St. Vincent's Medical Center, Quinnipiac University Bridgeport, CT, United States
Rishi Chadha, MD1, Sasraku Amanor-Boadu, MD, MPH2, Mahmoud Abdelrahman, MD1, Pankaj Nepal, MD1, Eddy Castillo, MD1 1St. Vincent's Medical Center, Quinnipiac University, Bridgeport, CT; 2St. Vincent's Medical Center, Quinnipiac University, Fairfield, CT
Introduction: Small bowel tumors are a rare cause of gastrointestinal malignancy. It is a difficult etiology to diagnose given its location and often presents late with a poor prognosis. Here we report on a patient who presents with small bowel obstruction over a short time interval and was found to have jejunal adenocarcinoma with pancreatic spread leading to intussusception.
Case Description/Methods: A 73-year-old female with a medical history of diabetes mellitus, CKD, and diverticulosis presented to the hospital for a four-week history of abdominal pain associated with vomiting and constipation. Patient recently underwent endoscopy few days prior which showed erosive gastritis and retained gastric content. CT abdomen and pelvis showed enlarged head and neck of the pancreas with pancreatic duct dilation of 8 mm, but otherwise unremarkable. The patient’s pain resolved and she was able to tolerate a diet. Plan was for outpatient MRI for further pancreatic evaluation. Patient returned two days later with worsening abdominal pain and vomiting. She underwent MRCP which showed massive dilatation of the stomach with a transition point at the distal duodenum. She underwent upper EUS which showed a medium-sized polypoid mass intussuscepted in the proximal jejunum. Biopsy was conducted, and pathology showed moderately differentiated adenocarcinoma. Patient was taken to the OR for bowel resection to remove the intussuscepted region. Intraoperative ultrasound showed the tumor invading directly into the pancreatic parenchyma and diverting gastrojejunostomy was conducted. Patient had symptomatic improvement and was discharged with Oncology follow-up.
Discussion: The small bowel composes most of the gastrointestinal tract, but only accounted for 0.6% percent of new cancer cases in 2021. In a single center review of 491 patients with small bowel adenocarcinoma, the most common tumor locations were the duodenum (57%), jejunum (29%), and ileum (10%). Explanations for the low rate of neoplasms include rapid transit in the small bowel compared to the large bowel as well as less bacterial colonization. Most subtypes are adenocarcinoma and carcinoid tumors, with lymphomas and stromal tumors making up a smaller portion. Given non-specific clinical symptoms such as abdominal pain and nausea, diagnosis is often delayed. While CT scan can detect lesions, in the case of our patient no abnormalities were initially found until MRCP days later. Diagnosis is usually through EGD, but distant lesions can be difficult to visualize.
Figure: Imaging of the patient with non-contrast CT abdomen and non-contrast MRI abdomen. A) Coronal non-contrast CT image of the abdomen showing non-specific mild gastric distention (yellow thin arrow), and prominent main pancreatic duct in the head of pancreas (red thin arrow). B) Coronal and C) axial T-2 weighted MRI images of the abdomen showing increased gastric distention (yellow bold arrow), distention of the duodenum (blue bold arrow), and dilated main pancreatic duct (red curved arrow). D) Axial T-2 weighted MRI image shows transition of the duodenal dilation with beak like narrowing (blue bold arrow).
Rishi Chadha indicated no relevant financial relationships.
Sasraku Amanor-Boadu indicated no relevant financial relationships.
Mahmoud Abdelrahman indicated no relevant financial relationships.
Pankaj Nepal indicated no relevant financial relationships.
Eddy Castillo indicated no relevant financial relationships.
Rishi Chadha, MD1, Sasraku Amanor-Boadu, MD, MPH2, Mahmoud Abdelrahman, MD1, Pankaj Nepal, MD1, Eddy Castillo, MD1. P2008 - Rapid Onset Gastrointestinal Obstruction in the Setting of Small Bowel Intussusception Due to Jejunal Adenocarcinoma: A Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.