Bleeding Para-Aortic Duodenal Neuroendocrine Tumour

We share a successful treatment of a gentleman of age 70 who presented with passing black stools (on and off) easy fatiguability, generalised weakness & loss of appetite. About a month ago, the patient was diagnosed with anaemia and was transfused 2 units of blood (PRBC) for the same. The patient was anemic and pulsatile abdominal lump. Multiple hospital admissions and Imaging led to a diagnosis of Bleeding Duodenal D3-D4 NeuroEndocrine Tumor. The patient sought multiple opinions from various tertiary care hospitals and was referred to us. The patient underwent a successful surgery with complete tumor clearance and required adjuvant chemotherapy. The patient is on follow-up for 2 years is doing well.

Duodenal Neuroendocrine Tumor of 3rd & 4th part of Duodenum sitting on Aorta.

FAQS

What is a Neuroendocrine Tumor (NET)?

A neuroendocrine tumor is a growth that arises from special cells called neuroendocrine cells.These cells are present throughout the digestive system and help control digestion by releasing hormones.

When these tumors occur in:

• Duodenum (first part of the small intestine), or

• Small bowel (jejunum and ileum),

they are called duodenal or small bowel NETs.

Most NETs are slow-growing, but some can spread if not treated on time.

Why are small bowel and duodenal NETs important?

• They are often silent and difficult to detect early

• Symptoms may be vague and present for years

• Surgery can be curative, especially when done early

What symptoms do these tumors cause?

Many patients have no symptoms initially.

When symptoms occur, they may include:

• Recurrent abdominal pain or cramps

• Unexplained weight loss

• Diarrhea

• Intestinal obstruction (vomiting, bloating)

• Gastrointestinal bleeding (black stools or anemia)

Carcinoid syndrome (in advanced cases)

If the tumor spreads to the liver, hormones may cause:

• Flushing of face

• Diarrhea

• Wheezing

• Fast heartbeat

How is NET of duodenum and small bowel diagnosed?

1. Blood and urine tests

These help suspect a NET but do not confirm it alone.

• Chromogranin A (CgA) – common blood marker

• 24-hour urine 5-HIAA – especially if flushing or diarrhea is present

What imaging tests are used to detect NETs? (Very important)

1. CT scan (Contrast-enhanced CT)

• First and most commonly used test

• Helps identify:

  • Tumor in the intestine

  • Enlarged lymph nodes

  • Liver metastasis

NETs often appear as small, strongly enhancing tumors.

2. MRI scan

• Especially useful for:

  • Detecting liver spread

  • Patients who cannot undergo CT contrast

MRI is more sensitive for liver lesions.

3. PET scan – Ga-68 DOTATATE PET-CT (Most important imaging)

This is the best scan for NETs.

Why it is important:

• Detects very small tumors

• Shows spread to lymph nodes, liver, and bone

• Helps decide whether surgery is possible

• Guides medical therapy

This scan works because NETs have somatostatin receptors.

4. Endoscopy and specialized tests

• Upper GI endoscopy → for duodenal NETs

• Capsule endoscopy → small bowel visualization

• Double balloon enteroscopy → biopsy and localization

How is the diagnosis confirmed?

A biopsy is needed to confirm NET.

The pathology report provides:

• Tumor type

• Grade (how aggressive it is)

• Ki-67 index (growth rate)

What is the role of surgery in duodenal and small bowel NETs?

Surgery is the main and most effective treatment

If the tumor is operable, surgery offers the best chance of cure.

Types of surgery

1. Surgery for duodenal NET

Depends on tumor size and depth:

• Small, superficial tumors → endoscopic removal

• Larger tumors or deep invasion → surgical excision

• Tumors near pancreas or ampulla → may require major surgery (like pancreaticoduodenectomy in selected cases)

2. Surgery for small bowel NET

Most patients require:

• Segmental resection of small intestine

• Removal of nearby lymph nodes (very important)

Why lymph node removal matters:

• Small bowel NETs commonly spread to lymph nodes early

• Removing them reduces future complications and recurrence

3. Surgery even when disease has spread

In selected patients:

• Removal of primary tumor helps prevent obstruction

• Liver surgery or debulking may reduce symptoms

• Improves quality of life and survival

What happens after surgery?

Follow-up is essential

NETs grow slowly and can recur late.

Follow-up includes:

• Periodic blood tests

• CT/MRI scans

• Ga-68 DOTATATE PET-CT when needed

Are medicines needed after surgery?

Depending on stage and spread:

• Somatostatin injections (control hormones and tumor growth)

• Targeted therapy or PRRT in advanced cases

Key points to remember

• NETs of duodenum and small bowel are often slow but sneaky

• Imaging, especially Ga-68 DOTATATE PET-CT, is crucial

• Surgery is the cornerstone of treatment

• Early diagnosis leads to excellent long-term outcomes

• Lifelong follow-up is important.