A ninety-year-old female, with a medical history of hypertension, hypercholesterolemia and gastritis, was transferred to our hospital with the diagnosis of small bowel obstruction due to adhesions found in a CT-Scan.
She came to the ER complaining of nausea, vomiting and constipation for 3 days. In the physical exam, she was found to be dehydrated and had a painless distended abdomen. No pneumoperitoneum or obvious signs of obstruction were found in the X Ray. The laboratory tests showed no leukocytosis or CR-P elevation, only a minor hypokalemia (3.25 mmol/L).
Initial conservative treatment was indicated with nasogastric tube decompression and intravenous fluid therapy. After an initial clinical improvement, the patient relapsed with nausea and vomiting, abdominal distension and constipation. The patient was reevaluated with a new CT-Scan, which showed a transition zone in the right lower quadrant where a marked dilation of the small bowel (> 35mm) was described (FIG 1).
Due to the clinical and X-ray findings, the patient underwent surgery. A laparotomy revealed a cystic intraluminal mass at 60 cm from the ileocecal valve, causing a retrograde obstruction (FIG 2). A small bowel resection with primary anastomosis was performed. The post-operative period was uneventful and patient was discharged on the fifth post-operative day.
The pathological analysis of the specimen showed a pT4N0 adenocarcinoma with negative margins.
Up to 30% of small bowel obstructions will require operating. Neoplasia is the third most common cause of these obstructions, with adenocarcinoma being the least common one. The diagnosis is frequently done intraoperatively, with primary resection being the method of choice. The 5-year overall survival of a patient with negative margins and no nodal involvement can reach up to 70%.