3218 Duodenal Adenocarcinoma Masquerading as Gastroenteritis: A Case Report

Abstract

INTRODUCTION: Small bowel cancers are rare only compromising 5% of gastrointestinal cancers and among those, 40% are small bowel adenocarcinomas.1 Duodenal adenocarcinomas in the 4th portion of the duodenum are even less frequent and are a diagnostic challenge as they typically at an advanced stage when they present.1,2 There are several risk factors associated with it including celiac disease, inflammatory bowel disease and smoking amongst others.1 Given the rarity we present a case of a young patient without any major risk factors that was thought to have gastroenteritis but was found to have something more sinister. CASE DESCRIPTION/METHODS: We present a 49 year old African American male with a medical history of hypertension who presented to the hospital with intermittent nausea, vomiting, and crampy abdominal pain over the last 4 months. He was seen in the emergency department (ED) early on, and was diagnosed with gastroenteritis and treated symptomatically. At this point his abdominal pain has worsened and recurrence of nausea and vomiting. He noted a 25 pound weight loss over this time. He denied blood in vomit or stools and any tobacco or alcohol use. He never had an endoscopy or colonoscopy. Physical exam showed decreased bowl sounds and tenderness in epigastrium, otherwise was unrevealing. In the ED the patient was evaluated during which a CT abdomen showed a severe bowel obstruction and bowel thickening suspected at the level of the third/fourth portion of the duodenum (Figure 1). With this a nasogastric tube was placed to decompress. On endoscopy there was a large circumferential fungating mass in the fourth portion of the duodenum causing a complete obstruction (Figure 2). Biopsies were taken which confirmed adenocarcinoma (Figure 3). He was returned to the floor and later underwent a resection of the 4th portion of his duodenum and first part of the jejunum. DISCUSSION: As seen here making a diagnosis can be a very challenging and might not always be correct the first time. We cannot perform endoscopies on all patients who arrive with nausea and vomiting, but with recurrent symptoms an endoscopy would be helpful in identifying these malignancies. In this case, even on endoscopy the lesion could have been missed since his malignancy was in the 4th portion which is rare and beyond the extent of the normal exam.2 In the end this case is a reminder to always keep the differential wide and be diligent to look further even when the patient does not fit perfectly with the description in the book.