| Home > Table
of Contents >
Case Reports |
| |
Adenocarcinoma of the Jejunum Presenting
with Intestinal Obstruction
Ajay H Bhandarwar, Shivkumar S Utture, Sunderraj Ellur,
Tanuj Shrivastava |
| |
Adenocarcinoma of the small bowel is a rare
entity, with a prevalence of 1% of all GI malignancies. It occurs
most commonly in the duodenum and then in the jejunum and least
commonly in the ileum.
Most of the small bowel adenocarcinomas present to the surgeon as a complication,
small bowel obstruction. Some present with a picture of obscure lower Gastrointestinal
bleed. Preoperative diagnosis is rarely possible and the delay in the diagnosis
accounts for the poor prognosis in these patients.
We present a case of jejunal adenocarcinoma presenting as a complete small bowel
obstruction, a rare cause of intestinal obstruction. |
| |
| Introduction |
Small bowel adenocarcinoma is a rare entity.
The small bowel comprises 80% length of the entire gastrointestinal
tract yet it accounts for only 1% of all gastrointestinal
malignancies
Adenocarcinoma is the most common malignant lesion in
the small bowel, accounting for about 40% while the carcinoids
account for 30% and the lymphomas 15% of all small bowel
adenocarcinomas. Various factors account for the relative
rarity of small bowel adenocarcinomas.
Small intestinal obstruction due to a malignancy is a
very rare occurrence.
We present a case of adenocarcinoma of the jejunum presenting
with intestinal obstruction.
|
| |
| Case Report |
Present case is a 30-year-old male who presented
to the emergency department with a history of abdominal pain,
vomiting and distension of abdomen. On enquiry the patient
had not passed flatus or stools in the last one day. There
was no history of patient having undergone any surgery in
the past. On examination, the patient had tachycardia, distension
of the abdomen with diminished bowel sounds while the examination
of other vital signs were normal. The patient had dilated
jejunal loops with air fluid levels in the erect plain abdominal
film. A provisional diagnosis of small bowel intestinal obstruction
was made.
Over the next 24 hours the patient had persistent tachycardia, the bowel
sounds diminished further and disappeared while the distension increased.
But, there was no guarding or generalized tenderness. In view of the
deteriorating clinical parameters a decision was taken to explore the
patient. The diagnosis of a jejunal obstruction was confirmed and was
due to a small bowel tumour without any evidence of lymph nodal enlargement,
peritoneal metastasis, ascites or liver metastasis. A resection of the
tumour with a 5 cm margin was done and the intestinal continuity established
with an end-to-end anastamosis. Histopathology showed adenocarcinoma
of the jejunum (Fig. 1). A two-year follow up has shown the patient to
be disease free.
|
 |
Fig. 1 : Adenocarcinoma in the jejunum: Normal appearing jejunal
mucosa with malignant glands of adenocarcinoma in the submucosa |
| |
| Discussion |
Small bowel adenocarcinoma is a rare entity.
The small bowel comprises 80% of the length of gastrointestinal
tract, yet it accounts for only 1% of all gastrointestinal
malignancies. Adenocarcinoma is the most common malignant lesion
accounting for 40% while the carcinoids account for 30% and
the lymphomas account for 15%. Adenocarcinomas usually present
in the 6th and 7th decades. Half of all adenocarcinomas occur
in the duodenum, nearly 20% in jejunum and a little over 10%
in ileum.1 Among the duodenal ones two third occur in the periampullary
region.
Various factors have been postulated to account for the relative rarity
of malignancies in the small bowel and these include rapid transit of contents,2
less bacteria, enzyme benzopyrene hydroxylase, which detoxifies toxins,
alkaline environment,3 liquid stools4 and high IgA content which neutralizes
the viruses. Risk factors that are associated with small bowel adenocarcinoma
include peutz Jeggers syndrome, Coeliac disease and immunosuppression.
The most common presenting complaint is intermittent pain due to partial
intestinal obstruction,5 10% of the patients may present with manifestations
of haemorrhage like obscure GI bleed and anaemia. Other features include
anorexia and weight loss. Periampullary lesions present with obstructive
jaundice. Intestinal obstruction is the commonest indication for surgery.6
While cases presenting with obstruction show classical features of obstruction
in the plain abdominal films, there are no specific methods to diagnose
these tumours in an early stage. Most of the cases require special investigations
for diagnosis. Barium contrast has a diagnostic accuracy of 83%.7,8 Enteroclysis
is the investigation of choice for the small bowel. Enteroscopy by the “push” method
using the paediatric colonoscope can yield a biopsy or a “sonde” enteroscopy
can be used to view the lesion.
Cases in the duodenum require a Whipple’s pancreatoduodenectomy if
resectable. If not resectable a triple bypass will be required. Jejunal
and proximal ileal malignancies require resection and anastomosis while
distal ileal ones require a right hemicolectomy. Curative resection is
possible in two third of the patients.9 The role of chemotherapy and radiotherapy
in small bowel adenocarcinoma is not clearly defined.
The overall 5-year survival was 30.5%,1 prognosis being worse in duodenal
malignancies. Patients should be followed up closely because the possibility
of sustaining another abdominal carcinoma is high. As associated polyps
are nearly always duodenal or jejunal a preoperative or intraoperative
endoscopy of the upper gastrointestinal tract including the initial portion
of the jejunum should be done to detect their presence so as to reduce
the risk of an early recurrence.10
Our patient underwent a resection of the jejunum with an end-to-end anastomosis.
A two-year follow up has shown the patient to be disease free. |
| |
| Acknowledgements |
We would like to thank Dr GB Daver, Dean, Grant
Medical College and Professor and Head, Department of General
Surgery, JJ Group of hospitals, Mumbai for his kind permission
in publishing this manuscript.
We would like to thank Dr KN Warhade, Superintendent, St Georges Hospital,
Mumbai for his permission in publishing this article.
We would like to thank Dr Ram Chilgar, Resident in General surgery, Grant
Medical college, Mumbai for his contribution in preparing this manuscript. |
| |
| References |
| 1. |
Howe JR, Karnell LH, Menck
HR, Scott-Conner C. Adenocarcinoma of the small bowel:
review of the National Cancer Data Base, 1985-1995. Cancer
1999; 86 (12) : 2693-706. |
| 2. |
Wattenber LW. Carcinogen detoxifying mechanisms
in the GIT. Gastroenterology 1966; 51. |
| 3. |
Feldman M. Primary carcinoma in the small
intestine. Am J Dig Diseases 1953; 20. |
| 4. |
Losenfil AB. Why small bowel tumors are
so rare. Lancet 1973; 1. |
| 5. |
Garcia Marcilla JA, Sanchez Bueno F, Aguilar
J, Parrilla Paricio P. Primary small bowel malignant
tumors. Eur J Surg Oncol 1994; 20 (6) : 630-4. |
| 6. |
Zollei I, Balogh A. primary malignant
tumors of small bowel. Acta Chir Hung 1997; 36 (1-4)
: 406-8. |
| 7. |
Kusumoto H, Takahashi I, Yoshida M, Maehara
Y, Watanabe A, Oshiro T, Sugimachi K. Primary malignant
tumors of the small intestine: analysis of 40 Japanese
Patients. J Surg Oncol 1992; 50 (3) : 139-43. |
| 8. |
Bheerappa N, Sastry RA, Mohan VS, Raju
GS, Srinivas GN, Satyanarayana G, Rajashekar, Primary
small intestinal adenocarcinoma. Trop Gastroenterol 1997;
18 (1) : 24-5. |
| 9. |
Cunningham JD, Aleali R, Aleali M, Brower
ST, Aufses AH. Malignant small bowel neoplasms: histopathologic
determinants of recurrence and Survival. Ann Surg 1997;
225 (3) : 300-6. |
| 10. |
Veyrieres M, Baillet P, Hay JM, Fingerhut
A, Bouillot JL, Julien M. Factors influencing long-term
survival in 100 cases of small intestine primary Adenocarcinoma,
Am J Surg 1997; 173 (3) : 237-9. |
|
|
| |
SAFER INJECTING FACILITIES
There has been a substantial misunderstanding about
the rationale for evaluating safer-injecting facilities
as a public-health strategy'
Why should an initiative designed to take injecting drug
users (IDUs) off the street and reduce parenteral transmission
of infectious diseases prove so controversial? The decision
to open in Vancouver, Canada, a pilot safer-injecting unit
(SIF) where IDUs can inject pre-obtained illicit drugs
under the supervision of medical staff, attracted local
press opposition. John Walters, Director of the US Office
of National Drug Control Policy, suggested that SIFs may
lead to increased HIV transmission among IDUs and warned
of migration of IDUs to Vancouver, despite lack of previous
experience to support these suggestions. In the May issue
of The Lancet Infectious Diseases Evan Wood and colleagues
explain how they intend to prospectively evaluate the effect
of the SIF in Vancouver.
BMJ, 2004; 4 : 301-6.
|
|
|
