Unmasking Jejunal Carcinoma With Dual Antiplatelet Therapy

Abstract

Small bowel neoplasms are extremely rare, comprising less than 1-3% of all gastrointestinal cancers. Adenocarcinoma is the second most common type of tumor in the small bowel and most commonly present in the duodenum, followed by jejunum/ileum. Jejunal carcinomas are most likely to present with abdominal pain, obstruction and less commonly with gastrointestinal bleeding. This case outlines a patient with jejunal carcinoma presenting with a gastrointestinal bleed following an increase in dual antiplatelet therapy. A 66 year old male with a 45 pack-year history of smoking and coronary artery disease on dual antiplatelet therapy presented with melena and exertional dyspnea for two-week duration. Aspirin was increased 3 weeks ago from 81 mg to 325 mg due to a transient ischemic attack. Remaining review of symptoms were negative. The patient never had a previous endoscopy or colonoscopy. Upon admission, vital signs were stable and physical exam was benign. Labs resulted in a hemoglobin of 7g/dl with a normal hemoglobin three weeks ago. Other labs were unremarkable. He was transfused two units of pRBC's with appropriate response in hemoglobin. Endoscopy and colonoscopy were unrevealing. Pill capsule study showed active signs of bleeding in the mid/proximal small bowel and subsequent enteroscopy uncovered a bleeding ulcerated lesion (occupying 35% of the lumen) with a clot seen in the distal duodenum and proximal jejunum. Snare was used to unroof the clot and the bleeding subsided with epinephrine injection. CT of the abdomen and pelvis showed an incidental pancreatic cyst that was determined to be unrelated to the jejunal lesion. Tissue biopsy of jejunum showed poorly differentiated carcinoma. Follow-up enteroscopy revealed proximal jejunal ulcerated mass with central area of necrosis with biopsies confirming the previous results. Dual antiplatelets were discontinued at discharge and patient remains asymptomatic. Small bowel carcinoma most commonly occur in duodenum and less frequently in jejunum/ileum. Given their indolent nature, most of these cancers are diagnosed at advanced stages. The etiology of small bowel neoplasms is unknown, however certain risk factors include hereditary cancer syndromes, inflammatory bowel disease and tobacco. Our patient was asymptomatic with no constitutional symptoms until he presented with acute gastrointestinal bleeding following an increase in his dual antiplatelet therapy with the source being a jejunum carcinoma.2489_A Figure 1. Proximal jejunal ulcerated mass with central area of necrosis.2489_B Figure 2. H&E showing poorly differentiated jejunal carcinoma.2489_C Figure 3. Pill capsule endoscopy showing active bleeding in mid small bowel.