New Hanover Regional Medical Center Wilmington, NC, United States
Jeremy M. Hess, DO, Michael Pietrangelo, DO New Hanover Regional Medical Center, Wilmington, NC
Introduction: Stage III colon cancer has an approximate 33% 5-year recurrence rate. When re-discovered symptomatically it typically presents with abdominal pain, altered defecation, or weight loss. Newly metastatic disease is most commonly found in the liver, lung, or peritoneum.
Case Description/Methods: A 76 year-old male with a history of stage III colon adenocarcinoma (T3N2MX) status-post right hemicolectomy 4 years prior, remote prostate cancer, and type 2 diabetes presented to the emergency department with complaints of burning epigastric abdominal pain that awoke him nightly for the past 2 weeks, feeling “like heartburn”. Vitals: blood pressure 107/48 mmHg, heart rate 77 bpm, temperature 98.4F, respiratory rate 16, pulse ox 100% on room air. Exam was unremarkable including abdominal exam without tenderness, rebound, guarding, palpable mass, or organomegaly. Labs were also unremarkable with a normal WBC and LFTs. CT abdomen/pelvis was performed and showed an irregular hypo-enhancing 4cm pancreatic head mass, a necrotic-appearing lymph node adjacent to the pancreas with additional adenopathy posterior to the SMA, numerous masses throughout the liver, and bilateral pulmonary nodules highly suspicious for pancreatic adenocarcinoma per radiology. Patient underwent EGD with EUS the next day for pancreatic mass biopsy, however there was a large amount of retained food in the stomach, and a large periduodenal mass with structure. The next day a duodenal stent was placed endoscopically. Pancreatic and liver mass biopsies resulted as metastatic colonic adenocarcinoma per pathology. Tumor markers were checked and supported this diagnosis with CEA 2,417 ng/mL, CA 19-9 < 1.2 U/mL, AFP < 2.2 ng/mL, and PSA 0.04 ng/mL. The patient is currently receiving palliative capecitabine monotherapy, as oxaliplatin was deemed to have greater risk than benefit for this individual, with resolution in his dyspepsia after stenting.
Discussion: This case is atypical in its presentation as dyspepsia secondary to gastric outlet obstruction from duodenal stricture that was initially radiographically and endoscopically concerning for advanced pancreatic adenocarcinoma. The diagnosis of recurrent colon adenocarcinoma with newly widespread metastases was only realized upon results of pathology and tumor marker testing. Also highlighted by this case is the utility of duodenal stenting in the palliative setting and the increased quality of life associated with this in our patient.
Figure: CT abdomen/pelvis showing irregular hypo-enhancing pancreatic head mass measuring 4.0 x 3.3cm (A), necrotic-appearing peri-pancreatic lymph node measuring 17mm in short axis (B), heterogeneous multi-cystic liver (C), and pulmonary metastases – the two largest being 2.2cm and 1.9cm in diameter (D).
Jeremy Hess indicated no relevant financial relationships.
Michael Pietrangelo indicated no relevant financial relationships.
Jeremy M. Hess, DO, Michael Pietrangelo, DO. P2304 - Recurrence of Colon Adenocarcinoma Presenting as Gastric Outlet Obstruction Mimicking Advanced Pancreatic Malignancy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.