DUODENAL LEIOMYOMA AS A RARE CAUSE OF GASTROINTESTINAL BLEEDING IN A NIGERIAN- CASE REPORT WITH PRESENTATION OF MINIMALLY INVASIVE THERAPEUTIC INTERVENTION

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N. Nwude², H. Ninalowo³, A. Rahman², A. Oluyemi¹

1. ReMay Consultancy & Medical Services, Ikeja, Lagos State. Nigeria.
2. Evercare Hospital, Victoria Island, Lagos State. Nigeria.
3. IRDOC Interventional Radiology Consulting Limited, Euracare Multispecialty Hospital, Victoria Island, Lagos State. Nigeria

Abstract

Findings from Nigerian pathological series have supported international reports about the rarity of the occurrence of duodenal leiomyomas. More recently, case reports from the country have detailed interventional radiological techniques being deployed successfully in the control of massive bleeding from the gastrointestinal system. The article seeks to document these rare elements coming together in a Lagos, Nigeria-based center in the case of bleeding duodenal leiomyoma in an elderly gentleman which was successfully controlled by selective transcatheter arterial embolization.

Introduction

Leiomyomas are the commonest benign mesenchymal tumors of the gastrointestinal tract (GIT). They are widely distributed along this tract, with the stomach being the commonest site of occurrence.1 Nigerian immunohistochemistry-based series have corroborated world reports that duodenal leiomyomas (DL) are a rare finding indeed.2-4 Also, recent scientific literature has heralded the successful deployment of minimally invasive vascular embolization techniques in the control of GIT bleeding in Nigerian patients.5,6 This report documents a recherché DL as the cause of GIT bleeding in our locality for the first time and highlights apposite clinical, diagnostic, and therapeutic aspects.

CASE REPORT
A 75-year-old man presented at the emergency unit with complaints of sudden onset of weakness, easy fatigability, and dizziness. He was diagnosed with upper gastrointestinal (GI) bleeding as he gave a history of passage of dark colored and tarry stools initially, but the color of these stools had changed to bright red within the intervening hour. He was not on any steroid, blood thinner nor non-steroidal anti-inflammatory drug.

He was observed to be markedly pale with a hemoglobin (Hb) of 5.9g/dl at presentation. Consequently, he was transfused with twelve units of packed cell over the course of 2 days. His vital signs showed little evidence of hemodynamic improvement as there was ongoing blood loss (indicated by the continued passage of bloody stools and the posttransfusion Hb was 6.1g/dl) and emergency gastroscopy was put on hold because of this.

He later became stable and underwent emergency gastroscopy which revealed a submucosal mass measuring about 12mm by 10mm at the second part of the duodenum. Blood was noted to be freely oozing from it and the mucosa around the mass was markedly erythematous and swollen which significantly obscured detailed inspection of the bleeding sites (Figure 1). Following a multi-disciplinary review

(MDR) of the case, and urgent magnetic resonance image (MRI) was obtained and interventional radiology (IR) therapy was suggested. The MRI revealed a welldefined, homogenously enhancing, soft tissue mass in the proximal portion of the second part of the duodenum.

The patient underwent IR therapy to arrest the bleeding. The celiac artery was selected and and an arteriogram performed. This demonstrated hyperemia and active extravasation into the bowel from branches of the GDA (especially the inferior pancreaticoduodenal artery). These branches and the main GDA were selectively embolized with 6-10 mm nitinol coils. After embolization, no further flow was demonstrable from= the said vessels in the post-embolization images (Figure 2).

The clinical response of the patient was dramatic. His post-operative vital signs showed marked improvement from within the hour and there was no further decline in serial PCV measurements. A repeat gastroscopy done 36 hours after the placement of nitinol coils showed complete cessation of bleeding. He remained stable and was discharged home after 48 hours. A follow up visit 1 week after showed no clinical evidence of recurrence.

Histology of sections of the endoscopic biopsy of the lesion showed nodular proliferation of smooth muscle cells in the submucosa with benign spindleshaped cells and bland elongated nuclei suggestive of a benign mesenchymal tumor (Figure 3). Immunohistology showed features consistent with DL (positive Desmin and Smooth Muscle Actin and negative for DOG1 stain). Thus, a diagnosis of DL was definitively made. Seven months after this incident, the elderly gentleman remains symptom free and is being followed up for possible recurrence. He has since refused overtures to have the mass surgically extricated. The follow up endoscopy and computed tomography scan results showed that there was still no bleeding and that the mass had not changed in size and radiological characteristics.