Gastroduodenal Intussusception Caused by a Gastric Collision Tumor Consisting of Adenocarcinoma and Neuroendocrine Carcinoma
A 77-year-old woman presented with vomiting for 1 month and loss of 25% of body weight during that time. She had previously visited a general practitioner for vomiting. Abdominal X-ray in that clinic had indicated gastric dilatation. She was referred to our hospital for further examination.\nOn physical examination, her abdomen was bloated without tenderness. She was 143 cm tall and weighed 30 kg. Vital signs were: body temperature 36.8°C, pulse 65 beats per minute, respiratory rate 18 per minute, and blood pressure 90/60 mm Hg. Laboratory data on admission were as follows: white blood cell count 5,800/μl, red blood cell count 326 × 104/μl, hemoglobin 10.2 g/dl, platelets 35.1 × 104/μl, total protein 4.4 g/dl, albumin 2.1 g/dl, total bilirubin 0.38 mg/dl, aspartate aminotransferase 13 IU/l, alanine aminotransferase 6 IU/l, alkaline phosphatase 68 IU/l, γ-glutamyl transferase 12 IU/l, cholinesterase 99 IU/l, total cholesterol 103 mg/dl, blood urea nitrogen 17.1 mg/dl, creatinine 0.42 mg/dl, C-reactive protein 1.20 mg/dl, Na 134 mEq/l, K 3.61 mEq/l, Cl 97 mEq/l, CEA 4.7 ng/ml, and CA19-9 7.3 U/ml. Abdominal X-ray showed gastric dilatation. Computed tomography (CT) of the abdomen revealed a duodenal giant mass spreading from the bulb to the horizontal part of the duodenum (fig. ). Upper gastrointestinal radiography with Gastrografin revealed smooth taper shape of the duodenum. No tumor was clearly detected (fig. ). A villous tumor was observed in the duodenal bulb endoscopically, but the pyloric ring was not confirmable (fig. ). There were no appearances suggestive of malignancy. The tissue obtained from biopsy did not include malignant cells. Insertion of the endoscope into the second part of the duodenum was easy.\nWe diagnosed the mass to be a huge duodenal tumor, and laparotomy was therefore performed. About one third of the stomach was invaginated through the pylorus into the duodenum (fig. ). We in vain performed manipulative reduction by Hutchinson's maneuver. Gastrotomy followed by duodenotomy was performed and revealed a villous tumor measuring 12 cm in maximum diameter. The tumor was excised and pathological examination of the frozen section showed malignant cells composed of well-differentiated adenocarcinoma and undifferentiated carcinoma. The infrapyloric lymph node was positive for metastasis. Therefore, additional distal gastrectomy with lymphadenectomy was performed. The patient made an uneventful postoperative recovery.