Pancreatic Adenocarcinoma Presenting as Acute Large Bowel Obstruction: Case Report

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1 IMAGES IN CLINICAL MEDICINE Surg. Gstroenterol. Oncol. 2018;23(3): DOI: /sgo Pncretic Adenocrcinom Presenting s Acute Lrge Bowel Ostruction: Cse Report Inês Cmpos Gil 1, Din Prente 1, Nuno Rm 2, Brnco Lopes 3, Virgíni Pulino 3, Cristin Amdo 4, M. Fernnd Cunh 4, Inês Sles 1, Vítor Fri 1 Corresponding uthor: Inês Cmpos Gil, MD Serviço de Cirurgi 1 Hospitl de Snto André Centro Hospitlr de Leiri Ru ds Olhlvs, Leiri, Portugl E-mil: inesmcgil@gmil.com 1 Serviço de Cirurgi 1, Centro Hospitlr de Leiri, Leiri, Portugl 2 Colorectl Unit, Centro Hospitlr de Leiri, Leiri, Portugl 3 Biliopncretic Unit, Centro Hospitlr de Leiri, Leiri, Portugl 4 Pthology Unit, Centro Hospitlr de Leiri; Leiri, Portugl ABSTRACT Introduction: Acute lrge owel ostruction is rre presenttion of pncretic cncer, with only six cses descried in the revised literture. In ll those cses, dignosis ws mde either intropertively or post-mortem. Cse presenttion: A 63-yer-old mn presented in the emergency room with 4 dys of owel constiption ssocited with ominl pin nd distention. Adominl CT reveled nrrowing t the colonic splenic flexure nd the colonoscopy reveled extrinsic compression t 40 cm from the nl verge. The ptient ws sumitted to emergent explortory lprotomy. We identified mss involving the colonic splenic flexure, splenic hilum nd the pncretic til. An en loc sutotl colectomy, splenectomy nd distl pncretectomy ws performed. Finl pthology reveled pncretic ductl denocrcinom. The postopertive period ws complicted with fecl peritonitis due to owel perfortion (dy 3), hemoperitoneum secondry to pncretic stump leeding (dy 10) nd surgicl site infection. The ptient ws dischrged home on dy 43. Conclusion: A high level of suspicion is necessry to tke into ccount pncretic crcinom s differentil dignosis of owel cute ostruction. Key words: pncretic denocrcinom, owel ostruction INTRODUCTION Received: Accepted: Copyright Celsius Pulishing House Pncretic denocrcinom ccounts for 3% of new cncer cses ech yer, nd its gressiveness cuses it to e the fourth leding cuse of cncer-relted deths in Western countries (1). Clssicl symptoms re dominl pin, weight loss, jundice due to iliry ostruction nd gstric outlet ostruction when the tumour is locted in the pncretic hed. However, tumours locted in the pncretic ody or til usully hve more insidious nd vgue presenttion, with dominl or ck pin, or new onset dietes mellitus; this vgueness my led to lte dignosis nd poor outcomes. 204 Surgery, Gstroenterology nd Oncology, 23 (3), 2018

2 Pncretic Adenocrcinom Presenting s Acute Lrge Bowel Ostruction: Cse Report Lrge owel ostruction is common condition clssiclly cused y colonic mlignncy, volvulus, fecl impcttion, diverticulr disese, inflmmtory owel disese, rdition enteritis nd colonic stricture (2). However, cute owel ostruction secondry to pncretic cncer is rre primry presenttion of pncretic denocrcinom. CASE REPORT We report the cse of 63-yer-old mn presenting to the emergency deprtment with diffuse dominl pin nd distention. The lst owel movement hd occurred four dys efore. He stted tht he hd hd complints of dominl discomfort, norexi nd dirrhe strting one month efore. The ptient hd pst medicl history significnt for hypertension nd hyperlipidemi. No known history of previous surgeries. His lst colonoscopy hd een performed 6 yers efore, showing three polyps which were excised. Pthology reveled low grde displsi. No fmilir history of pncretic or colonic mlignncies. On the emergency deprtment his vitls were ll within norml vlues nd his physicl exmintion ws significnt only for dominl distention nd diffuse tenderness, ut without reound tenderness or other signs of peritonitis. Adominl sounds were diminished. Digitl rectl exmintion ws norml. Lortory nlysisdid not revel ny normlities. Plin dominl X-ry showed ir-fluid levels nd owel distention (fig. 1). Intrvenous contrst enhnced CT scn of the domen nd pelvis reveled nodulr lesion ner the pncretic tilnd splenic hilum nd nrrowing of the colonic splenic flexure. There ws no evidence of intrperitonel free ir or fluid (fig. 2, 3). Colonoscopy showed colonic stenosislocted t 40 cm from the nl verge, suspicious of extrinsic compression, with no signs of colonic intrinsic neoplstic chnges. The ptient ws sumitted to n explortory emergentlprotomy using midline skin incision. We identified suspicious mss involving the colonic splenic flexure, splenic hilum nd the pncretic til. All the colon ws distended with risk of cecum rupture. No signs of heptic or peritonel metstsis were found. The decision ws mde to performn en loc sutotl colectomy, splenectomy nd distl pncretectomy. Bowel continuity ws primrily restored y performing ltero-lterl mechnicl ileocolic nstomosis. The ptient ws dmitted in the intensive cre unit (ICU) during the immedite postopertive period due to the extent of surgery. At dy 3, the ptient developed fecl peritonitis identified y fecl content in the Figure 1 - Admission plin dominl X-ry Figure 2 - Admission contrst-enhnced dominl CT scn, coronl view Figure 3 - Admission contrst-enhnced dominl CT scn, xil view dominl drins nd septic shock. He ws promptly sumitted to n emergent re-lprotomy. We identified n ilel perfortion nd fecl peritonitis. We constructed Surgery, Gstroenterology nd Oncology, 23 (3),

3 Inês Cmpos Gil et l Figure 4 - Surgicl specimen: en loc sutotl colectomy, distl pncretectomy nd splenectomy diverting ileostomy nd dominl lvge ws performed. At postopertive dy 10, the ptient hd sudden onset dominl pin nd hypotension ssocited with hemtic content in the dominl drins nd drop in hemogloin levels. We ssumed the presence of hemoperitoneum nd the ptient ws sumitted to nother emergent re-lprotomy. We found mssive hemoperitoneum due to leeding from the pncretic stump. Hemostsis ws chieved nd the ptient ws redmitted in the ICU for nother 4 dys, nd fter tht to the surgicl wrd. He lter developed superficil surgicl wound infection, which ws pprently resolved with ntiiotic therpy. The ptient ws dischrged home t the 43 rd postopertive dy. He ws redmitted one week lter ecuse of persistent purulent secretion from the dominl surgicl wound; microiologic nlysis reveled the presence of multiresistent Escherichi coli nd Proteus mirilis. New dominl CT scn did not revel ny other locl complictions. He hd slow ut stedy improvement with intrvenous ntiiotics nd edside surgicl deridment. The infection ws resolved fter two months. The gross specimen consisted of sutotl colectomy with ttched distl pncres nd spleen (fig. 4). Microscopiclly, the tumour ws pncretic ductl denocrcinom, with extr-pncretic extension, with invsion of peripncretic ft, wll of the colonic segment nd splenic hilum. Surgicl resection mrgin ws invded t the level of peripncretic ft. Finl stging ws pt3, pn1, with 4 of 39 lymph nodes positive for metstsis (figs. 5, 6, 7). The cse ws presented t the multidisciplinry group consult nd the decision ws mde to mintin ctive surveillnce only. No djuvnt therpies were Figure 5 - Finl pthology: pncretic prenchim (on the left) with denocrcinom (ottomright). H&E, 100x. proposed since the dominl wound infection ws only resolved within 3 months from the initil surgery. Current follow-up is of 7 months. The ptient showed signs of tumour regrowth in the 6th-month torco-dominl CT scn. He is currently underchemotherpy with DeGrmont protocol. DISCUSSION Acute owel ostruction secondry to pncretic cncer is rre primry presenttion of pncretic denocrcinom. This is only the seventh reported cse of ptient whose primry presenttion of pncretic cncer ws lrge owel ostruction. In the revised literturedted from 1979, we found 3 cse reports of djcent colonic involvement of pncretic denocrcinom cusing mechnicl ostruction (tle 1) (3, 4, 5). We lso found 3 other cse reports of metsttic pncretic cncer cusing mechnicl ostruction (6, 7, 8). Overll outcomes 206 Surgery, Gstroenterology nd Oncology, 23 (3), 2018

4 Pncretic Adenocrcinom Presenting s Acute Lrge Bowel Ostruction: Cse Report Tle 1 - Literture review of pncretic cncer csespresenting with lrge owel ostruction Adjcent invsion Metstsis Cse report Welch, 1979 Tresdern, 1981 Griffin, 2012 Present cse Slm et l., 2007 Bellows, 2009 Kelley, 2016 Initil Adominl pin, Adominl pin, Adominl pin, Adominl pin, Adominl pin, Adominl pin, symptoms constiption nd constiption/ distention, vomiting, distention nd distension nd distention nd weight loss dirrhe, wheight constiption nd constiption constiption constiption loss nd jundice weight loss Gender Mle Mle Mle Mle Mle Mle Femle Age 54-yer-old 68-yer-old 73-yer-old 63-yer-old 78-yer-old 45-yer-old 67-yer-old Colon No Yes Yes No Yes No perfortion Primry Til of pncres Hed of pncres Til of pncres Til of pncres Til of pncres Til of pncres tumor Point of Splenic flexure Right trnsverse Splenic flexure Splenic flexure Splenic flexure Proximl sigmoid invsion cólon Pthology Adenocrcinom Adenocrcinom Mucinous Adenocrcinom Mucinous Adenocrcinom denocrcinom denocrcinom Procedure Emergency Nonopertive En loc sutotl En loc sutotl Right colectomy Right colectomy Left colectomy decompression tretment. colectomy, distl colectomy, distl with primry with end trnsverse pncretectomy pncretectomy nstomosis. colostomy colostomy. Perfurtion on dy nd splenectomy. nd splenectomy. 5 nd decision ws Reopertion: en Reopertion: mde for confort Reopertion: Re-opertion: loc resection of segmentl colon mesures. ileostomy formtion diverting pncretic til, resection with ileostomy spleen nd left primry nstomosis, colon with primry pncretic cncer nstomosis non-resectle Dignosis Postmortem Outcome Died "severl Died 5 dys lter Died 17 dys lter Survivl t seven Survivl t three months lter" months follow-up months follow-up Figure 6 - ) Pncretic denocrcinom with invsion of the colonic wll; note tht the colonic mucos is not invded. H&E, 100x. ) Colonic invsion, spring the musculris mucos nd mucos. H&E, 400x. were poor, with one ptient live t three-months follow-up, since dvnced disese ws present t the time symptoms were developed. Acute owel ostrution is n uncommon presenting symptom of pncretic disese; when it hppens, it is usully consequence of pncretitis, tht my cuse loclized spsm of the splenic flexure leding to diltion of proximl colon (3, 9). Pncretic cncer is rrer cuse of owel ostruction, which my e due to contiguous invsion or to metsttic disese. When there is known history of pncretic cncer nd the ptient presents with colonic mss, loclly dvnced or metsttic disese must e considered in the differentil dignosis; therefore, these ptients should e worked Surgery, Gstroenterology nd Oncology, 23 (3),

5 Inês Cmpos Gil et l Figure 7 - Left: invsion of the peripncretic ft. Right: invsion of the splenic hilum. H&E, 100x. up efore eing considered for resection (8), since extended resection my not e justified nd is ssocited with high rtes of moridity nd mortlity. Frozen section exmintion, when ville, my e helpful in these circumstnces (4). CONCLUSION Although rrely, pncretic denocrcinom cn present s cute owel ostruction; therefore, it should e considered in the differentil dignosis of lrge owel ostruction. Conflicts of interest The uthors hve no potentil conflicts of interest to declre. REFERENCES 1. Jeml A, Siegel R, Xu J, Wrd E. Cncer sttistics CA Cncer J Clin 2010;60: Errtum in CA Cncer J Clin. 2011;61(2): Townsend CM, (ed): Siston Textook of Surgery 17th edition. Phildelphi, Elsevier; Welch, JP. Acute lrge-intestinl ostruction s the initil sign of pncretic crcinom. Dis Colon Rectum. 1979;22(6): Tresdern J. Crcinom of the pncres presenting s mechnicl ostruction of the colon. Postgrd Med J. 1981;57(663): Griffin R, Vills B, Dvis C, Awrd ZT, Crcinom of the til of the pâncres presenting s cute domen. JOP. 2012;13(1): Slm KD, Clkins S, Cson FD. LPlce's lw revisited: cecl perfortion s n unusul presenttion of pncretic crcinom. World J Surg Oncol. 2007;5: Bellows C, Gge T, Strk M, McCrty C, Hque S. Metsttic pncretic crcinom presenting s colon crcinom. South Med J. 2009;102(7): doi: /SMJ.0013e31818fd7. 8. Kelley KM, Myer BS, Berger JJ. Mlignnt lrge owel ostruction: A rre presenttion of metsttic pncretic cncer. Am Surg. 2016;82(8):e Slvin J, Smedley FH, Chill CJ. Closed loop lrge owel ostruction secondry to pncretitis. J R Soc Med. 1990;83(8): Surgery, Gstroenterology nd Oncology, 23 (3), 2018