Adenocarcinoma of the small intestine complicating Crohn’s disease

Abstract

Dear Sir, Small bowel adenocarcinoma is an uncommon tumor comprising 2% of all gastrointestinal tract malignancies. Chronic inflammatory bowel disease predisposes to the development of carcinoma in the colon of patients with ulcerative colitis and Crohn’s disease (CD). There is growing evidence that CD is associated with an increased incidence of adenocarcinoma of the small bowel. In contrast with ulcerative colitis, the magnitude of the problem (risk for cancer development) in CD remains controversial. Large series from tertiary referral centers report a significant comparative risk for small intestinal cancer development in CD ranging from six to 320 times than in the general population. Neoplastic lesions have been often described on the grounds of fibrotic strictures and fistulas. A few cases of adenocarcinoma arising at the site of previous strictureplasty have also been confirmed. Unfortunately, specific radiographic findings that would indicate the presence of carcinoma in these patients have not been identified. We present a patient with CD complicated by the development of small bowel adenocarcinoma. The relevant literature is briefly reviewed. A 61-year-old man with a 27-year history of CD presented with a 6-month history of increasing colicky abdominal pain and vomiting, eventually resulting in frank complete small bowel obstruction. The patient appeared with general malaise and loss of weight. Clinical investigation revealed a recrudescence of symptoms of anemia. Physical examination confirmed a firm, tender mass in the right ileac fossa. Erect abdominal X-rays depicted multiple small bowel fluid levels, indicating intestinal obstruction. Abdominal computed tomography scan showed a concentric, sharply marginated mass lesion with mucosal destruction and associated enterocolic fistulas combined with strictures near the ileocolic anastomosis. Endoscopic bioptical sampling demonstrated CD in the active stage. In the past, he had recurrent episodes which required the administration of both rectal and oral steroids and sulfasalazine to obtain control of his symptoms. Further acute exacerbation failed to respond satisfactorily to medical treatment and he was referred for surgery. Histology showed transmural disease, patchy involvement of the mucosa, noncaseating epithelioid granulomas with Langhans giant cells, fissures, and neuromatous hyperplasia, and the diagnosis of CD was confirmed. One year later, he presented with symptoms of ankylosing spondylitis. The long-term distribution of vitamin B12 was implemented for the improvement of associated polyneuropathy. The patient was operated on with the diagnosis of intestinal obstruction due to CD. During laparotomy, the small bowel showed the typical macroscopic manifestations of CD. Moreover, extensive malignant deposits were found throughout the peritoneum and the pelvis, probably representing metastatic peritoneal implantations. The diseased part of the bowel was resected and an end-to-side ileotransverse anastomosis was performed. Intraoperative examination of the resected specimen showed numerous strictures and sacculation with superficial ulceration and fissures, mucosal edema, and fibrosis. A larger ulcerated lesion was also identified within the resected specimen. The postoperative course was Int J Colorectal Dis (2009) 24:1245–1246 DOI 10.1007/s00384-009-0718-y