Babić, Emil

Bevanda Glibo, Daniela

Buhovac, Teo

Marijanović, Inga

Trninić, Zoran

Čuljak, Vjekoslav

Šutalo, Nikica

English

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 69 Psychiatria Danubina, 2016; Vol. 28, Suppl. 2, pp S253–S255 Medicina Academica Mostariensia, 2016; Vol. 4, No. 1-2, pp 69-71 Case report © Medicinska naklada - Zagreb, Croatia ADENOCARCINOMA OF THE SMALL INTESTINE  AS THE CAUSE OF AN ACUTE ABDOMEN –  TWO CASE REPORTS WITH A REVIEW OF THE LITERATURE Nikica Šutalo1, Inga Marijanović2, Teo Buhovac2, Vjekoslav Čuljak1, Zoran Trninić1, Daniela Bevanda Glibo3 & Emil Babić3 1Department of Surgery, University Clinical Hospital Mostar, Mostar, Bosnia & Hercegovina 2Department of Oncology, University Clinical Hospital Mostar, Mostar, Bosnia & Hercegovina 3Department of Internal Medicine, University Clinical Hospital Mostar, Mostar, Bosnia & Hercegovina received: 27.6.2016; revised: 15.9.2016; accepted: 3.11.2016 *  *  *  *  *  TWO CASE REPORTS Case 1 A male patient aged 47 admitted at the emergency surgery department presenting an acute abdomen. Clini-cal presentation and laboratory test results indicated a perforated appendix. Medical history revealed discom-fort lasting several months, colelythiasis was verified following a gastrointestinal examination and chole-cystectomy performed 2 weeks before the present admission. Discomfort persisted. Surgery was perfor-med after an urgent pre-operative preparation. Intra-operative verification of tumorous changes to the ileum approximately 40 centimetres from the valvula with perforations on the antimesenteric side of the small intestine and signs of peritonitis. A resection of the small intestine with the tumorous changes and a T-T anastomosis were performed. The patient had a regular post-operative course and was discharged to home care 15 days after surgery. Histopathological finding: Adenocarcinoma intestine tenui cum meta lymphonodorum. The patient received oncology treatment parallel to regular surgery follow-up. Exitus occurred three years after surgery due to disease dissemination. Case 2 A female patient aged 78 admitted presenting an acute abdomen. Radiography showed an air sickle sign below the diaphragm. In the last 6 months intermittent pain in the epigastrium. Weight loss of 8 kilograms over the preceding two months. Gastrointestinal examination and tests did not indicate an ulcus. Urgent laparotomy led to the discovery of a perforated tumour of the proxi-mal jejunum with a diffuse fibrinopurulent peritonitis. Post-operative complications occurred due to comor-bidity and general poor status. On the fifteenth day exitus occurred due to cardiac arrest. PHD: Adenocarcinoma intestinije juni cum meta lymphonodorum. DISCUSSION Primary tumours of the small intestine are a rare type of tumour, the incidence of which, as epidemio-logic reports show, has been growing in the past couple of decades (Haselkorn et al. 2005). Global incidence is below one sufferer per 100 000 population, occurring more often in males in highly developed countries (Vagholkar et al. 2009). More than 40 different histologic types of small in-testine tumours have been described. The most frequent are adenocarcinomas (Schottenfeld et al. 2009), follo-wed by carcinoids, lymphomas and sarcomas (Qubaiah et al. 2010). Diagnosing this disease is a challenge because of rare localisation of such tumours, with a wide variety of clinical presentations. As a result, these tumours are diagnosed late, limiting treatment options. Although the small intestine occupies 75% of the length of the entire gastrointestinal system and 90% of its absorptive surface area, tumours of the small intestine are less frequent than the other gastrointestinal tumours, mainly colorectal carcinoma (Haselkorn et al. 2005).  Aetiologically, adenocarcinoma of the small intes-tine are linked with genetic factors. The group at risk comprises persons with a family history of familial adenomatous polyposis of the intestine and hereditary nonpolyposis colorectal cancer (Aparicio et al. 2014, Babba et al. 2010). Another group at risk are those who suffer from coeliac disease (Richir et al. 2010) Peutz-Jeghers syndrome (Chaaya et al. 2012), Crohn disease (Feldstein et al. 2008), Gardner and Lynch syndrome (Sun et al. 2016). A detailed histopathological processing of the re-moved parts of the small intestine of our two patients did not show the above aetiological factors which could give rise to the small intestine adenocarcinoma. Literature data indicate that small intestine adeno-carcinoma most frequently occur between the 6th and the 8th decade, although there are more and more reports of occurrence in earlier age (Bilimoria et al. 2009). Nikica Šutalo, Inga Marijanović, Teo Buhovac, Vjekoslav Čuljak, Zoran Trninić, Daniela Bevanda Glibo & Emil Babić:  ADENOCARCINOMA OF THE SMALL INTESTINE AS THE CAUSE OF AN ACUTE ABDOMEN – TWO CASE REPORTS WITH  A REVIEW OF THE LITERATURE          Medicina Academica Mostariensia, 2016; Vol. 4, No. 1-2, pp 69-71   70 In terms of local distribution, the most frequent loca-tion of small intestine adenocarcinoma is the duodenum, followed by the jejunum, and the ileum (Abrahams et al. 2002). Clinical presentation of small intestine tumours is non-specific and laboratory parameters are completely normal until the latter stages. Evidence of this are the laboratory results of the two reported patients whose results, apart from increased inflammation parameters, were normal.  The condition most often presents with non-specific symptoms which include abdominal pain, nausea, vomiting and loss of body weight, resulting in over 50% of small intestine carcinoma being diagnosed during urgent surgery procedures (Negoi et al. 2015). Such lack of early and specific signals and symp-toms contributes to late diagnosis, which is significant for the treatment of small intestine adenocarcinoma. Literature shows an average delay in diagnosis of 8 to 12 months (Maglinte et al. 1991). In our reported cases, the first symptoms appeared around 3-4 months before surgical treatment, while no pre-operative diagnosis was made despite diagnostic processing. Possible reason is that physicians probably do not consider small intestine adenocarcinoma in their differential diagnoses.  Methods used in diagnosing small intestine adeno-carcinoma include abdominal x-ray imaging without contrast, MSCT and abdominal MR, which offer high probability of diagnosing the condition (Anzidei et al. 2011). More recently capsule endoscopy has gained importance (Eliakim et al. 2010). In patients pre-senting symptoms of small intestine tumours, capsule endoscopy should be the diagnostic method of first choice as it differs from others in that it allows the detection of smaller lesions and their more accurate localisation (Van de Bruaene et al. 2015, Rondonotti et al. 2017). The main treatment method is surgical resection of the small intestine. Segmental resection with 5 cm mar-gins and complete extirpation of the segment’s lymph nodes are recommended, followed by post-operative chemotherapy (Agrawal et al. 2007). Research into adjuvant chemotherapy or radiotherapy after a full resection of adenocarcinoma of the small intestine has not indicated any significant improvement in survival rates. Even though an analysis by Cochran in 2007 indicated that there were insufficient data and studies to analyse the effectiveness of adjuvant chemotherapy, same is still recommended for patients with positive lymph nodes on the basis of clinical experiences and clinical research of patients with colon cancer (Singhal et al. 2007). Systemic chemotherapy for advanced-stage or meta-static adenocarcinoma of the small intestine is based on the treatment principles for metastatic colorectal car-cinoma.  Patients with adenocarcinoma of the small intestine face a poor prognosis with a total 5-year survival rate standing at 14-33%. Performing a curative surgical resection improves survival prospects (Overman et al. 2008).  CONCLUSIONS By reporting on the above two cases it is emphasised that diagnosing tumours of the small intestine is difficult due to lack of specific clinical symptoms. These are rare tumours which pose a major diagnostic challenge for clinicians. In recent times, capsule endoscopy has become the diagnostic method of choice in cases of suspected adenocarcinoma of the small intestine. The main treatment method is surgical resection, which constitutes the only potentially curative mode of treatment. No standard adjuvant chemotherapy for small intestine tumours exists. In metastatic stage, the condition is usually treated with systemic chemotherapy based on research of oncology treatment of colorectal carcinoma. An analysis of treatment efficacy in the case of such tumours is limited by the small number of patients in conducted studies.  Acknowledgements: None. Conflict of interest : None to declare. Contribution of individual authors: All authors contributed to the conception of the article. First draft was done by Nikica Šutalo. Acquisition of data and surgical and oncology treatment analysis of small bowel carcinoma in this paper has been done by Zoran Trninić and Inga Marijanović. Review and selection of literature used in this paper was perfo-med by Teo Buhovac, Emil Babić, Danijela Bevanda Glibo. Nikica Šutalo and Vjekoslav Čulajk have given final approval of the version to be published.  References 1. Abrahams NA, Halverson A, Fazio VW, Rybicki LA, Goldblum JR: Adenocarcinoma of the small bowel: a study of 37 cases with emphasis on histologic prognostic factors. Dis Colon Rectum 2002; 45:1496-502. 2. Agrawal S, McCarron EC, Gibbs JF, Nava HR, Wilding GE, Rajput A: Surgical management and outcome in primary adenocarcinoma of the small bowel. Ann Surg Oncol 2007; 14:2263–2269. 3. Anzidei M, Napoli A, Zini C, Kirchin MA, Catalano C, Passariello R: Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects. Br J Radiol 2011; 84:677–690. 4. Aparicio T, Zaanan A, Svrcek M, Laurent-Puig P, Carrere N, Manfredi S, Locher C, Afchain P: Small bowel adeno-carcinoma: Epidemiology, risk factors, diagnosis and treatment. Dig Liver Dis 2014; 46:97–104. Nikica Šutalo, Inga Marijanović, Teo Buhovac, Vjekoslav Čuljak, Zoran Trninić, Daniela Bevanda Glibo & Emil Babić:  ADENOCARCINOMA OF THE SMALL INTESTINE AS THE CAUSE OF AN ACUTE ABDOMEN – TWO CASE REPORTS WITH  A REVIEW OF THE LITERATURE          Medicina Academica Mostariensia, 2016; Vol. 4, No. 1-2, pp 69-71   71 5. Babba T, Schischmanoff O, Lagorce C, Wind P, Des Guetz G, Aparicio T, Benamouzig R: Small bowel carcinoma revealing HNPCC syndrome. Gastroenterol Clin Biol 2010; 34:325-8. 6. Bilimoria KY, Bentrem DJ, Wayne JD, Ko CY, Bennett CL, Talamonti MS: Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann Surg 2009; 249:63-71. 7. Chaaya A, Heller SJ: Introduction to small bowel tumors. Tech Gastrointest Endosc 2012; 14:88–93. 8. Eliakim R: Video capsule endoscopy of the small bowel. Curr Opin Gastroenterol 2010; 26:129-33. 9. Feldstein RC, Sood S, Katz S: Small bowel adeno-carcinoma in Crohn's disease. Inflamm Bowel Dis 2008; 14:1154-7. 10. Haselkorn T, Whittemore AS, Lilienfeld DE: Incidence of Small Bowel Cancer in the United States and Worldwide: Geographic, Temporal, and Racial Differences. Cancer Causes Control 2005; 16:781–787. 11. Maglinte DD, O’Connor K, Bessette J, Chernish SM, Kelvin FM: The role of the physician in the late diagnosis of primary malignant tumors of the small intestine. Am J Gastroenterol 1991; 86:304–308. 12. 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Schottenfeld D, Beebe-Dimmer JL, Vigneau FD: The epidemiology and pathogenesis of neoplasia in the small intestine. Ann Epidemiol 2009; 19:58–69. 18. Singhal N, Singhal D: Adjuvant chemotherapy for small intestine adenocarcinoma. Cochrane Database Systemic Review, 2007. 19. Sun KK, Gang Liu, Xiaojun Shen, Xiaoyang Wu: Small bowel adenocarcinoma in Lynch syndrome: A case report. Oncol Lett 2016; 12:1602-1604. 20. Vagholkar K, Mathew T: Adenocarcinoma of the small bowel: a surgical dilemma. Saud J Gastroenterol 2009; 15:264–267. 21. Van de Bruaene C, De Looze D, Hindryckx P: Small bowel capsule endoscopy: where are we after almost 15 years of use? World J Gastrointest Endosc 2015; 7:13–36. Correspondence: Nikica Šutalo, MD, PhD Department of Surgery, University Clinical Hospital Mostar Kralja Tvrtka bb, 88 000 Mostar, Bosnia & Hercegovina E-mail: nikica.sutalo@tel.net.ba  

ADENOCARCINOMA OF THE SMALL INTESTINE AS THE CAUSE OF AN ACUTE ABDOMEN – TWO CASE REPORTS WITH A REVIEW OF THE LITERATURE

ADENOCARCINOMA OF THE SMALL INTESTINE AS THE CAUSE OF AN ACUTE ABDOMEN – TWO CASE REPORTS WITH A REVIEW OF THE LITERATURE

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