[ ISSN : 2573-3680 ]
Large bowel obstruction; Ileus; Pancreatic cancer
Background: Despite the close anatomical relationship between the pancreatic tail and left colonic flexure, large bowel obstruction due to pancreatic cancer is a rare condition.
Case presentation: We present two cases of large bowel obstruction due to pancreatic cancer.
Conclusion: In case of large bowel obstruction due to pancreatic cancer, an aggressive approach should be considered due to the nature of invasive pancreatic cancer in these cases with a palliative aim
Acute mechanical large bowel obstruction is a surgical emergency. The treatment is either stenting or surgery – depending on the nature of the obstruction, anatomic location, dissemination and patient comorbidity. In case of sigmoid volvulus, endoscopy is preferred [1,2].
Common causes of mechanical large bowel obstruction are:
• Malignant: primary colon tumor, recurrent colon tumor, metastatic disease or pelvic malignancies (e.g. ovarian cancer).
• Benign: crohns disease, diverticulitis, volvulus, adhesions, giant lipoma, acute pancreatitis, radiation therapy or fecal impaction [3]. • Colonic neoplasm is the dominating cause followed by volvulus and adhesions [4].
• Obstruction due to pancreatic cancer is exceedingly rare. Only four cases have previously been reported [5].
The anatomical relationship between the pancreatic tail and left colonic flexure, causes the colon to be susceptible to severe and expanding pancreatic disease, in worst cases, causing fistulas, ischemia, ulcers, stenosis [6] or as in this case series, obstruction of the colon due to adenocarcinoma in the pancreatic tail.
Patient 1
48-years old male, presented with 2 days of diffuse abdominal pain, intermittent vomitus and dizziness. Last defecation and flatus less than 12 hours prior to admission. Known history of chronic pancreatitis, alcohol abuse and previous treatment with extracorporeal shock wave lithotripsy (ESWL) due to pancreatic duct stones. An abdominal computed tomography (CT) scan had revealed thickening of the colonic wall at the left flexure a year before.
Clinically the abdomen was slightly distended, with direct pain to the epigastrium and left curvature. Furthermore no peritoneal reaction and normal bowl sounds was found. Blood samples where normal, except for a creatinin of 200 μmol/l(ref 60-105 μmol/l). Normal vital signs (blood pressure, pulse, respiratory frequency, temperature and Glasgow coma scalescore) were found. An abdominal ultrasound showed thickening of bowel segments, and gastric retention indicating a possible ileus. An abdominal CT scan was performed, showing large and small bowel ileus with a transition zone at the left colonic flexure with no suspicion of a tumor (Figure 1). An X-ray with retrograde colonic contrast only reached the left colonic flexure (Figure 2). The patient was clinically unaffected, and initial treatment was conservative.
Figure 1: Abdominal CT scan without contrast: Gastric retention, normally calibrated proximal small intestines and distal small intestines distended to 3,5cm with fluid. Ascending and transverse colon distended to 8 cm. Transition zone in the left colonic flexure. Left colon collaborated. No wall thickening of the colon is observed.
Figure 2: Colonic contrast pouring: Contrast reaching the left colonic flexure where the contrast stops and the colon is seen narrowing.
The next day a colonoscopy was performed, showing an obstruction at the left flexure. Stenting was attempted, but unsuccessful. The patient underwent an emergency explorative laparotomy, where a mass involving the left colonic flexure, the spleen and pancreatic tail, was found, reaching the greater curvature of the stomach, causing gross distension of the large bowel. Descending colon, distal transverse colon, spleen and pancreatic tail was resected enbloc, a transverse colonostomyand a sigmoid fistula were performed.
An intraoperative gastroscopy showed an intact stomach. During the procedure the diaphragm was breached leading to pneumothorax and a pleural drain was inserted. The patient initially recovered well, was treated with, metronidazole, piperacillin/tazobactam, and later anidulafungin due to fungal infection in the blood. On the 15th day after surgery, the patient´s condition worsened rapidly and he passed away on the 16th day after surgery. The histology of the resected specimen showed adenocarcinoma in all the resected organs with primary tumor location in the pancreatic tail.
Patient 2
92-year old female presented with a history of progressively distended abdomen during one day. Last defecation the day before, no nausea or vomiting. She was known mitral valve prolapse and mitralin sufficiency, hypertension, hypercholesterolaemia and previous hysterectomy and oophrectomy. Clinically the patient´s abdomen was distended with diffuse pain and dampened bowel sounds. Blood samples were normal. A CT scan showed large bowel obstruction, with a suspected stenosis at the left colonic flexure, with suspicion of a malignant colon tumor T3 N0 M0. The CT scan showed mild degree of ascites, left sided pleural exudate and a small ventral hernia (Figure 3).
Figure 3: Participant observation during regular training with LY and the centre staff.
A colonoscopy was planned with the intention of placing a selfexpanding metal stent (SEMS). The patient’s condition worsened before the procedure, and an emergency laparotomy, was performed. Total colectomy, distal pancreas resection and splenectomi were performed, and a suction drain placed. The day after the procedure the patient became hemodynamically unstable, with bleeding in the drain, and underwent an explorative laparotomy. Bleeding from a small gonadal vessel was identified A colonoscopy was planned with the intention of placing a selfexpanding metal stent (SEMS). The patient’s condition worsened before the procedure, and an emergency laparotomy, was performed. Total colectomy, distal pancreas resection and splenectomi were performed, and a suction drain placed. The day after the procedure the patient became hemodynamically unstable, with bleeding in the drain, and underwent an explorative laparotomy. Bleeding from a small gonadal vessel was identified
Patients presenting with pancreatic cancer usually complain of jaundice, abdominal pain and/or loss of appetite/weight loss [7]. Bowel obstruction in these patients is most likely due to carcinosis in the small bowel. Initial workup should include contrast enhanced abdominal CT, to evaluate possible advanced disease, and early fluid resuscitation despite, normal blood samples and vitals. Chronic pancreatitis is on rare occasions known to cause stenosis of the left colonic flexure [6]. In these cases surgery should be considered [8].
We have presented two cases where large bowel obstruction, initially suspected of colonic cancer and chronic pancreatitis, was due to pancreatic cancer. The patients must be treated for the large bowel obstruction primarily, either by stenting, resection and/or anastomotic bypass as possible choices of treatment. In these cases the cancer is advanced with a short expected lifespan, and procedures should be performed with a palliative aim.
Since the oncological treatment is different for colonic and pancreatic cancer, it is important to obtain biopsies, if a SEMS is placed and no resection is done. In case of large bowel obstruction, due to pancreatic cancer invading the colon, a more aggressive approach is recommended, although the procedure has a palliative aim.
The six patients in the published cases with large bowel obstruction, due to pancreatic tail cancer, passed away within months, hereby highlighting the palliative aim of treatment and care.
Author contribution: A Bang-Nielsen is lead author and drafted the manuscript. MW Noack, AM Bohm and ML Lauritsen and A Bang-Nielsen designed the study, did picture editing and edited the article. All authors have approved the article.
Informed consent statement: All involved persons have given their informed consent for obtaining medical records and to be included in this case report. Institutional review board statement: The study was reviewed and approved by the Department on Gastrointestinal surgery Institutional Review Board.
1. Pujahari AK. Decision Making in Bowel Obstruction: A Review. J Clin Diagn Res. 2016; 10: 7-12.
3. Baron TH. Acute colonic obstruction. Gastrointest Endoscopy Clin N Am. 2007; 17: 323-339.
8. Van Minnen LP, Besselink MGH, Bosscha K, Vang Leeuwen MS, Scipper ME, Gooszen HG. Colo.
Bang-Nielsen A, Noack MW, Bohm AM and Lauritsen ML. Large Bowel Obstruction due to Pancreatic Cancer - A Case Series. SM J Clin Med. 2018; 4(1): 1033.
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Sonu Sahni1,2*, Sameer Verma1,2, Reeju S Thomas1 , Barbara Capozzi3 and Arunabh Talwar1,2
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Sreenivasa Rao Sudulagunta1 *, Shyamala Krishnaswamy Kothandapani2 , Mahesh Babu Sodalagunta3 , Hadi Khorram2 , Mona Sepehrar4 and Zahra Noroozpour1
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH