CASE 1

Female, 69 yrs old

C.C: abdominal pain(onset: 5 days ago)
Lab finding: non-specific
PMHx: nonspecific
Case summary
Ileocecal wall and three short segmental
ileal wall thickening with bowel dilatatio
n.
Homogeneous wall enhancement on po
rtal phase.
No perienteric infiltration of fat.
Rt omental infiltration and nodules.
No ascites or LN enlargement.
Differential diagnosis

Relatively Multiple wall Distal ileum

homogeneous thickening with with
enhancement skip lesion marked narrowing

either neoplastic Crohns disease Crohns disease

or
non-neoplastic GI GVHD Tuberculous enteritis

(more frequent Mesenteric Behcet disease

with vasculitis
non-neoplastic
entities) Tuberculous AIDS related infection
enteritis (CMV, actinomycosis)

Lymphoma Lymphoma

Metastasis Metastasis
 Differential Possibility
diagnosis
Crohns disease Low possibility due to no typical finding, such as mesnteric
side ulceration, no pseudosacculation, no fistula formation,
no comb sign, no fibrofatty mesenteric change, no mural
stratification

Lymphoma Low possibility due to significant obstruction sign, no

significant lymph node enlargement

Metastasis Low possibility due to very rare disease entity, no history of

underlying primary malignant lesion, such as stomach
cancer, melanoma, breast cancer, lung cancer

Tuberculous enteritis Relatively high possibility due to circumferential wall

thickening, cecal involvement, multiple short segmental
involvement
But no tuberculous lymphadenopathy in this case
Colonoscopy finding
IC valve
3cm length
stenotic lesion
of terminal
ileum, mucosal
nodularity,
hyperemia,
edma
.

 Colonoscopy finding

Cecurm appendical oriice mild erythema

edema . biopsy hard
subepithelial lesion . .
Pathology report
Colonoscopic biopsy
A. Terminal ileum: Signet ring cell carcinoma
in the mucosa and submucosa
B. Cecum: Signet ring cell carcinoma in the
mucosa and submucosa

Multifocal signet ring cell carcinoma

 Signet ring cell carcinoma
of intestine
Involve many organs, including the stomach, gallbladder, b
reast, lung, pancreas, genitourinary tract, esophagus and
large intestine.

But most frequently in the stomach.

Less commonly in the rectosigmoid colon.

Very poor prognosis.

Early peritoneal seeding, low incidence of liver metastasis

Signet ring cell ca. of small bowel is extremely rare.

 Several case reports
Signet Ring Cell Carcinoma Of The Ileum
The Internet Journal of Surgery. 2009 Volume 25 Number 1

Our case
Multifocal signet ring cell carcinoma in cecal and ileum
CASE 2
Female, 31 years old
C.C: 2004 Crohns disease .
2006 , F/U .
fever, abdominal pain .
CRP 59.7mg/L
Aug 5, 2015
 Case summary
Current
Multiloculated abscesses adjacent to
thickened distal ileal loop, involving appendix tip.
Severe pelvic fat infiltration.
Multiple enlarged lymph nodes at ileocolic chain.

Past
Multisegmental asymmetric wall thickening
with hyperenhancement in distal ileum.
Comb sign, pseudodiverticulum of small bowel.
Prominent inflammatory stricture at distal ileal loop.
Differential diagnosis
DDx. 1. Active Crohns disease with
complicated abscesses formation.

DDx. 2. Appendiceal tip perforation

with periappendiceal abscess,
less likely
Laparoscopic ileocecectomy
cecum

Thickned distal ileum ileum

loop and
Inflammatory lesion
 Pathology report
Main diagnosis: Signet ring cell carcinoma with neu
roendocrine differentiation (mixed adenomeuroendocr
ine carcinoma)
Location: distal ileum, gross type: ulcerative
Size: 5.9x4.9cm
Depth of invasion: Invades subserosa (pT3)
Resection margin : Free of carcinoma
Lymph nodes, regional (5/17): Metastasis in 5 out of 17 regi
onal lymph nodes (pN2a)
Lymphovascular invasion: Not identified
Associated lesions: Mucosal atrophy with histologic evidenc
e of chronic crypt change, pyloric gland metaplasia, and non
-caseating granuloma, consistent with Crohn's disease
Appendix: Free of carcinoma
 Small bowel cancer
in Crohns disease patient
Small bowel cancer in Crohns disease patient
12-60-fold increase in risk of small bowel cancer
Arising from IC valve and stricture segment
Almost adenocarcinoma, signet ring cell ca is very rare

signet ring cell ca

Diagnosis of small bowel cancer in Crohn patient

, ,

 Small bowel cancer
in Crohns disease patient
Risk factor of small bowel cancer in crohn pt
Stricure, fistula formation
Duration of the disease (at least 10 years)
Diagnosis before age 30 years
Male
Case report 2007;50:51-55
A Case of Small Intestinal Signet Ring Cell Carcinoma in Cro
hns Disease
 Small bowel cancer
in Crohns disease patient
CT finding suggesting small bowel cancer
Sacculated loop with asymmetric thickening.
Loss of mural stratification
Moderate enhancement after IV contrast
Enlarged adjacent mesenteric lymph nodes
Lack of response in healing of fistula
on medical therapy, signify presence of carcinom
a