Regional enteritis leading to carcinoma of the small bowel

Abstract

SUMMARY A case of carcinoma of the small bowel intimately associated with long-standing regional enteritis (Crohn's disease) is described. Sixteen similar cases reported in the literature are briefly reviewed. This neoplasm presents at a younger age than other small bowel carcinomas and there seems little doubt that it is causally related to the inflammatory bowel lesion. He was anaemic (haemoglobin 10-3 g/100 ml, electrolytes within normal limits); no intestinal pathogens were isolated; serum proteins, total 5.4 g/100 ml (albumin 1. 6 g/100 ml, globulin 3.8 g/100 ml). Alkaline phosphatase 50 KA units 100 ml; total serum bilirubin 0.3 mg 100 ml; SGOT 125 units, and SGPT 180 units. A barium meal showed a normal oesophagus, stomach, and duodenum, but the follow-through films showed abnormal small bowel with considerable dilatation and coarse mucosal folds. This appeared to begin in the lower jejunal region and extended down to the terminal ileum. The large bowel was also rather dilated and showed fluid levels in the erect position. A xylose excretion test was done: 9-2 % of a 25 g dose had been excreted in five hours, a marked impairment. A duodenal biopsy was taken by Crosby capsule and showed thickening and flattening of the villi.Treatment for a supposed malabsorption syndrome was instituted but his condition deteriorated further.A barium enema was then done which showed an irregular channel from the right of the rectum communicating with the small bowel and the most probable diagnosis now seemed to be Crohn's disease of the ileum with an iliorectal fistula. By this time he was even weaker; he became occasionally confused and developed bronchopneumonia. Intravenous feeding with aminosol and intralipid, plasma and blood transfusions together with antibiotics resulted in some degree of improvement for three or four days but then his condition began to deteriorate again and immediate correction of the fistula seemed to offer the only hope of survival.The abdomen was explored through a right paramedian incision. A grossly dilated loop of lower ileum was found firmly adherent to the pelvis. Below this was a stricture and then the final four or five inches of terminal ileum which were grossly thickened. On dividing the adhesions an ileal fistula and two iliorectal fistulae were apparent in the region of the stricture. The mesenteric glands were enlarged. The liver was pale and fatty. The lower two feet of ileum and the caecum, appendix, and ascending colon were resected and an end-to-end anastomosis was made. The patient recovered consciousness after the anaesthetic but despite intensive treatment he died the following day. At necropsy the cause of death was said to be bronchopneumonia. PATHOLOGYStudy of the opened operation specimen showed the terminal ileum to be thickened and fibrotic with numerous pits and clefts in a rather smooth fixed mucosa; above this was a very narrow strictured region and above this again the greatly distended obstructed ileum showing gross cobblestonechanges, ulceration, and pseudopolyps....

Adenocarcinoma and crohn's disease a report of 2 cases and analysis of the literature

“…That this age difference and distribution simply reflect the group sampled is unlikely. A comparable incidence of other smallbowel malignant tumours would be expected, but only 3 cases have been reported-a lymphosarcoma in this series and 2 cases of reticulum-cell sarcoma (Hughes, 1955;Wyburn-Mason, 1968). There is Vol.…”

Coeliac disease and small bowel carcinoma

“…There is a suggestion, therefore, that the part of the bowel most affected in coeliac disease is also the most common site for carcinoma. Yet this evidence is much less striking than it is in regional enteritis, where many more small bowel carcinomas have been described and nearly all of them have been in the ileum (Wyatt, 1969). Furthermore, in regional enteritis, the mean age at diagnosis of malignancy, about 43 years, is also younger.…”

Impaired lymphocyte reactivity against tumour cells in patients with Crohn's disease

“…The granulomatous character of the typical bowel lesions shows a resemblance to sarcoidosis and some patients with Crohn's disease have been shown to react in weak but characteristic manner to a Kveim antigen by skin testing (Mitchell and Rees, 1970) and by inhibition of macrophage migration in the presence of this antigen (Willoughby and Mitchell, 1971). Wyatt (1969), in a study of reported cases of adenocarcinoma of the small bowel complicating Crohn's disease, found 17 examples and noted that the mean age of occurrence was almost 20 years earlier than would be expected from the available world figures. A similar conclusion was reached by Mottet (1971) and by Papp and Pollard (1971), ponderance of tumour involvement in the ileum with Crohn's disease as compared with a more frequent distribution in the duodenum and jejunum in the absence of Crohn's disease.…”