Varied Clinical Presentations of Small Bowel Malignancies Posing Diagnostic Uncertainty and their Management

Abstract

Introduction: Incidence of small bowel malignancy is lower compared to other parts of gastrointestinal tract for various reasons explained in literature. Adding to it, small bowel is not an easily accessible area by the commonly available endoscopic modalities. Clinical presentation may vary due to obscure behaviour of disease. Hence, a high index of suspicion is required for early diagnosis and treatment. Aim: To evaluate the clinical behaviour of small bowel malignancies, its histological characteristics and to identify optimal imaging modality for early diagnosis and to assess its prognostic behaviour. Materials and Methods: Retrospective data was collected of all patients who were diagnosed and treated as small bowel malignancy. The patient’s medical records were reviewed. A literature review was also conducted on its clinical, pathological and treatment aspects by using terminologies mentioned in the heading keywords on PubMed, Google scholar. Total of 12 cases were managed over a period of four years with varied clinical presentations both in elective and emergency settings. Paediatric cases and benign tumours were excluded from the evaluation. Those diagnosed with small bowel cancer and not willing for any form of treatment were not included. Only those who were treated under department of surgical oncology and completing atleast 2-3 monthly follow ups were included. Results: Seven of the cases seen in our series were above age of 50 years, with male sex predominance. Jejunum was the most common subsite involved, with GIST being the most common histology. In the present series, majority presented with pain abdomen, two cases had chronic anaemia, one case presenting with mass per abdomen, and one case presented to emergency department with shock and massive haematemesis. Only in one case, small bowel was involved secondary to metastases from lung sarcoma. Resection and anastomosis was done in majority of cases and in one case of jejunal lymphoma infiltrating distal pancreas, en bloc resection of small bowel, distal pancreas and spleen was done. Conclusion: Rarity of incidence, vague presentation, inaccessibility to commonly available endoscopic techniques, lack of accuracy in assessment of small bowel by commonly available simple imaging modalities makes the early diagnosis difficult. Hence, we hereby propose to consider small bowel as one of the primary source in case of uncertain clinical situations described above, due to the fact that it can be easily treated surgically in most of the situations.

Keywords

• gist
• lymphoma
• neuroendocrine carcinoma
• sarcoma
• small intestine