous, soft, polypoid, non-infiltrating tumors. During propagation of peristalsis, on compression, or gas distension of the duodenum, they change in shape and dimensions. Deep peristaltic waves could cause apparent vanishing of the angiomas. Possible mechanisms of such behaviour of angiomas are discussed. Listed characteristics enabled the radiologic distinction of angiomas from solid submucous duodenal tumors. Duodenoscopy allows differentiation of duodenal lymphangiomas from hemangiomas and duodenal varices. Final diagnoses were based on histologic analysis of surgical specimens. Key words: Duodenum; lymphangioma; hemangioma; radiography; endoscopy. Lymphangiomas and hemangiomas are infrequent tumors of the alimentary canal (4, 8). About ten duodenal lymphangiomas have been reported (5, 6, 8). The frequency of duodenal hemangiomas is even smaller (12). Radiologically and endoscopically, alimentary canal angiomas are described as submucosal, expansive, broad-based growths protruding into the lumen and leaving the overlying mucosa intact (8, 10). Poiypoid angiomas with the stalk are less common (13, 15). Most angiomas of the digestive canal, including the duodenum, are cavernomas (8, 10). To distinguish duodenal angiomas from other tumors and morphologically similar states is important because of the different diagnostic and therapeutic approaches. Material and Methods The duodenal angiomas were observed in a group of 13 140 in-patients (48% men, 52% women, age range 2 days91 years) with upper gastrointestinal complaints. They were submitted to a conventional barium examina- tion (7) including demonstration of mucosal pattern, and compression studies. The patients with tumors and tumorlike lesions were also examined using drug-induced hypotonia and the double contrast technique (16). For duodenal hypotonia Buscopan (Boehringer) or Glucagon (Novo) in doses of 20 mg and 0.2 mg, respectively, were applied intravenously. In the double contrast studies gas was introduced into the stomach and duodenum by using effervescent granules. Patients with radiologically demonstrated tumors also underwent duodenoscopy. The findings were confirmed by microscopic analysis of surgical specimens. Results Duodenal lymphangiomas were detected in one female patient aged 24 and in one male patient aged 32, while one male patient, 22 years old, had a duodenal hemangioma. The clinical course in patients with both kinds of duodenal angiomas was similar, comprising periodical upper abdominal pain and discomfort, loss of lymph, or bleeding from the tumors. Before being operated upon the female patient with duodenal lymphangioma (Fig. 1) was twice in hypovolemic shock following profuse loss of lymph from the tumor. The male patient with lymphangioma had one episode of oligemia due to lymphorrhagia from the tumor. The patient with hemangioma (Fig. 2) exhibited longstanding sideropenic anemia resulting from occult bleeding from the tumor. All three patients underwent surgery. In both cases of lymphangioma the upper gastrointestinal series demonstrated tumors situated in the region of the inferior flexure affecting neighbouring oral and aboral parts of the duodenum (Fig. 1). The hemangioma occupied the superior flexure and the entire descending part of the duodenum (Fig. 2). - Accepted for publication 23 April 1987. 735

736 B. PLAVSIC AND B. JEREB-PROVIC a b Fig. 1. Lymphangioma deforming the horizontal part of the duodenum, (a). Deformation disappears during peristalsis (b). a Fig. 2. Duodenal hemangioma (a). Morphology of lesion changes on compression (b). b Lymphangiomas and hemangiomas were mutually indistinguishable by radiologic examination. However, they could be distinguished by duodenoscopy without biopsy. The radiologic examination demonstrated multiple oval or spherical, broad-based, polypoid tumors of various dimensions (Figs 1, 2). The tumors were rather well demarcated from surrounding structures, i.e. no radiologic signs of adjacent tissue infiltration were noticed. The mucosa overlying the angiomas was without signs of destruction. In periods between peristaltic waves during a conventional barium examination, the morphologic features of the angiomas were constant. Peristaltic contractions of the duodenal wall changed the shape and dimensions of the tumors (Fig. 1). In the course of deep peristaltic waves some angiomas seemingly vanished (Fig. 1). On Fig. 3. Duodenal lymphangioma. Endoscopic presentation.

DIAGNOSIS OF DUODENAL ANGIOMA 737 compression, identical effects were obtained (Fig. 2). Gas distension of the duodenum after application of a hypotonic agent caused some flattening of the tumor s protrusion into the duodenal lumen. During duodenoscopy multiple submucous, easily compressible smooth, round or oval, polypoid tumors were found (Fig. 3). The lymphangiomas were seen through the mucosa as pale yellowish and hemangiomas as bluish masses. Microscopy of specimens obtained at surgery in all three cases exhibited cavernous tumors, i.e. cyctic lymphangiomas and hemangiomas of the duodenum. Discussion By using the descibed data on the characteristics of duodenal angiomas and those already reported, we tried to identify features enabling a distinction between angiomas and other duodenal tumors and tumor-like changes at radiologic and endoscopic examinations. Duodenal angiomas had the following characteristics: multiple polypoid, submucous growths of different sizes. They changed dimensions and shape during peristaltic wave propagation and on compression, most probably due to the liquid content of these tumors, the great distensibility of the fluid-filled spaces, and the communication of angiomas with draining vessels. The overlying mucosa was in no instance found to be ulcerated, which corresponds with previously reported cases (10). Angiomas can originate from any part of the duodenum (14) but are most often in the descending part (6), as in our cases. In some series the tumors were solitary (4, 6, 10, 12). The present findings and earlier reported data (8, 12) enabled a radiologic differentiation of angiomas from solid tumors. Endoscopic features allowed a distinction to be made between lymphangiomas and hemangiomas. Duodenal varices are radiologically indistinguishable from angiomas. The varices are, however, most frequently situated in the first part of the duodenum (3). With duodenoscopy, bluish varices are easily differentiated from the pale, yellowish lymphangiomas (17), but not from hemangiomas. Angiodysplasia cannot be differentiated from angioma, neither by radiologic nor by endoscopic examination (1 1). Solitary duplication cysts of the duodenum are usually intramural and cannot be differentiated from angiomas by radiologic methods. With duodenoscopy, a duplication cyst can be differentiated from a hemangioma but not from a lymphangioma. Angiomas should be distinguished radiologically from solid tumors and tumor-like lesions (3). Enlarged Brunner s glands are multiple polypoid solid tumorous formations; however, they occupy mainly oral parts of the duodenum above the major duodenal papilla. Duodenal lymphoid hyperplasia, indistinguishable from enlarged Brunner s glands, is a frequent finding too (2). The formations in both of these conditions are more often of equal dimensions and remarkably well demarcated from surrounding unchanged parts of the duodenum. Lymphomas can be multiple and may develop in any part of the duodenum. Other growths like myoma and choristoma are less pliable; they do not change significantly in shape and dimensions during peristalsis, compression, or duodenal gas distension (1, 8). In contrast, alimentary canal lipomas are of fluid consistency at body temperature, and thus change their shape when under pressure. In addition, the mucosa overlying alimentary canal lipomas is often ulcerated (8). Duodenal folds of more than 4 mm in caliber seen in duodenitis (9) have a more constant morphology during duodenal motility. The results of biopsy with simultaneous photocoagulation (1 1) for alimentary tract angiomas have been poor (8). Therefore, and because of the potential threat of bleeding and loss of lymph, we did not perform biopsy in suggested duodenal angiomas. Confirmation of the diagnoses was obtained only by histologic analysis following surgery. The majority of duodenal angiomas described so far (4, 6, 10, 12) have been of the same histologic type as those found in the present series, i.e. cavernous lymphangiomas and hemangiomas. ACKNOWLEDGEMENTS The authors thank Miss Ana HajdaroviC and Mr Stjepan IvekoviC for their excellent technical assistance. Request for reprints: Professor Branko PlavSiC, Zavod za radiologiju KBC, YU-41000 Zagreb, KiSpatiCeva 12, Yugoslavia. REFERENCES 1. AGHA F. P., FRANCIS J. R. and SIMMS. M.: Cystic lymphangioma of the colon. Amer. J. Roentgenol. 141 (1983), 709. 2. ANDREOLI J. C., SAKAI P. and IRIA K.: Nodular lymphoid hyperplasia of the duodenum. Study of 3 cases. Arch. Gastroenterol. 17 (1980), 26. 3. BERGEG S. N.: Pseudotumors of the duodenal bulb. Amer. J. 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