Malignant neoplasms of the small bowel, especially from the jejunum, are among the rarest types of cancer. Given its location, a delayed diagnosis is frequent and sometimes only made in an emergency context. The authors present a case of intestinal obstruction, where ultrasonography was pivotal in establishing a diagnosis. Point-of-care ultrasonography seems to be particularly sensitive in assessing emergency patients with abdominal pain, allowing effective orientation and saving human and technical resources.info:eu-repo/semantics/publishedVersio

Caldeira, A

Capela, T

Pereira, E

Sousa, P

GE Portuguese Journal of Gastroenterology

Repositório da Unidade Local de Saúde São José

Obstrução Intestinal de Causa Rara e Ecografia Point-of-Care - Em que Ponto nos Encontramos?

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Malignant neoplasms of the small bowel, especially from the jejunum, are among the rarest types of cancer. Given its location, a delayed diagnosis is frequent and sometimes only made in an emergency context. The authors present a case of intestinal obstruction, where ultrasonography was pivotal in establishing a diagnosis. Point-of-care ultrasonography seems to be particularly sensitive in assessing emergency patients with abdominal pain, allowing effective orientation and saving human and technical resources

Tiago Capela

Paula Sousa

Ana Caldeira

Eduardo Pereira

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Intestinal Obstruction of Uncommon Cause and Point-of-Care Ultrasonography - Where Do We Stand

Malignant neoplasms of the small bowel, especially from the jejunum, are among the rarest types of cancer. Given its location, a delayed diagnosis is frequent and sometimes only made in an emergency context. The authors present a case of intestinal obstruction, where ultrasonography was pivotal in establishing a diagnosis. Point-of-care ultrasonography seems to be particularly sensitive in assessing emergency patients with abdominal pain, allowing effective orientation and saving human and technical resources.</jats:p

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E-Mail karger@karger.com Clinical Case Study   GE Port J Gastroenterol 2018;25:38–41  DOI: 10.1159/000477550  Intestinal Obstruction of UncommonCause and Point-of-Care Ultrasonography – Where Do We Stand?  Tiago Capela a    Paula Sousa b    Ana Caldeira c    Eduardo Pereira c  a  Gastroenterology Department, Hospital Santo António dos Capuchos, Centro Hospitalar Lisboa Central,  Lisbon ,  b  Gastroenterology Department, Centro Hospitalar Tondela-Viseu,  Viseu , and  c  Gastroenterology Department, Hospital Amato Lusitano,  Castelo Branco , Portugal  Obstrução Intestinal de Causa Rara e Ecografia  Point-of-Care – Em que Ponto Nos Encontramos?  Palavras Chave  Adenocarcinoma do jejuno · Ecografia  point-of-care ·  Obstrução intestinal · Tumor de intestino delgado   Resumo  As neoplasias malignas do intestino delgado, particular-mente as do jejuno, estão entre os tipos de tumores mais raros. Devido à sua localização, é frequente existir um atraso no diagnóstico e muitas vezes apenas em contexto de emergência a situação é solucionada. Os autores apre-sentam um caso de obstrução intestinal, onde a ecografia realizada por gastrenterologista foi fundamental no esta-belecimento diagnóstico. A ecografia  point-of-care  pare-ce ser muito sensível no diagnóstico em urgência, nomea-damente em doentes com dor abdominal, permitindo orientação adequada e poupando recursos humanos e técnicos.  © 2017 Sociedade Portuguesa de GastrenterologiaPublicado por S. Karger AG, Basel  Keywords  Jejunal adenocarcinoma · Point-of-care ultrasonography · Intestinal obstruction · Small bowel tumor  Abstract  Malignant neoplasms of the small bowel, especially from the jejunum, are among the rarest types of cancer. Given its loca-tion, a delayed diagnosis is frequent and sometimes only made in an emergency context. The authors present a case of intestinal obstruction, where ultrasonography was pivotal in establishing a diagnosis. Point-of-care ultrasonography seems to be particularly sensitive in assessing emergency patients with abdominal pain, allowing effective orientation and saving human and technical resources.  © 2017 Sociedade Portuguesa de GastrenterologiaPublished by S. Karger AG, Basel  Received: December 16, 2016  Accepted after revision: February 21, 2017  Published online: July 14, 2017  Dr. Tiago Capela   Gastroenterology Department, Hospital Santo António dos Capuchos   Centro Hospitalar Lisboa Central, Alameda de Santo António dos Capuchos   PT–1169-050 Lisbon (Portugal)  E-Mail teixeira.capela   @   gmail.com   © 2017 Sociedade Portuguesa de GastrenterologiaPublished by S. Karger AG, Basel  www.karger.com/pjg Th is article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes as well as any dis-tribution of modifi ed material requires written permission. Intestinal Obstruction of Uncommon Cause and Point-of-Care Ultrasonography  GE Port J Gastroenterol 2018;25:38–41 DOI: 10.1159/00047755039 Introduction  Malignant neoplasms of the small bowel are among the rarest types of cancer, accounting for only 2% of all gastrointestinal neoplasms. In Western countries, adeno-carcinomas generally represent the largest histological type; in the small bowel, the duodenum is its most fre-quent location  [1] . For neoplasms from the jejunum and ileum, diagnostic delays range from months to years. Many patients are misdiagnosed as being neurotic or as having irritable bowel syndrome  [2] . It is sometimes only due to emergency situations that a correct diagnosis is fi-nally established. Concepts like bedside ultrasonography (US) and point-of-care US are becoming routine in our clinical practice, expanding the possible applications of US, thus sharing the importance of ultrasound knowl-edge between senior physicians and residents of several specialties  [3] .  Case Report  We report the case of a 79-year-old male, without a relevant medical history, who presented with a 5-month history of weight loss, vomiting, and periumbilical cramping. The initial evaluation showed microcytic anemia and hypoalbuminemia. Later, upper gastrointestinal endoscopy, colonoscopy, and abdominal and pel-vic CT scans were performed but demonstrated no relevant find-ings. Because of clinical worsening with daily vomiting and ab-dominal tenderness, the patient returned to the emergency room. An US evaluation with a linear probe was performed by a gastro-enterologist who observed a 3-cm-long, jejunal, obstructive lesion, with irregular intestinal wall thickness and loss of stratification ( Fig.  1 ,  2 ), increased stiffness on elastography ( Fig.  3 ), and in-creased vascularization on Doppler ( Fig. 4 ). A proximal dilatation of the duodenum and the jejunum ( Fig. 2 ) was also noted, indicat-ing an obstruction of the small bowel. No local adenopathies were seen.  After clinical discussion, segmental enterectomy was per-formed. Histology showed a jejunal adenocarcinoma (based on the surgical sample and anterior radiologic findings, the tumor’s stage was T3N0M0). Six months later, the patient remains well and with-out complaints. A retrospective evaluation of the CT scan per-formed 3 months before surgery showed a slight thickening of the enteric wall that could have corresponded to the tumor later found in the emergency room.  Discussion  Malignant neoplasms of the small bowel are rare en-tities. The duodenum seems to be the most frequently affected segment with 55–82% of all cases  [4] . The esti-mated incidence in the United States is around 7 per 1 million individuals  [5] . In Europe, an incidence rate of 3,600 new cases per year has been reported  [6] . The strongest known risk factor for small bowel adenocarci-noma is prior Crohn’s disease  [7] . Other suggested fac-tors include cigarette smoking, alcohol consumption, prior peptic ulcer disease, familial adenomatous polypo-sis, prior colon cancer, celiac sprue, and cystic fibrosis  [1] . With none of the risk factors (as in the present case), a jejunal adenocarcinoma is an even rarer diagnosis. Re-cently, Young et al.  [8] have revealed that surgery seems to be the only treatment that improves survival on small bowel adenocarcinoma, and no benefit was seen by add-ing chemotherapy regimens. Even so, the 5-year surviv-al rate after diagnosis is around 30%  [5] . The clinical, ultrasound-assisted approach has proved to be particu-larly sensitive in assessing emergency patients with nod-ules of the neck, dyspnea, abdominal pain, and limb ede-ma  [9] .  Fig. 1. Wall thickness and loss of stratification. W, wall; L, lumen.  Capela/Sousa/Caldeira/Pereira  GE Port J Gastroenterol 2018;25:38–41 DOI: 10.1159/00047755040Fig. 2. Wall thickness and loss of stratification. Proximal luminal dilatation with enteric heterogeneous content. W, wall; L, lumen. Fig. 3. Elastography showing increased stiffness.  Fig. 4. Doppler showing increased vascularization.  Intestinal Obstruction of Uncommon Cause and Point-of-Care Ultrasonography  GE Port J Gastroenterol 2018;25:38–41 DOI: 10.1159/00047755041 We present this case because of the rarity of the previ-ously described entity, but also to exhibit that point-of-care US allows a quick and effective patient orientation, with innumerous clinical applications, saving human and technical resources, and showing once more that US competences should be transversely acquired perhaps by all physicians. Statement of Ethics  This study did not require informed consent or review/approv-al by the appropriate ethics committee. Disclosure Statement  All authors declare no conflicts of interest.  References  1 Neugut I, Jacobson S, Suh S, et al: Epidemiol-ogy of cancer of the small intestine. Cancer Epidemiol Biomarkers Prev 1998; 7: 243–251.  2 Bauer L, Palmer L, Bauer M, et al: Adenocar-cinoma of the small intestine: 21-year review of diagnosis, treatment, and prognosis. Ann Surg Oncol 1994; 1: 183–188.  3 Sabath BF, Singh G: Point-of-care ultraso-nography as a training milestone for internal medicine residents: the time is now. J Com-munity Hosp Intern Med Perspect 2016; 6:  33094.   4 Aparicio T, Zaanan A, Svrcek M, et al: Small bowel adenocarcinoma: epidemiology, risk factors, diagnosis and treatment. Dig Liver Dis 2014; 46: 97–104.  5 Bilimoria KY, Bentrem DJ, Wayne JD, et al: Small bowel cancer in the United States: changes in epidemiology, treatment, and sur-vival over the last 20 years. Ann Surg 2009;  249: 63–71.  6 Faivre J, Trama A, De Angelis R, et al: Inci-dence, prevalence and survival of patients with rare epithelial digestive cancers diag-nosed in Europe in 1995–2002. Eur J Cancer 2012; 48: 1417–1424.  7 Cahill C, Gordon C, Petrucci A, et al: Small bowel adenocarcinoma and Crohn’s disease: any further ahead than 50 years ago? World J Gastroenterol 2014; 20: 11486–11495.  8 Young J, Mongoue-Tchokote S, Wieghard N, et al: Treatment and survivl of small-bowel adenocarcinoma in the United States: a com-parison with colon cancer. Dis Colon Rectum 2016; 59: 306–315.  9 Arienti V, Di Giulio R, Cogliati C, et al: Bed-side ultrasonography (US), Echoscopy and US point of care as a new kind of stethoscope for Internal Medicine Departments: the train-ing program of the Italian Internal Medicine Society (SIMI). Intern Emerg Med 2014; 9:  805–814.  

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Obstrução Intestinal de Causa Rara e Ecografia Point-of-Care - Em que Ponto nos Encontramos?

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