MULTIPLE SYNCHRONOUS SMALL BOWEL ADENOCARCINOMAS IN A CASE OF BOWEL OBSTRUCTION DUE TO FAECALOMAS SECONDARY TO MULTIPLE STRICTURES – A DIAGNOSTIC SURPRISE

Small bowel adenocarcinoma(SBA)is a rare neoplasm presenting usually in elderly patients as a single tumour. Multiple synchronous SBA is unique and difficult to diagnose due to non-specific presentations.Faecalomas have been described in association with Hirschsprung’s disease, psychiatric patients, Chagas disease, both inflammatory and neoplastic conditions, and in patients suffering with chronic constipation.We herein report a case of multiple faecalomas secondary to multiple small bowel strictures leading to small bowel obstruction in a patient with previous history of pulmonary tuberculosis.Thepatient was successfully treated surgically. The strictures on histopathology turned out to be adenocarcinoma. Multiple synchronous SBA as well as multiple fecalomas are individually rare entities, and their combined occurrence is even rarer.

Small bowel adenocarcinoma(SBA)is a rare neoplasm presenting usually in elderly patients as a single tumour. Multiple synchronous SBA is unique and difficult to diagnose due to non-specific presentations.Faecalomas have been described in association with Hirschsprung's disease, psychiatric patients, Chagas disease, both inflammatory and neoplastic conditions, and in patients suffering with chronic constipation.We herein report a case of multiple faecalomas secondary to multiple small bowel strictures leading to small bowel obstruction in a patient with previous history of pulmonary tuberculosis.Thepatient was successfully treated surgically. The strictures on histopathology turned out to be low grade adenocarcinoma. Multiple synchronous SBA as well as multiple fecalomas are individually rare entities, and their combined occurrence is even rarer.

ISSN: 2320-5407
Int. J. Adv. Res. 9(11), 1194-1198 1195 We hereby present a case of an elderly lady who presented with recurrent small bowel obstruction due to multiple faecalomas secondary to multiple small bowel strictures which later turned out to be small bowel adenocarcino mas on histopathology.

Case Report:
A55-year-old, diabetic and hypertensive lady presented to the emergency department with complaints of abdominal pain, distension, and vomiting on and off from 5 days. It was associated with constipation from past 3 days. She had been having similar complaints from the past 15 years for which she had been seeking medical advice from various sources and had temporary relief from her symptoms.The patient had also undergone a prior abdominal surgery 10 years back, details of which were not available. She was diagnosed to have Pulmonary tuberculosis in the past for which she completed a full course of antitubercular therapy. A history of significant weight loss was also given by the patient and her relatives.
On physical examination, the patient was afebrile, had a pulse rate of 80/minute, blood pressure of 130/70 mmHg and normal respiration.Abdominal examination revealed distension with no visible veins or sinuses and diffuse tenderness over whole abdomen.Previous midline vertical laparotomy scar was noted. On auscultation hyperperistaltic bowel sounds were present. A digital rectal exam revealed no positive findings.
Plain standing abdominal radiography showed multiple air-fluid levels and were suggestive of a small bowel obstruction. Meanwhile, the patient was resuscitated, a nasogastric tube was inserted for decompression and routine blood investigations were sent. Previously available colonoscopy reports were suggestive of age-related chronic constipation. After the initial assessment, a CECT abdomen was ordered which showed dilated ileal loops with intraluminal obstruction due to faecaloma and bowel wall thickening at multiple places.
The patient was taken up for a diagnostic laparoscopy andadhesiolysis was performed. Multiple faecal balls within multiple ileal strictures were found on laparoscopy. A laparoscopic assisted resection and anastomosis of the involved ileal segment with faecalomas and strictures was performed. A solitary distal ileal stricturoplasty was performed. (Fig.1-4) The patient was discharged after a favourable postoperative course in the ICU and wards. The histopathology report of the resected segment was suggestive of an underlying low-grade adenocarcinoma and was a diagnostic surprise. The resected margins were free of tumour cells. The specimen was also analysed to rule out any nidus of bezoar over which the faecalomas had formed, but there was no such evidence and only faecal matter was found to be present. The patient was then lost to follow up.

Discussion:-
SBA is rare and most tumours are single and commonly located inthe duodenum. SBA often develops with vague and nonspecificgastrointestinal symptoms, including obscurebleeding, abdominal pain, nausea and vomiting, weightloss, diarrhoea, and intestinal obstruction. Multiple synchronous SBA is a rare and unique and very few studies on these tumours have been found in literature. These studies showthat it is difficult condition to diagnose. [13] Chronic inflammation is associated with the formation of several malignant tumours, with Crohn's disease for example increasing the risk of SBA. [14] Patients with familial adenomatous polyposis (FAP), hereditary non-polyposis colorectal cancer (HNPCC), Peutz-Jeghers syndrome, and celiac disease also show an increased risk of SBA development. [15,16] Faecaloma is an extremely rare form of faecal impaction and is the defined as the accumulation of hard faecal matter within the bowel lumen that is separable from rest of bowel contents [17,18] .It is most commonly seen on the left side of the colon (rectum & sigmoid) because stool becomes firmer, and diameter of the left colon is smaller. It been seen in association with Chagas disease, Hirschsprung's disease, inflammatory disease, neoplasm, chronic constipation, psychiatric patients, and elderly institutionalized population. [7,9] Patients with faecaloma usually presents with nonspecific complaints such as constipation, weight loss, vague abdominal discomfort after meals and "overflow type" of diarrhoea. [9] In very rare cases small bowel involvement has been described in literature. [7,8,19] Previously it has been reported that, none of the patients in a large series of 411 patients with bowel obstruction were found to have faecaloma. [20] In our case, Multiple SBA were thought to be secondary to a previous history of pulmonary tuberculosis causing chronic inflammation of the bowel and strictures as a part of its other systemic effects. Out of all the abovementioned causes for faecaloma formation like chronic constipation, underlying inflammatory disease and adenocarcinoma seemrelevant in our case. Peri-operatively, the strictures were suspected to be secondary to tuberculous pathology as our patient had history of pulmonary tuberculosis.However, the final histopathology report 1197 of a low-grade adenocarcinoma came as a diagnostic surprise.Protocols to identify multiple synchronousSBA at an early stage are currently lacking and are urgently required. The complex presentation and rare occurrence of multiple SBA condition makes it easy to be misdiagnosed.
We would like to emphasize that, weshould not ignore multiple synchronous SBA when diagnosing intestinal diseases and intestinal tuberculosis may represent risk factor for multiple SBA, although the pathology does not providesufficient evidence. Since no specific methods exist for the diagnosis of multiple synchronous SBA, several diagnostic techniques used, including radiologic (CT,MRI, PET-CT) and endoscopic approaches (enteroscopy, video capsule) are usually combined for a more accurate evaluation and diagnosis. Doctors should strive to obtain pathological diagnosis to avoid diagnostic treatments and treatment delays. To-date, surgical resection remains the treatment of choice for patients with SBA. The 5-year survival is poor and dependent on tumor stage: 50-60% for stage I, 39-55% for stage II, 10-40% for stage III and 3-5% for stage IV. [21] Majority of the diagnosis of SBA occurs at stage IVbecause the disease is easily misdiagnosed, and surgery is delayed. No dedicated TNM staging for multiple synchronous SBA exists. A higher number of adjuvant therapies are used for SBA treatment due to its poor prognosis and high risk of relapse. [22,23] The most used chemotherapyregimen in the past was based in fluorouracil with modest results.Drugs like oxaliplatin and capecitabine are showing better outcomeand a prospective international randomized trial (BALLAD) is beingcarried to assess its efficacy. [6] The management is of faecalomas is controversial. Most of the faecal impactions are successfully managed conservatively with bowel rest, laxative, enema, and digital evacuation. [24] Endoscopic removal of the faecaloma has also been reported in the literature. [18] Surgical procedure generally involves either exploratory laparotomy or laparoscopy followed by removal of faecaloma and/or resection of the involved segment. [7,9] In patients who are successfully treated, it is important to keep a close follow up and prescribe stool softeners. Emphasis on proper dietary habits which include high fiber diet, adequate water intake is also needed along with regular toilet training sessions. [9] The outcome is mostly favourable after both conservative and surgical management. However, in elderly and those with intestinal rupture the outcome is poor. [12,25] Conclusion:-Mutiple synchronous small bowel adenocarcinoma (SBA) is a rare cancer. This coupled with multiple faecalomas causing small bowel obstruction makes it an extremely rare occurrence. To the best of our knowledge this case is one of the first few reported cases in literature. The diagnosis requires a high index of suspicion. Small bowel resection with negative margins is thetreatment of choice.Options for adjuvant treatment include fluoropyrimidine or oxaliplatin-based regimens and are under trial.