SciELO - Scientific Electronic Library Online

 
vol.31 issue4Chagasic megacolon and large bowel neoplasms: case series and literature reviewTreatment of rectal leiomyoma by endoscopic resection author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Journal of Coloproctology (Rio de Janeiro)

Print version ISSN 2237-9363

J. Coloproctol. (Rio J.) vol.31 no.4 Rio de Janeiro Oct./Dec. 2011

http://dx.doi.org/10.1590/S2237-93632011000400010 

CASE REPORT

 

Non-Hodgkin lymphoma as a cause of acute intestinal obstruction/perforation in patients with adenocarcinoma of the sigmoidcolon: a case report

 

 

Marcelo Pandolfi BassoI; Adriana Borgonovi ChristianoI; Letícia Vieira GuerrerII; Francisco De Assis Gonçalves-FilhoIII; João Gomes NetinhoIV

IResident, Coloproctology, Hospital de Base da Faculdade de Medicina de São José do Rio Preto (FAMERP) - São José do Rio Preto (SP), Brazil
IIResident, General Surgery, Hospital de Base da FAMERP - São José do Rio Preto (SP), Brazil
IIIAssistant Physician, Coloproctology, Hospital de Base da FAMERP - São José do Rio Preto (SP), Brazil
IVHead of Coloproctology, Hospital de Base da FAMERP - São José do Rio Preto (SP), Brazil

Correspondence to

 

 


ABSTRACT

Report of a rare case of an 83-year-old patient with lymphoma of the terminal ileum causing obstructive/perforated acute abdomen synchronous with sigmoid colon adenocarcinoma and review of literature data about small bowel malignancies, particularly lymphomas. It seems to correspond to a rare disease (2% of all bowel cancers), more prevalent in elderly and immunocompromised patients, whose symptoms are vague and early diagnosis is difficult, often making it impossible to establish the correct therapy.

Keywords: gastrointestinal neoplasm; lymphoma; adenocarcinoma; intestinal obstruction; intestinal perforation.


RESUMO

Relato de caso raro de um paciente de 83 anos, com linfoma de íleo terminal causador de abdome agudo obstrutivo/perfurativo sincrônico à adenocarcinoma de cólon sigmoide e revisão dos dados disponíveis na literatura acerca das neoplasias de intestino delgado, em especial os linfomas. Constata-se que corresponde a uma afecção rara (2% de todas as neoplasias intestinais), mais predominante em pacientes idosos e imunodeprimidos, cuja sintomatologia é vaga e o diagnóstico precoce difícil, fato que impossibilita muitas vezes a instituição da terapêutica correta.

Palavras-chave: neoplasia gastrointestinal; linfoma; adenocarcinoma; obstrução intestinal; perfuração intestinal.


 

 

INTRODUCTION

Acute abdomen refers to the group of signs and symptoms, especially pain, of an intra-abdominal disease, for which the surgical treatment is most indicated1.

Obstructive acute abdomen is an urgent or emerging clinical situation caused by interrupted gastrointestinal flow. This condition is one of the most frequent acute abdominal diseases, associated with high morbidity and mortality rates, especially in case of late diagnosis or treatment start, and, in these circumstances, it may reach 20% mortality2.

The main causes of intestinal obstruction vary with the level of obstruction, with brides and adhesions, internal hernia and large stomach tumors as causes of high obstruction, and colorectal diseases, volvulus and stenosis from intestinal inflammatory disease (terminal ileum) as causes of low obstruction, both in order of decreasing frequency2.

Perforated acute abdomen is the perforation of any hollow viscera resulting from inflammatory, infectious and/or neoplastic processes. In addition, it can have traumatic causes, including iatrogenesis.

The main intra-abdominal places of gastrointestinal tract perforation are the stomach and duodenum, followed by colons and other small bowel regions3.

Perforation of small bowel segments is considered a complication of intestinal inflammatory diseases, especially in the Crohn's disease. This complication is more common in patients with ileitis or ileocolitis, with incidence of around 23%. The infectious causes (such as tuberculosis in its intestinal form) and neoplasms (1-5% of all gastrointestinal tumors) should also be taken into account4.

In patients with non-Hodgkin lymphoma, perforation or obstruction has been described, especially in the terminal ileum. However, this situation is uncommon2,4.

 

CASE REPORT

A.A.O., male, 83 years old, white, retired farm worker, formerly a smoker, was receiving multidisciplinary outpatient care due to systemic arterial hypertension, coronary artery disease, chronic kidney disease and chronic obstructive pulmonary disease. He had history of abdominal surgery to correct an aorta aneurism.

The patient was admitted to another outpatient care in June 2008, due to a subocclusive acute abdomen, with improved conditions after a non-surgical treatment during the hospitalization, as well as episodes of hematochezia that started in January 2009.

Without following the recommendations to investigate intestinal bleeding, the patient returned to the Emergency Service of the Hospital de Base in May 2009, reporting, one day before admission, strong abdominal pain in the mesogastric region, associated with vomiting, hyporexia, non-quantified weight loss, intestinal constipation, as well as occasional episodes of hematochezia, which had started 6 months before. The patient had with him the result of a recent colonoscopy made at another service, which showed a vegetative injury in the sigmoid colon, with no biopsy result.

Three days after the symptoms appeared, the patient presented intense abdominal pain, abdominal distension and fecaloid vomiting (obstructive acute abdomen from probable neoplastic etiology), and was submitted to an emergency exploratory laparotomy. It showed neoplasm in rectum-sigmoid transition with macroscopic invasion of urinary bladder, without upstream colon distension, as well as presence of injury probably from the secondary graft in the terminal ileum, at approximately 15 cm from the ileocecal valve, associated with the obstruction, distension of the loops of small intestine and blocked perforation. The selected treatment was right-side enterocolectomy (Figures 1 to 3) and production of a Mickulicz ileotransversostomy, as well as exhaustive wash of the peritoneal cavity with physiological solution. The rectum-sigmoid transition injury was not addressed due to the patient's emergency situation, bladder size and invasion and as it was not the cause of the acute abdomen observed. The patient to the Intensive Care Unit in the immediate postoperative period, progressed with clinical decompensation of comorbidities and died on the second postoperative day.

 

 

 

 

 

 

The anatomopathological exam of the vegetating injury of the sigmoid observed in the colonoscopy showed a very differentiated and ulcerated tubular adenocarcinoma and the anatomopathological and immunohistochemical exams (Figure 4) of the injury in the distal ileum showed diffuse large B-cell lymphoma expressing immunophenotyping (CD20+).

 

 

DISCUSSION

The small bowel is rarely the place of neoplastic injuries, which represent only 1 to 5% of all gastrointestinal tract tumors4. The incidence of malign neoplasm is even lower, around 1 to 2%5. The terminal ileum is where malign injuries occur more frequently (50%), with the others equally occurring between the duodenum and the jejune. In contrast, the frequency of benign tumors seems to increase starting at the duodenum towards the ileum4,6.

Only 10% of the large intestine tumors are symptomatic and the frequency of benign injuries is ten times the frequency of malign injuries4.

Lymphomas are some of the malign neoplasms of the small bowel (7-25%). Primary lymphomas correspond to less than 2% of all intestinal tumors, with prevalence of intestine infiltration by neoplastic cells from other locations. The terminal ileum is the most common place of lymphoma occurrence, due to the higher concentration of lymphoid tissue associated with the intestine. The main risk factor to be considered is the immunosuppression, especially the one caused by the human immunodeficiency virus (HIV), chemotherapies and/or corticotherapy. In addition, celiac disease presents increased risk for the development of primary lymphomas3,5.

The intestinal invasion by lymphomas may not present specific symptoms and remain silent for a long time. Their initial manifestation can be obstruction or perforation (25%). In general, they present vague symptoms, common to other histopathological types: unclear abdominal pain, nauseas, alteration to the intestinal rhythm, anorexia and weight loss7.

Gastrointestinal tract lymphomas are most of non-Hodgkin type. The diffuse lymphoma of large B cells corresponds to the most frequent histopathological and immunohistochemical type8, more prevalent in people in their 70s and older.

The preoperative diagnosis is difficult, considering the insidious clinical manifestations that many times cause late search for specialized medical attention. In addition, given the similar symptoms and signs to other common diseases in the digestive tract, the correct diagnosis can only be obtained after the histomorphological and immunohistochemical analysis of the injury, many times after the patient is submitted to a surgical procedure.

In contrast, the distinction between primary lymphomas and the secondary infiltration of the gastrointestinal tract can be made through a biopsy of the bone marrow or other organs under suspicion of being affected by the disease. When this procedure is not possible, the consolidated and accurate criteria of Dawson9 can be used: non-palpable peripheral lymphadenopathy, normal thorax radiography, leukometry with differential showing no alterations, injury affecting particularly the gastrointestinal tract - only regional lymph nodes, and not the liver or spleen. The presence of these four criteria indicates the primary origin of lymphomas.

The case reported refers to an elderly patient with intermittent symptoms, suggesting a malign intestinal disease, confirmed through complementary exams (colonoscopy with biopsies). Emergency laparotomy showed the disease already well advanced locally in the sigmoid colon, as well as injury suggesting distance metastasis (terminal ileum), with signs of intestinal obstruction and perforation. The anatomopathological analysis of the resected intestinal segment showed a terminal ileum lymphoma synchronous with adenocarcinoma of the sigmoid colon. With no proper time for further investigations of the patient's conditions and with the criteria of Dawson described above, we concluded that the lymphoma in the reported case was a primary lymphoma of the gastrointestinal tract, since it fulfilled all criteria established, and was synchronous with the neoplasms presented by the patient.

Synchronization between intestinal neoplasms is frequent, especially in the case of sigmoid colon adenocarcinoma, and it should always be investigated10,11. The incidence of a second synchronous neoplasm with sigmoid colon adenocarcinoma, regardless of the histological type and the location in the gastrointestinal tract, ranges between 1 and 6.8% in general population10.

 

CONCLUSION

Small bowel neoplasms are rare, and the benign type is more frequent. Gastrointestinal tract lymphomas are among the malign injuries, primary or secondary to a neoplastic infiltration. The most frequent place of incidence is the terminal ileum, considering its histological peculiarities.

Signs and symptoms are vague and unspecific, which makes early diagnosis and accurate treatment more difficult. However, these diseases should always be remembered and considered in the differential diagnosis of the various intestinal syndromes.

 

REFERENCES

1. Postier RG, Squires RA. Abdome agudo. In: Townsend Jr CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabinston - Tratado de cirurgia. 19a ed. Rio de Janeiro: Elsevier; 2009. p. 1108-25.         [ Links ]

2. Sallum EA. Abdome agudo obstrutivo. In: Gama-Rodrigues JJ, Machado MCC, Rasslan S, editors. Clínica cirúrgica. Barueri (SP): Manole; 2008. p. 1071-8.         [ Links ]

3. Silva AL, Barbosa CA. Obstrução intestinal aguda. In: Lopes AC, editor. Tratado de clínica médica. São Paulo: Roca; 2006. p. 1092-109.         [ Links ]

4. Steinman E. Perfuração de víscera oca. In: Gama-Rodrigues JJ, Machado MCC, Rasslan S (Eds). Clínica cirúrgica. Barueri (SP): Manole; 2008. p. 1079-94.         [ Links ]

5. Evers BM. Intestino delgado. In: Townsend Jr CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabinston - Tratado de cirurgia. 19a ed. Rio de Janeiro: Elsevier; 2009. p. 1201-51.         [ Links ]

6. Torricelli FCM, Lopes RI, Dias AR, Marchini GS, Bonafe WW, Lopes JM, et al. Linfoma ileal primário como uma causa de intussuscepção ileocecal recorrente. J Coloproctol 2008;28(2):246-50.         [ Links ]

7. Rangel MF, Silva MVM, Fernandes MJC, Ferreira MAS, Nóbrega LPS, Souza MG. Tumores malignos do intestino delgado. Rev Col Bras Cir 2000;27(6):385-8.         [ Links ]

8. Silva FE, Scofano V, Ascoly MH, Arakaki Jr N, Reis OCA, Silva Sá MAG. Fístula êntero-vesical como complicação de linfoma intestinal. J Coloproctol 2003;23(3):200-4.         [ Links ]

9. Dawson IMP, Comes JS, Morson BC. Primary malignant lymphoid tumours of the intestinal tract. Report of 37 cases with study of factors influencing prognosis. Br J Surg 1983;49:80-9.         [ Links ]

10. Jara RLS, Santos CHM, Alves LP, Miiji LNO. Tumor de reto e cárdia sincrônicos. Relato de caso e revisão da literatura. J Coloproctol 2007;27(1):80-2.         [ Links ]

11. Santos CHM, Silva CN, Miiji LNO. Adenocarcinoma de cólon e carcinoma espinocelular de canal anal concomitante. Relato de caso e revisão da literatura. J Coloproctol 2005;25(2):162-4.         [ Links ]

 

 

Correspondence to:
João Gomes Netinho
Rua San Francisco, 481, Condomínio Débora Cristina
CEP 15093-030 - São José do Rio Preto (SP), Brazil
E-mail: jgnetinho@riopreto.com.br

Submitted: 07/14/2012
Approved on: 08/03/2010
Financing source: none.
Conflict of interest: nothing to declare.

 

 

Study carried out at the Hospital de Base da Faculdade de Medicina de São José do Rio Preto - São José do Rio Preto (SP), Brazil.

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License