S3497 Tubulo-Villous Adenoma of the Distal Ileum Presenting With Small Bowel Obstruction-Like Symptoms

Abstract

Introduction: Small bowel tumors (SBT) are rare and account for < 3% of all gastrointestinal tumors in the United States. Given their insidious presentation with non-specific symptoms, they can evade detection and cause delays in diagnosis. Case Description/Methods: A 74-year-old lady came to the ER with abdominal pain, nausea, vomiting and abdominal distention since two days. Past medical history included esophageal spasm, GERD, achalasia, hypertension, CKD with anemia and fibromyalgia and had undergone total abdominal hysterectomy. At her last colonoscopy 10 years ago a 5 cm tubular adenoma was excised and a repeat was advised after 5 years, which she did not follow up with. EGD 8 years ago showed grade 1 reflux esophagitis, normal stomach and small bowel. Pulse was 100/minute and BP was 132/77. Abdomen was soft and distended, with tenderness in the right upper quadrant and epigastrium. Hb was 9.2 g/dL, consistent with her baseline. Though abdominal CT suggested SBO with a transition point just proximal to the ileocecal valve, a small bowel series ruled out an SBO. The patient was made NPO and NGT was placed. Colonoscopy revealed a partially obstructing, medium-sized, fungating, friable, infiltrative, circumferential, villous mass, 8-10 cm away from the ileocecal valve. Histopathology confirmed tubulovillous (TV) adenoma with no signs of dysplasia or malignancy. The patient underwent robotic-assisted ileocecectomy and recovered well. Follow up colonoscopy 4 months later showed healing ileocolonic anastomosis, with no stricture or ulceration. (Figure) Discussion: Though the small bowel constitutes 90% of the surface area of the GI tract, it contributes to < 2% of GI malignancies. Reasons for this include the more liquid contents causing less mucosal irritation than solid colonic contents and rapid transit. Adenomatous polyps, the most common benign SBTs, have an epithelial origin. Histological types include tubular, villous and tubulovillous. Villous components, atypia or large size increase the risk for malignancy. Presenting symptoms are nonspecific and they are commonly found unexpectedly during surgery in patients with SBO. Evaluation in symptomatic patients includes endoscopy with biopsies. Push, double-balloon, or video capsule endoscopy may be needed. Diagnostic laparoscopy or surgical exploration can help establish a definitive diagnosis. Given their potential for malignant transformation, TV adenomas must be removed, and patients should be monitored for recurrence.Figure 1.: A: XR small bowel with oral contrast suggestive of mucosal irregularity with narrowing around distal ileum. B: Colonoscopy showing partially obstructing, circumferential villous mass, 8-10 cm from the ileocecal valve. C: Histo-pathology showing epithelial finger-like projections away from the muscularis mucosae, lined by dysplastic epithelium.