Observation of Lymphangioma of the Duodenum by a Magnifying Endoscope with a Narrow-Band Imaging System
A 65-year-old Japanese man presented to Onomichi Municipal Hospital with anorexia and abdominal fullness lasting for 1 week. He had been taking no medications. He had no particular past history except for appendicitis. His blood pressure was 127/80 mm Hg, and his body temperature was 36.6°C. Physical examination revealed mild tenderness around the umbilicus, but there was no evidence of peritoneal irritation sign. His white blood count was elevated to 11,900/μl and blood urea nitrogen was 52.2 mg/dl. Other laboratory findings were within normal ranges.\nEsophagogastroduodenoscopy revealed an active peptic ulceration in the angular portion of the stomach, which was considered the cause of his symptoms. No cancer cells were detected in the biopsy specimen from the gastric ulcer. Additionally, a soft submucosal tumor approximately 20 mm in diameter, the top of which showed white spots, was demonstrated in the duodenal second portion (fig. ). Narrow-band imaging (fig. ) and indigo carmine spraying (fig. ) emphasized the white spots. When the tumor was grasped by biopsy forceps, chyle flowed into the duodenal lumen (fig. ). The view by the magnifying endoscope showed elongated microvessels on the surface of the white spots (fig. ). Based on these features, duodenal lymphangioma was highly suspected. Subsequent histopathological examination of the biopsy specimen revealed dilated lymphatic structures in the duodenal mucosa and thereby confirmed the diagnosis of duodenal lymphangioma (fig. ). The patient's symptoms were relieved after the initiation of antacids for his active gastric ulceration. Additionally, Helicobacter pylori bacteria were eradicated, as shown by a positive rapid urease test result. No particular treatment was applied to the duodenal lymphangioma.