Leiomyoma as a Cause for Massive Lower Gastrointestinal Bleed

LEIOMYOMA AS A CAUSE FOR MASSIVE LOWER GASTROINTESTINAL BLEED
Shilpa A Rao*, Prakash P Shilotri**, Avinash Katara***
*Lecturer; **Prof.; ***Resident; Dept of Gen Surgery Topiwala National Medical College and BYL Nair Hospital, Mumbai.

INTRODUCTION
Leiomyoma is one of the commonest symptomatic benign lesions affecting the small intestine. Usually diagnosed in the fifth decade of life, two-thirds of the patients present with lower gastrointestinal bleed and about one-fourth with intestinal obstruction. There is no sex predilection. Though mostly jejunoileal there has been a disproportionately high incidence of smooth muscle neoplasms in Meckel’s diverticula.
CASE REPORT
A 58 year old male complained of painless, acute onset massive bleeding per rectum 4 days prior to being admitted at our institute. The bleeding was mixed in nature and associated with watery stools. There were no gastrointestinal complaints or any history of similar complaints in the past. Patient was a known hypertensive with one recorded myocardial infarction 4 years back, from which he seemed to recover uneventfully.

This patient was followed on a conservative line of management, with multiple blood transfusions, for 4 days elsewhere which did not stop the bleeding and he was then transferred to our hospital.

On admission the patient was haemodynamically stable with a pulse of 96/min and a blood pressure of 110/70 mmHg. On examination, the abdomen was soft with no evidence of free fluid or lump. Per rectal examination showed evidence of mixed blood.

Blood investigations were all within normal limits. His haemoglobin was 11.5 gm% and his coagulation profile, liver and renal functions were unaltered. Platelets were adequate. The returning fluid on nasogastric lavage was clear and upper gastrointestinal bleed was further ruled out by an OGD scopy. An ultrasonogram abdomen as well as plain X-rays of the abdomen did not reveal any abnormality or evidence of obstruction or lump.

An angiogram was attempted through the transfemoral route which showed normal inferior mesenteric artery filling and branching. However the superior mesenteric artery could not be canulated because of a stenotic opening.

Colonoscopy showed evidence of diverticular disease with active bleeding and 1 litre of pooled blood in caecum and ascending colon.

On exploratory laparotomy, the patient was found to have a growth arising from the antimesenteric border of the ileum 3 feet from the ileocaecal junction which was firm in consistency. There was evidence of blood in the distal ileum. Proximal ileum was normal. We did a wide resection and then in view of the colonoscopic findings, a catheter was passed into the colon through the appendicular stoma and a segmental lavage performed. Returning fluid from the ascending and mid transverse colon showed evidence of active bleeding and therefore a right hemicolectomy was also done. On gross examination and cross section of the tumour mass, there was evidence of bleeding from the tumour into the ileum (Fig. 1).

Fig. 1 : Leiomyoma in the ileum as a cause of lower gastrointestianal bleeding (Massive).

There was an uneventful post operative recovery. However, the patient died of a fresh cerebral infarct on post operative day 2 which was confirmed on post mortem. Intraabdominal find ings were normal. There was also evidence of old myocardial infarct. The histopathology report reads as follows - Leiomyoma of the small intestine with resected margins free of tumour. The colon showed no abnormality. Liver was normal. No lymph node or mesenteric involvement was seen.

DISCUSSION
Tumours of the small intestine are rare. Even though the small bowel accounts for 80% of the length and 90% of the mucosal surface of the gastrointestinal tract, only 3% to 6% of gastrointestinal tumours and 1% of gastrointestinal malignancies arise from the small bowel. Most small bowel tumours are incidental findings at operation or autopsy. Smooth muscle tumours of the gastrointestinal tract can be classified as leiomyomas, leiomyosarcomas and high grade leiomyosarcomas, depending on the cytologic atypia and mitotic rate.

Leiomyoma is the commonest symptomatic benign lesion. It is usually diagnosed in the fifth decade of life, although it may occur at any age. There is no sex predilection. Though mostly jejunoileal there has been a disproportionately high incidence of smooth muscle neoplasms in Meckel’s diverticula, followed by the duodenum, if the unit area is considered. The distribution of these tumours in the alimentary tract, in the study from Taiwan in 1995, [2] in decreasing order of frequency, were found in the stomach (40%), jejunum (20%), ileum and rectum (14.3% each), duodenum (8.57%) and oesophagus (2.86%).

Leiomyoma has 4 types of growth patterns[1] i.e. extraluminal (65%), intramural (16%), dumb-bell shaped (11%) and intraluminal (8%).

Grossly, leiomyomas are white-gray lesions.

Microscopically, they contain well differentiated smooth muscle cells and no mitoses, which differentiates them from their malignant counterpart.

The major concern is bleeding, either into the lumen or the peritoneal cavity. Two-thirds of patients present with evidence of bleeding, whereas only one-fourth present with obstructive symptoms. The various clinical presentations in the above mentioned study [2] are gastrointestinal bleeding (43.8%), abdominal mass (37.5%), abdominal pain (21.3%) and obstruction (16.4%). No symptom or sign were evident in 8.8% of the cases studied. On X-ray studies, they appear as ovoid filling defects. A fluid cavity may appear when they grow large. This central necrosis is the result of tumour outgrowing its vascular supply.

The treatment of leiomyoma is segmental resection with clear margins, since differentiation from leiomyosarcoma is difficult, even on pathological examination. Lymph node resection is not routinely performed because leiomyosarcoma does not spread via lymphatics. Recurrence and metastasis is rare.
REFERENCES

Agustin A Burgos, Mignel E Martinez, Bernard M Jaffe, Michael J Zinner, Seymour I Schwartz, Harrold Ellis. Maingot’s Abdominal Operations. USA : Appleton and Lange 1997; 2 : 116.

Fong-Fu Chou, Hock-Liew Eng, Shyr-Ming Sheen-Chen. Smooth muscle tumours of the gastrointestinal tract: Analysis and prognostic factors. Surgery Feb. 1996; 119 (2) : 171-7.

To Section TOC