Introduction: Esophageal cancer is known to metastasize to various organs, but its initial presentation as a small bowel obstruction (SBO) appears to be a unique occurrence. We report the case of a patient who presented with an SBO and further work up identified metastatic esophageal squamous cell carcinoma as its likely source. Case Report: A frail 77-year-old male presented with a two-week history of progressive abdominal discomfort. He denied recent vomiting, diarrhea, or GI bleeding, and he initially reported no dysphagia. He was a life-long smoker with a medical history of anemia with recent transfusion, and diverticulosis. His surgical history included an appendectomy, a left inguinal hernia repair, and a left upper extremity amputation secondary to infection from a brown recluse spider bite. Except for a hemoglobin level of 8.6 g/dL, the patient's lab values were relatively unremarkable. His abdomen was softly distended, and without appreciable masses or significant tenderness. An abdominal CT scan, however, showed a high-grade bowel obstruction. Conservative management failed to relieve the patient's worsening symptoms. He then underwent an exploratory laparotomy and an obstructive mass with adhesions necessitated the resection of approximately 12 cm of small bowel. Microscopic examination of the resected specimen identified poorly differentiated carcinoma with squamous differentiation. A subsequent CT of chest revealed a 2.7 × 1.6 cm mid-esophageal mass along with left axillary lymphadenopathy. Upon further questioning, the patient stated he had experienced mild dysphagia and some weight loss over a few months prior to his presentation. The patient thereafter underwent an EGD that demonstrated an ulcerative lesion at the mid esophagus. Biopsies confirmed invasive squamous cell carcinoma as the source of both the primary malignancy and the small bowel obstruction. Discussion: It is rare for metastases to the small bowel to present with clinically significant symptoms. In fact, they are often merely a finding on autopsy. Even more unusual are intestinal metastases as the causative agent of an SBO prior to an established diagnosis of the primary cancer. In this unique case, our patient arrived at the hospital, not with dysphagia suggesting esophageal cancer, but with typical SBO symptoms. Thus, the metastatic lesion of undiagnosed esophageal carcinoma first presented as a symptomatic obstruction of the small bowel. Consequently, while there are of course more common causes, it is still prudent to keep in mind metastatic disease in the evaluation of intestinal obstruction, even in the absence of established diagnosis of a primary cancer.
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Oct 1, 2023
Sabah Mahmood + 7
Open Access