Terminal Ileal Adenocarcinoma as a cause of Gastrointestinal Bleeding
- 1. Department of Gastroenterology and Endoscopy, San Angel Inn Patriotismo, Mexico
- 2. Department of Gastroenterolgy and Endoscopy, Regional Hospital of Oaxaca, Mexico
Citation
Sanchez X, Santiago JE (2021) Terminal Ileal Adenocarcinoma as a cause of Gastrointestinal Bleeding. JSM Gastroenterol Hepatol 8(1): 1100.
CLINICAL IMAGE
A 71-year-old woman, with history of chronic ingestion of non-steroidal anti-inflammatory drugs previously diagnosed with osteoporosis, currently under treatment with calcium and vitamin D.
On April 2018 patient started with gastrointestinal bleeding characterized by melena, abdominal pain, and low Hemoglobin levels up to 6.4 g / dl. An endoscopy was performed, which reported Forrest III prepyloric ulcer. 2 units of red blood cells were transfused and omeprazole and sucralfate started as oral treatment.
On May 2018, patient starts with rectal bleeding; an anoscopy was schedule and bleeding hemorrhoids were diagnosed; rubber band ligation was performed.
On February 2019, patient starts once more with abdominal pain, adding to the symptoms asthenia, adynamia, lower hemoglobin levels up to 7.5 gr/dl, with positive fecal occult blood test. Patient underwent a new endoscopy without finding the apparent cause of the bleeding so a colonoscopy was scheduled and reported as normal.
At that point it was decided to undergo endoscopic capsule protocol to rule out small bowel hemorrhage (Figure 1) which reported enteropathy of the jejunum and ileum, probably secondary to non-steroidal anti-inflammatory drugs; at the level of terminal ileum; an ulcerated lesion with submucosal appearance was found, etiology still to be determined.
A double balloon enteroscopy was performed (Figure 2), and showed an exophytic lesion, with a polypoid appearance of 25mm, ulcerated, with stigmata of recent hemorrhage at the level of the terminal ileum (70 centimeters from the ileocecal valve), an attempt was made to infiltrate and performed a thermal loop resection, however the base didn’t raised; surgery was schedule.
An enteral-enteral anastomosis Intestinal resection was performed, pathology demonstrated a 25?mm poorly differentiated mucinous adenocarcinoma of the terminal ileum with free margins lesion.
Primary small bowel malignancy is unusual and accounts for 1-3% of all gastrointestinal tract neoplasmsv [1]. Adenocarcinoma is one of the most common histologic types, but its frequency decreases with more distal locations. The most common location for small bowel adenocarcinoma is in the duodenum (57%), followed by the jejunum (29%) and the ileum (10%) [2].
Current options for diagnosing small bowel diseases include push enteroscopy, capsule endoscopy, doble balloon enteroscopy, Single balloon enteroscopy, and intraoperative enteroscopy. Capsule endoscopy can be recommended as the first investigation for obscure gastrointestinal bleeding, if necessary, followed by doble balloon esteroscopy [3] Most small bowel tumors are detected during work-up for obscure gastrointestinal bleeding or iron-deficiency anemia, the clinical manifestations of small bowel tumor, unfortunately, tend to be very nonspecific, and this can delay the diagnosis, especially in the early stages [4].
