AbstractsL ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS - SMALL INTESTINE/UNCLASSIFIED
Small Bowel Carcinoids: Big Bleeds in a Small Percentage
Small bowel carcinoids (SBCs) represent a small portion of gastrointestinal (GI) tumors, and typically cause abdominal pain, intestinal obstruction, and carcinoid syndrome with spread to the liver. In 5% of cases, SBCs may cause GI bleeding. A 67 year old male was admitted for 1 week of diffuse periumbilical abdominal pain with 1 day of melena and hematochezia. The patient had epigastric discomfort in the past, but workup with colonoscopy and esophagogastroduodenoscopy were unremarkable. Upon admission, his vitals were stable and abdominal exam revealed a tender right upper quadrant and periumbilical area. Labs showed no leukocytosis and Hb 13.1. CT abdomen/pelvis showed no changes. EGD was unremarkable, but colonoscopy showed blood all the way up to the cecum, concerning for a small bowel bleed. The patient continued to have melena with hematochezia, and his hemoglobin trended down to 7.9. Bleeding scan was negative. Capsule endoscopy revealed a 2 cm submucosal mass with ulceration (Figure A). Surgery successfully resected a 2 cm submucosal mass in the distal third of the small bowel (Figure B) without lymph nodes. Pathology showed carcinoid invading the subserosal tissue with negative surgical margins (Figure C). As this was a Stage IIA carcinoid tumor, there was no indication for adjuvant therapy. Surveillance with a CT scan and biochemical markers 3 months later showed no signs of recurrence. Primary small bowel neoplasms are generally rare, accounting for 3-6% of GI neoplasms. Of these, carcinoids are the second most common type, comprising 20-30% of small bowel tumors and 2% of all GI tumors. What makes this case so unique is the presentation of bleeding which is extremely uncommon in SBCs. In fact, without bleeding, the tumor may not have been discovered. Sparse case reports have documented bleeding, but those patients typically have numerous lesions, as opposed to our patient who had one isolated mass. Furthermore, due to physical limitations of traditional endoscopy, capsule endoscopy is pivotal in isolating small intestinal tumors, as demonstrated in our patient's case. Incidence of GI carcinoid, specifically of the small bowel, has risen over the last few decades likely from increased use of endoscopy, and should be carefully considered as a differential diagnosis for abdominal pain and occult GI bleeding.© The American College of Gastroenterology 2016. All Rights Reserved.