Gastric Outlet Obstruction in a 39-Year-Old Male Patient with HIV

Abstract

Purpose: A 39-year-old male patient with a past medical history of HIV (not on a treatment) presented with epigastric abdominal pain, bilious emesis and 21 lbs weight loss over 1 month prior to admission. Family history was unremarkable. Physical was significant for tachycardia, dry mucous membranes, and epigastric fullness and mild tenderness. He had normal blood counts (but CD4 of 255/l), hypochloremic metabolic alkalosis and slightly elevated bilirubin and alkaline phosphatase. Computed tomography (CT) imaging showed a 5-cm duodenal mass, proximal duodenal and gastric dilatation and peritoneal, omental and liver metastatic lesions. Esophagogastroduodenoscopy showed an obstructive duodenal mass in D3 along with esophageal and gastric ulcers. Duodenal biopsy showed invasive adenocarcinoma while esophageal ulcers showed viral cytopathic effect. Tumor marker C19-9 was normal but CEA was elevated (104.9 ng/ml). Nuclear imaging showed bone involvement. CT guided liver biopsy confirmed metastasis. He underwent palliative gastrojejunostomy and was started on FOLFOX and bevacizumab. He finished two cycles chemotherapy so far. Gastric outlet obstruction incidence is declining due to the decrease in peptic ulcer disease (PUD), earlier recognition, and better endoscopic capabilities for detection and treatment of its causes. Causes include malignancy, PUD, Crohn's disease, pancreatitis, polyps and others. Small bowel tumors constitute 3% of all gastrointestinal tumors. 25-40% of these are adenocarcinoma. Mean age at diagnosis is 67-68 years. Younger age at presentation was reported with predisposing conditions as Crohn's disease and Lynch and Peutz-Jeghers syndromes. Definitive association between colon polyps, advanced polyps, colorectal cancers and gastrointestinal lymphomas and Kaposi's sarcoma and HIV has been reported. Whether HIV infection is also associated with increased risk of small bowel adenocarcinoma has not been addressed in the literature. This report of duodenal adenocarcinoma in a young HIV patient with no other personal or family history of predisposing conditions opens the discussion for possible association between the two diseases. To answer such a question, a large scale epidemiologic review of small bowel carcinomas in HIV patients is warranted.Figure