Duodenal metastases

Fig. 5.8a-d. A 79-year-old male, who underwent a left nephrectomy for renal cell cancer 1 year previously, now presents with melena from bleeding duodenal metastases. a DSA of the common hepatic artery showing hypervascular tumor blush (arrows) in the duodenum, supplied by hypertrophied duodenal branches of the gastroduodenal artery. b,c Superselective visualization of two different tumor compartments (arrows) with a 2.7-F microcatheter (arrowheads), d Control DSA after injection of several millilitres of PVA 150-250 p and 250-355 p in four tumor feeders (two of them shown here), confirming tumor devascularization. After each injection of 0.5-1 ml of PVA, superselective DSA was performed to control flow arrest and prevent reflux of particulates. Patient stopped bleeding for about 7 months and was then retreated... 

Bleeding from hypervascular tumors, such as duodenal metastasis of renal cell carcinoma, can be stopped by palliative particulate embolization (Fig. 5.8), although other authors preferred Gelfoam [88,89). 

Recurrent anastomotic ulcers when they occur are usually found on the jejunal side of the anastomosis (Fig. 5.8a). In patients who present with persistent or complex duodenal or anastomotic ulcer, especially if associated with diarrhoea, weight loss, and liver metastasis, Zollinger-Ellison syndrome should be suspected. The syndrome consists of recurrent intractable peptic ulcers caused by hypergastrinae-mia produced by gastrin-secreting tumours of the pancreas (75%) or duodenum (15%) (Hirschowitz 1997). Tumour localisation is critical to aid in the identification of patients with potentially respectable disease (Berg and Wolfe 1991). Twenty percent of patients have multiple endocrine neoplasia type I which includes parathyroid, pituitary, and adrenal tumours. 

Fig. 9.17. a Intraluminal villous adenoma. CECT shows a soft-tissue polypoid mass with a small pedicle, arising from the medial aspect of the descending duodenum, with no mural thickening or extraduodenal disease, b Malignant villous tumor of the duodenum. Note the extensive carpetlike lesion involving most of the inferior duodenal flexure as well as the liver metastasis (c)... 

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