1902 Small Bowel Tumor: The Answer to Unexplained Overt Gastrointestinal Bleeding

Abstract

INTRODUCTION: The rarity of small bowel tumors often makes diagnosis difficult due to nonspecific and variable presenting symptoms. This can result in a delay of diagnosis and consequent poor treatment outcome. Small bowel tumors can be either malignant (adenocarcinomas, lymphomas, sarcomas, and neuroendocrine tumors) or benign (adenomas, leiomyomas, and lipomas). CASE DESCRIPTION/METHODS: We present the case of a 58-year-old male, who presented to the hospital with dizziness, lightheadedness, and dyspnea on exertion for 3 days. History was significant for GERD, and iron deficiency anemia. Recent outpatient evaluation of weakness and fatigue revealed hemoglobin of 10 g/dL, decreased from 16.3 g/dL one year prior. An outpatient colonoscopy was scheduled for the following month but presented to the hospital because of multiple episodes of melenic stools. He denied any hematochezia, abdominal pain, weight loss, dysphagia, nausea, vomiting or hematemesis. He denied any family or personal history of malignancy or inflammatory bowel disease. He was tachycardic on examination. Initial lab work revealed hemoglobin of 8.2 g/dL. During his hospitalization, the patient experienced frank hematochezia and required transfusion of several units of blood due to acute blood loss. The patient underwent endoscopic evaluation, which revealed a small hiatal hernia with normal stomach and normal examined duodenum. A colonoscopy revealed red blood in the entire examined colon as well as the distal ileum. The patient then underwent video capsule endoscopy (VCE), which localized a source of bleeding in the proximal jejunum. A subsequent small bowel enteroscopy revealed a large infiltrative, polypoid, submucosal and ulcerated mass in the proximal jejunum. A CT scan revealed the location of the mass. The patient ultimately went to the operating room. Intraoperative visualization noted the mass to be exophytic, approximately 5 cm in diameter with mild purulence into the peritoneal cavity but without evidence of carcinomatosis. DISCUSSION: Adequate diagnosis of small bowel tumors, which present with varied and nonspecific symptoms, can inform early and appropriate treatment. In this case, endoscopic evaluation with EGD, colonoscopy, and VCE, resulted in the localization of the tumor and facilitated its surgical excision. This case exemplifies a practical algorithmic approach to the evaluation of an unexplained overt gastrointestinal bleed in a patient with nonspecific symptoms.