Patch adams

Small bowel malignancy: an elusive diagnosis
Ronil V Chandra, Julie A Miller, Ian T Jones, Brett Manley and G Bruce Mann
MJA 2004; 180 (4): 182-183

Clinical records
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Discussion
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Conclusion
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Author details

Clinical records
|Patient 1 | |Patient 2 |
|A 77-year-old womanwas referred to us for an urgent surgical | |A 68-year-old man was admitted to our department for |
|opinion regarding an abdominal mass. | |laparotomy for a small bowel tumour. |
|Fifteen months previously, she had been referred to a major | |The patient had a past history of an open cholecystectomy. |
|metropolitan hospitalwith symptomatic iron deficiency anaemia,| |Twenty-eight months before admission, he had been referred to |
|and weight loss of 5 kg in 6 months. Gastroscopy, colonoscopy | |a gastroenterologist with symptoms of gastro-oesophageal |
|and abdominal CT scan were unremarkable. There were no clinical| |reflux disease; he underwent gastroscopy, which showed reflux |
|features to suggestmalabsorption, nutritional deficiency or | |oesophagitis, and was treated with proton pump inhibitors. |
|inflammatory bowel disease. | |Eleven months later, he was referred to a gastroenterologist |
|A diagnosis of angiodysplasia was considered, although there | |again with persistent symptoms. He was seen several times in |
|was no direct evidenceof this. The patient received a 5-unit | |the next 9 months, and was then admitted to a general surgical|
|blood transfusion and iron supplements. During the 7 months | |service of a metropolitan hospital with abdominal pain. A |
|after initial presentation, she was seen in medical outpatient | |provisional diagnosis of small bowel obstruction was made, and|
|clinics six times. Overthe next 8 months, she was admitted six| |the patient was discharged the following day once his pain had|
|times, transfused 13 units of red cells, and given two iron | |settled. Twice during the next 5 months, he presented to the |
|infusions. A labelled red cell scan showed no gastrointestinal | |emergency department with abdominal pain, nausea and vomiting.|
|bleeding. An abdominalultrasound was unremarkable. Results of | |His symptoms settled with analgesia and fluids. Persistent |
|investigations for coeliac disease and pernicious anaemia were | |retrosternal pain had not been helped by a variety of H2 |
|normal. A bone marrow biopsy was consistent with iron | |antagonists, proton pump inhibitors or prokinetic agents. He |
|deficiency anaemia. On oneoccasion, the admitting registrar | |was admitted to our surgical service after presenting on two |
|considered a small bowel follow-through, but this was not | |successive days with severe epigastric pain. |
|performed. Paroxysmal nocturnal haemoglobinuria was excluded. | |Upper gastrointestinal endoscopy showed severe reflux |
|During the last of theseadmissions, a firm abdominal mass was | |oesophagitis. The first and second parts of the duodenum were |
|palpated. A computed tomography (CT) scan revealed an 8 cm | |normal. Abdominal CT showed a circumferential mass in the |
|heterogeneously enhancing soft tissue mass in the proximal | |proximal jejunum with dilation of proximal bowel (B). Small |
|jejunum. Lymphoma wasconsidered the most likely diagnosis, and| |bowel follow-through then showed an annular, stenosing lesion |
|the patient was referred to our department. | |in the region of the duodenojejunal flexure. |
|Push enteroscopy revealed an ulcerated adenocarcinoma in the | |At laparotomy, a localised adenocarcinoma was resected (C). |
|proximal jejunum (A)....