Multiple Bile Duct Adenomas in a Patient with Small Bowel Adenocarcinoma

Abstract

Purpose: A 76-year-old man was hospitalized with melena and iron deficiency anemia. EGD revealed Barrett's esophagus and colonoscopy revealed tubular adenomas. Melena and anemia resolved. He remained symptom-free for two years before he again developed melena and anemia. Repeat EGD demonstrated Barrett's esophagus and repeat colonoscopy revealed tubular adenomas. Wireless capsule endoscopy demonstrated several areas of inflammation and oozing of bright red blood in the jejunum and ileum. CT of the abdomen showed thickening in the proximal jejunum. Push enteroscopy was done and biopsies of the proximal jejunal lesion showed inflammation, cryptitis with focal erosions and occasional crypt abscesses without granulomas or microorganisms. The diagnosis of Crohn's disease of the small bowel was entertained and IBD serologies demonstrated a pattern consistent with this diagnosis. Over the next seven months, the patient had intermittent melena and abdominal pain with unintentional weight loss. He then sought a second GI opinion. Repeat CT of the abdomen showed the proximal jejunal lesion to have increased in size. Because of concern for small bowel malignancy, the patient was referred for surgical exploration; laparoscopy was performed. Adenocarcinoma of the jejunum was discovered. Incidentally, multiple nodules on the capsular surface of the liver were also noted. Liver biopsy demonstrated these to be multiple bile duct adenomas. The pathologic stage of the small bowel adenocarcinoma was IIB. The patient subsequently underwent adjuvant chemotherapy for treatment of the malignancy. No specific treatment was recommended for the multiple bile duct adenomas. Small bowel adenocarcinoma is rare, accounting for 2% of all GI tract malignancies. Symptoms are nonspecific and diagnosis often delayed, resulting in advanced stage cancer at the time of diagnosis. Bile duct adenomas are exceedingly rare benign epithelial tumors of the liver. They are usually solitary but may occur as multiple nodules, as in this case. They are almost always asymptomatic and are found on the surface of the liver incidentally at surgery or autopsy. Their appearance often raises the concern for metastatic cancer. This patient was found to have two rare and unrelated pathologic findings, one of which was benign, and the other malignant.