Advertisement

An Unexpected Cause of Small Bowel Obstruction

      Question: A 62-year-old man with a history of umbilical hernia repair presented with a 1-day history of abdominal pain, nausea, and vomiting. He endorsed constipation but no obstipation. He denied any melena or hematochezia. Owing to a history of alternating diarrhea and constipation associated with abdominal pain, he carried a clinical diagnosis of mixed-type irritable bowel syndrome. He also had 2 prior episodes of small bowel obstructions (SBO) that were attributed to adhesions and managed conservatively. Additional past medical history included type 2 diabetes mellitus and psoriasis. He also had a history of heavy smoking and frequent use of nonsteroidal antiinflammatory drugs for chronic neck pain. Physical examination was notable for a nondistended abdomen with diffuse, mild tenderness and normoactive bowel sounds. Initial laboratory tests were pertinent for normal lipase and lactic acid but an elevated C-reactive protein at 3.82 mg/dL (normal, <0.5) and leukocytosis to 14.7 × 1000/UL (normal, 4-11 × 1000/UL). Stool calprotectin was elevated. Anti-Saccharomyces cerevisiae antibody along with antibodies to flagellins A4-Fla2 and FlaX were positive, which were compatible with Crohn’s disease (CD). Initial computed tomography (CT) scan of abdomen and pelvis revealed partial SBO associated with a 20-cm, continuous segment of wall thickening in the terminal ileum extending to the ileocecal valve. Owing to concern for subclinical inflammatory enteritis manifesting as intermittent SBO and no prior endoscopic evaluation, a colonoscopy was pursued after resolution of his obstruction. The colonoscopy identified 2 colojejunal fistulae at 45 and 55 cm and polypoid lesions in the terminal ileum for a distance of 10 cm (Figure A, B).
      What is the likely diagnosis of these lesions?
      See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

      Answer to: Image 6: Small Bowel Adenocarcinoma

      Figure thumbnail gr1cd
      Initial histology of the polypoid lesions from the distal portion of inflamed ileum showed tubulovillous-like lesions with low-grade dysplasia, compatible with visible, sessile, polypoid dysplastic lesions (Figure C). Because malignancy could not be ruled out, an exploratory laparotomy was performed, which showed Crohn’s ileitis with enter–entero and entero–sigmoid fistulas. The patient underwent ileosigmoid fistula closure and small bowel and ileocolic resections. Pathology results from the resected ileum confirmed Crohn’s ileitis (Figure D) with tubulovillous-like histological findings consistent with the initial biopsies without any evidence of adenocarcinoma.
      Owing to the high risk of developing colorectal cancer, current inflammatory bowel disease (IBD) guidelines recommend beginning surveillance colonoscopies with biopsies 7-8 years after diagnosis with UC or CD colitis. Historically, the polypoid lesions visualized in this case were termed dysplasia-associated lesions or masses. However, the relatively recent SCENIC Consensus Statement recommends abandoning this terminology and, instead, use descriptive phrases.
      • Laine L.
      • Kaltenbach T.
      • Barkun A.
      • et al.
      SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease.
      Despite updated guidelines for surveillance and management of dysplasia in IBD, surveillance and management protocols are not well-defined for dysplastic lesions in the small bowel.
      Small bowel adenocarcinoma (SBA) is a complication of CD that can develop about 11 years after diagnosis.
      • Elriz K.
      • Carrat F.
      • Carbonnel F.
      • et al.
      Incidence, presentation, and prognosis of small bowel adenocarcinoma in patients with small bowel Crohn's disease: a prospective observational study.
      Its nonspecific and variable presentations can mimic SBO or active CD. Thus, detection is often delayed by several months and at a late stage with a grim prognosis. Fistulizing, fibrostenosing, and small bowel CD are possible risk factors. However, detection modalities for SBA, including capsule endoscopy, CT enterography, and double balloon enteroscopy, have potential but carry inherent limitations that hinder a satisfactory examination.
      • Feldstein R.C.
      • Sood S.
      • Katz S.
      Small bowel adenocarcinoma in Crohn's disease.
      Current treatment is generally wide segmental surgical resection, but the role of adjuvant chemotherapy remains undefined for SBA.
      This case demonstrates visible, sessile, polypoid, dysplastic lesions involving the terminal ileum in the setting of severe untreated fistulizing CD presenting as SBO. This case highlights that, similar to the colon, premalignant lesions may occur in the small bowel of IBD patients and that polypoid lesions in terminal ileum may not be simply dismissed as lymphoid hyperplasia or inflammatory polyps. Therefore, further investigation may be warranted to better define surveillance and management strategies for small bowel dysplasia in patients with small bowel CD.

      References

        • Laine L.
        • Kaltenbach T.
        • Barkun A.
        • et al.
        SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease.
        Gastroenterology. 2015; 148: 639-651 e28
        • Elriz K.
        • Carrat F.
        • Carbonnel F.
        • et al.
        Incidence, presentation, and prognosis of small bowel adenocarcinoma in patients with small bowel Crohn's disease: a prospective observational study.
        Inflamm Bowel Dis. 2013; 19: 1823-1826
        • Feldstein R.C.
        • Sood S.
        • Katz S.
        Small bowel adenocarcinoma in Crohn's disease.
        Inflamm Bowel Dis. 2008; 14: 1154-1157