Christina M Sanders, DO. Department of Surgery, Anna Jaques Hospital, Newburyport, MA
Introduction. Carcinomas of the small intestines are rare. Adenocarcinoma is the most common of the small bowel neoplasms and most commonly found in the duodenum, followed by the jejunum, and rarely the ileum. The following is a rare case report of a patient diagnosed with multiple adenocarcinomas of the distal ileum on diagnostic laparoscopy.
Case Presentation. A 77 year old female with a history of an abdominal exploration for a ruptured ectopic pregnancy and recurrent Clostridium difficile infections presented to the hospital with the initial complaint of persistent diarrhea. Her laboratory studies revealed a mild normocytic anemia and heme negative stool. CT scan of the abdominal and pelvis showed a partial small bowel obstruction with a transition to normal caliber distal ileum within the right upper quadrant. The patient denied abdominal pain, nausea, or vomiting and her abdominal x-ray improved within 24 hrs. Stool studies were positive for a campylobacter infection for which the patient was treated and discharged home. Over the subsequent 6 weeks, the patient was admitted to the hospital 3 more times for persistent diarrhea. A CT scan was done at each admission and showed continued evidence of partial bowel obstruction with a transition point in the distal ileum. An upper GI with small bowel follow through showed slow progression of contrast through the stomach and small bowel taking 10 hours to reach the colon and a transition point was noted within the left abdomen. No mass lesions were identified on any imaging study. In continued work up of her diarrhea, her stools studies remained positive for campylobacter infection and the patient was noted to have markedly elevated celiac antibodies. An upper endoscopy was performed on the patient’s fourth admission to biopsy the duodenum and rule out active celiac disease. During endoscopic examination the patient was noted to have over a 500 ml of bilious fluid suctioned from the stomach and duodenum. After surgical evaluation, an nasogastric tube was placed to decompress the bowel and a diagnostic laparoscopy was performed. Ascites fluid was noted and samples of the fluid were sent for cytology and culture. The omentum appeared thickened and nodular. The distal ileum revealed 2 annular masses with no additional masses noted elsewhere in the abdomen. A laparoscopic resection of the obstructing distal ileal masses was performed with final pathology revealing moderately differentiated adenocarcinomas with invasion through the serosa. An omental biopsy and cytology of the peritoneal fluid were also positive for malignancy and consistent with metastatic disease.
Conclusion. Small bowel carcinomas are rare and often diagnosis is delayed as many patients remain asymptomatic until development of advanced disease. Additionally, diagnosis may be complicated by symptoms explained by overlapping gastrointestinal infection or inflammatory disease. Abdominal exploration should be considered when symptoms persist despite medical management and with imaging that remains abnormal.
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