Signet-ring cell carcinoma of the duodenal bulb presenting with gastrointestinal hemorrhage: a case report and literature review

Abstract

Background: Primary duodenal cancer (PDC) is rare, especially signet-ring cell carcinoma (SRCC) of the duodenal bulb, and it is commonly misdiagnosed as an ulceration. Here, we report a rare case of SRCC of the duodenal bulb presenting with gastrointestinal hemorrhage in an 82-year-old man.

Case presentation: An 82-year-old man was admitted for gastrointestinal hemorrhage. Physical examination revealed upper abdominal tenderness and pale appearance, but was otherwise unrevealing. Laboratory workup was significant for anemia. Imaging showed no abnormalities. Two endoscopic evaluations along with interventional embolization were attempted and, unfortunately, adequate hemostasis was not achieved, resulting in distal subtotal gastrectomy, including the duodenal bulb. SRCC of the duodenal bulb was diagnosed based on pathology after surgery. Post-operatively, the patient experienced persistent gastrointestinal bleeding. Family declined further intervention and the patient eventually died one month post-resection.

Conclusions: SRCC in the duodenal bulb is difficult to diagnose. For those with high-risk factors, endoscopic examination and biopsy are recommended. For patients who can receive radical tumor resection, pancreaticoduodenectomy (PD) is considered a first-line option. Early diagnosis and resection have been shown to improve prognosis.

Keywords: Bulb; Duodenal; Signet-ring cell carcinoma.

Fig. 1

First endoscopy showing a 1.0 × 1.0 cm lesion with ulceration and active bleeding in the duodenal bulb. No active bleeding was observed after multipoint injection with solution consisting of L-HS-E

Fig. 2

Second endoscopy showing a slightly depressed centre with active bleeding in the posterior wall of the duodenal bulb. L-HS-E was injected into 5 points, with 1–1.5 mL per point

Fig. 3

Pathological findings showing proliferation of SRCs with vacuolated foamy cytoplasm and displaced ovoid nuclei, resembling xanthoma cells (hematoxylin–eosin staining × 10)

Fig. 4

Positive staining of the AE1/AE3 immunohistochemical makers

Fig. 5

Immunohistochemistry showing a Ki-67 labelling index of approximately 10%