A 45-year-old woman with a 3-year history of chronic anemia was followed up at the Gastroenterology outpatient department of another hospital, with a 6-month history of abdominal pain. The pain was intermittent, worse in the mornings, and localized to the epigastric region. The patient noticed that her abdomen became distended after meals and distension was relieved after a bowel movement. The patient noticed a 12-kg weight loss over the last 6 months. There was a history of nausea but no vomiting. The patient denied any history of loss of appetite, diarrhea or constipation, and upper or lower gastrointestinal bleeding. There was no significant past medical history other than anemia and multiple blood transfusions. The patient denied any history of tobacco smoking, alcohol consumption, drug abuse, Helicobacter pylori (H. pylori) infection, chronic renal failure, peptic ulcer disease, and chronic pancreatitis. Her family history was unremarkable. The patient did not have any prior surgeries or history of malignancy. Workup for her chronic anemia included CT scan of the abdomen and pelvis with intravenous and oral contrast, which revealed duodenal intussusception. The patient was booked for upper gastrointestinal endoscopy in the referral hospital but missed her appointment and asked for a referral to another hospital.\nUpon arrival at our hospital, she appeared underweight (height, 162 cm; weight, 43 kg). Her vitals were stable, and she was afebrile (blood pressure, 118/67 mm/Hg; heart rate, 96 bpm; respiratory rate, 23 bpm; oxygen saturation, 98% in room air; temperature: 36.9 °C). On examination, her abdomen was soft and laxative, with no tenderness, or organomegaly. A complete blood count on the day of admission revealed the following: low hemoglobin level, 7.2 g/dL (12.0–17.0 g/dL); mean corpuscular volume (MCV), 78.0 fL (80.0–100.0 fL); low hematocrit, 24.8% (40.0%–51.0%); leukocyte count, 8.2 × 109/L (4.5-11.0 × 109/L); and platelet count, 323 × 109/L (150-450 × 109/L). Other laboratory profiles were unremarkable. Contrast CT of the abdomen and pelvis revealed significant dilation of the stomach with no detectable gastric lesion. The third part of the duodenum was distended by a sausage-shaped intraluminal structure with alternating fat planes and dilated vessels reaching up to the first part of the duodenum, suggesting retrograde jejuno-duodenal intussusception. There was no detectable soft tissue lesion, and the rest of the bowel was unremarkable (A–C). Endoscopic examination of the upper digestive tract revealed a large, long, mobile submucosal longitudinal and tortuous bulge extending from the first to the second part of the duodenum that moved freely with bowel contraction. The papilla of Vater was normal with no neoplastic process.\nThe patient underwent laparoscopic exploration, which revealed antiperistaltic intussusception in the proximal jejunum (). A jejunostomy was performed, and the mass was pulled through in the proximal jejunum (A).\nA cholecystectomy was performed, and a pediatric feeding tube was passed through the cystic duct to locate the ampulla of Vater. The mass was not resectable without affecting the ampulla, so the decision was made to perform a pancreas-sparing duodenal resection. The excised duodenum with mass was sent for histopathological examination (B).\nPathological findings showed a large polypoid mass with the mucosa pedunculated from the bowel lumen, measuring 12 × 7.5 × 2.0 cm3. Microscopic examination revealed a bowel mucosa with underlying submucosa showing lobules of benign normal-appearing Brunner's glands separated by fibrous stroma. The nodular proliferation of Brunner glands was accompanied by cystically dilated ducts and adipose tissue with no microscopic features of malignancy (A–C). The patient was discharged postoperatively in good condition, given an appointment after 1 month.
A 53-year-old man was admitted to the local hospital with left upper abdominal pain lasting 2 weeks. A gastroscopy showed a bulging gastric lesion in the antrum. However, the pathology was benign. The patient did not receive any treatment, and still had abdominal pain. Then, he was referred to the Second Affiliated Hospital of Xi’an Jiaotong University. Physical examination revealed no mucocutaneous pigmentation, no palpable masses in the abdomen, but left upper abdominal tenderness. The patient had no family history of polyps or tumors in the gastrointestinal tract. Laboratory tests were normal, and the tumor markers were within normal limits. Abdominal computed tomography revealed that the gastric wall in the antrum was thickened (Fig. ). A gastroscopy showed a giant and extensive bulging gastric lesion located on the greater curvature and posterior and anterior walls of the gastric antrum, involving three-quarters of the gastric wall. The mucosal surface of the lesion was smooth without erosion or ulcer. Magnifying endoscopy with narrow-band imaging showed the almost normal microvascular morphology of the lesion (Fig. ). Endoscopic ultrasonography was performed, showing a low-echo area in the muscularis mucosae and no invasion into the submucosal layer, without enlarged celiac lymph nodes (Fig. ). An endoscopic mucosal resection was performed, and a bigger specimen was sent for histopathological examination to confirm the diagnosis. The final pathology report indicated a hamartomatous polyp (Fig. ). After excluding PJS, a solitary Peutz–Jeghers-type hamartomatous polyp was diagnosed. Then, the patient underwent an ESD. The resected specimen was measured in 110 × 80 × 4 mm3 (Fig. ). We treated patients with acid suppression. The patient recovered quickly, without any complications. A gastroscopy on the fourth day after endoscopic surgery showed a large postoperative artificial ulcer (Fig. ). A gastroscopy on the 40th day after endoscopic surgery showed a narrow lumen of the stomach caused by ulcer healing. Also, a polyp of 4 × 4 mm2 was observed in the lesser curvature of the gastric body (Fig. ). The patient was followed up regularly.