Neuromesenchymal hamartoma of small bowel - an extremely rare entity: a case report
© Theodosiou et al; licensee BioMed Central Ltd. 2009
Received: 26 December 2008
Accepted: 27 November 2009
Published: 27 November 2009
Neuromuscular and vascular hamartoma (NMVH) is a very rare stricturing condition of the small intestine, occurring focally and causing recurrent obstructive symptoms or occult chronic gastrointestinal bleeding. Salas et al. (Neuromesenchymal hamartoma of the small bowel. J Clin Gastroenterol. 1990, 12 (6): 705-9) proposed the term of "Neuromesenchymal hamartoma" for the cases of NMVH with participation of mesenchymal tissues.
We present the case of a 60-year-old male patient admitted twice in a month with abdominal pain. On the third admission with clinical signs of acute abdomen, an exploratory laparotomy was performed. The clinical and laboratory findings that occurred after the patient's evaluation, the intraoperative findings and the pathological features of this lesion are reported.
Neuromuscular and vascular hamartoma (NMVH) is a very rare stricturing condition of the small intestine, occurring focally and causing recurrent obstructive symptoms or occult chronic gastrointestinal bleeding. It is a hyperplasia of varied tissue of the submucosa such as smooth muscle bundles, peripherals nerve tracts, vessels and ganglia. In our case there is an additional pathological feature: the diffuse fatty infiltration of the submucosa. Salas et. al. proposed the term of "Neuromesenchymal hamartoma" for the cases of NMVH with participation of mesenchymal tissues .
Laparotomy revealed a single 30 cm long stricture of the small intestine with brown discoloration extending approximately 10 cm and edema of the bowel wall and mesentery. Enlarged mesenteric lymph nodes were present as well.
Presuming Crohn's disease or other colitis, 80 cm length of small intestine was resected and anastomosed. Cholecystectomy was also performed due to cholelithiasis. The postoperative course of the patient was uneventful.
The vessels showed muscular hypertrophy and locally ectasia and were observed also in the serosa. Small areas of fibrosis were seen everywhere. The mucosa was ulcerated and severe inflammed by lymphoplasma cells and less eosinophils. Foci of inflammation were seen in the subserosa. There was no transmural inflammation, granulomas or fissuring. No microorganism with histochemical stains was observed. Hyperaemic, thick wall vessels were observed in the mesenterium. The regional lymph nodes showed no significant morphological alterations.
The neuromuscular and vascular hamartoma of small bowel has been reported in <15 cases up to today [1–6]. In all these cases similar gross and morphological findings were found. In our case we noted also other characteristics. In gross examination there was only a long concentric stenosis measured 25 cm. Pathological features were the same as the previously described "NMVH", but a widely fatty submucosal infiltration was observed to the whole length of the stenotic region. These alterations were also described by Salas et. al. He proposed the term of "NMeH" in those cases with similar pathological characteristics of NMVH in which there is an additional mesenchymal tissue participation . In our case a submucosal extensive infiltration of the adipose tissue was observed. The morphological features of NMVH can be observed in some other situations which cause luminal stenosis of the bowel such as thickening of muscularis mucosa. Shepherd et al. presented some cases where diagnosis of Crohn's disease or of NMVH was questionable . Muscularization, hyperplasia of bundle nerves of the submucosa or hemangiomatous vessels can be also seen in Crohn's disease, ischemia, enteritis by radiation injury, etc. Therefore, the main differential diagnosis should be from Crohn's disease. In our case the hallmark features were absent: no transmural inflammation, no granulomas or fissuring of the mucosa were observed. The postoperative course of the patient was uncomplicated and now, six months later, he is free of any gut symptoms.
In summary, the gross characteristics and the morphological features, the clinical history and the postoperative health status of the patient support the diagnosis of Neuromesenchymal hamartoma of the small bowel.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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