Small bowel adenocarcinoma arising in longstanding fibrostenotic Crohn’s disease

Abstract

Empirical evidence suggesting a link between neoplasia and chronic inflammation was first noted by Virchow more than a century ago, but the intricacies of the involved pathological processes have not yet been entirely elucidated. With a growing number of Crohn’s disease (CD) cases worldwide, it is only logical to consider that the complications of this entity would become proportionally more prevalent. We report a case of small bowel adenocarcinoma arising in a patient with longstanding CD and discuss the current differences in paradigms related to surgical decisions in patients with inflammatory small bowel disease. A 56-years-old male patient known with CD was admitted in emergency to our clinic for intense diffuse abdominal pain spontaneously and on palpation, Blumberg +, with signs of peritoneal irritation, episode apparently much more severe compared to the previous ones. Laboratory investigations confirmed the diagnosis of acute abdomen and immediate surgery was performed. Intraoperative findings were peritonitis due to ileal perforation and ileal adenocarcinoma with “signet ring” cells, moderately differentiated (G2), on the background of active inflammatory bowel disease (CD). Segmental enterectomy and ileostomy were performed. The postoperative outcome was relatively favorable, with resumption of digestive tolerance and of intestinal transit at ileostomy level. As increased evidence suggest causality between chronic inflammation and malignant transformation one should contemplate whether the old treatment paradigms applied for other conditions such as fistulae in anal and leg ulcers should not be translated to inflammatory bowel disease (IBD) patients. Are we doing too much or not enough surgery for IBD? Could we diagnose small bowel adenocarcinomas in CD in early stages or there is too much risk for the patients and very few to benefit from a more aggressive surveillance?