Synchronous carcinoid tumor of the small bowel.

Abstract

An 84-year-old woman was an outpatient for chronic abdominal pain for 1 year at another institution. She required 5 to 10 Percocet (Endo Pharmaceuticals, Chadds Ford, PA) per day to control her symptoms. She had no earlier abdominal operations and was otherwise healthy. Colonoscopy, esophagogastroduodenoscopy, and a small bowel series were reportedly normal. Dissatisfied with her care she presented to our institution. Gastroenterology and vascular surgery evaluated the patient for food fear and postprandial pain. Duplex of the mesenteric arteries, angiography, CT scan with contrast, colonoscopy, and esophagogastroduodenoscopy were nondiagnostic. Two months into her evaluation by our institution she presented to the emergency room with increased pain and signs of a partial small bowel obstruction. A small bowel barium study showed a high-grade stenosis of the mid-small bowel (A, large arrow). Proximal to this stenosis the bowel was dilated and had numerous filling defects (A, small arrows). Given the patient’s symptoms and small bowel study, she was taken to the operating room for exploratory laparotomy. There were two strictures of the mid-small bowel. On palpation there were numerous hard, freely mobile masses within the dilated, proximal segment. The small bowel and mesentery were resected and sent for pathologic inspection. The bowel had numerous pills consistent with the reported Percocet the patient had been consuming (B). Microscopic analysis of the two stricture sites found carcinoid tumors. Retrospective analysis of the CT scan performed 2 months earlier demonstrated a loop of small bowel with numerous filling defects, initially interpreted as normal sigmoid colon (C). No distinct mass lesion was seen on this scan. Carcinoid tumors are the most common malignant neoplasm of the small bowel and are rarely diagnosed early.