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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 40  |  Issue : 1  |  Page : 30-33

Intractable small-bowel obstruction due to urothelial cell carcinoma metastasis to the distal ileum: A rare cause of malignant bowel obstruction


1 Department of Internal Medicine, Division of Gastroenterology and Hepatology, Taichung Armed Forces General Hospital, Taichung; Department of Internal Medicine, Division of Gastroenterology and Hepatology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
2 Department of Internal Medicine, Division of Gastroenterology and Hepatology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
3 Department of Surgery, Division of General Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
4 Department of Pathology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan

Date of Submission19-Feb-2019
Date of Decision26-Jun-2019
Date of Acceptance22-Aug-2019
Date of Web Publication04-Oct-2019

Correspondence Address:
Dr. Hsuan-Hwai Lin
Department of Internal Medicine, Division of Gastroenterology and Hepatology, National Defense Medical Center, Tri.Service General Hospital, No. 325, Section 2, Cheng-Gong Road, Neihu District, Taipei City 114
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_32_19

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  Abstract 


Most patients with partial intestinal obstruction can be managed without surgical intervention. Here, we report the case of a patient who presented with partial intestinal obstruction. He had been diagnosed with high-grade urothelial cell carcinoma (UCC) 1.5 years previously, for which the surgery and adjuvant chemotherapy had been successfully performed. He showed a poor response to medical treatment for the partial intestinal obstruction, and surgery provided only a short-term benefit. Such cases of intractable small-bowel obstruction are infrequent and pose a challenge to clinicians. Although very rare, the possibility of UCC metastasis to the gastrointestinal tract should be considered in the differential diagnosis of refractory intestinal obstruction and history of UCC.

Keywords: Malignant bowel obstruction, small-bowel obstruction, urothelial cell carcinoma


How to cite this article:
Tseng YC, Lin HH, Huang SH, Wen LW. Intractable small-bowel obstruction due to urothelial cell carcinoma metastasis to the distal ileum: A rare cause of malignant bowel obstruction. J Med Sci 2020;40:30-3

How to cite this URL:
Tseng YC, Lin HH, Huang SH, Wen LW. Intractable small-bowel obstruction due to urothelial cell carcinoma metastasis to the distal ileum: A rare cause of malignant bowel obstruction. J Med Sci [serial online] 2020 [cited 2020 Feb 23];40:30-3. Available from: http://www.jmedscindmc.com/text.asp?2020/40/1/30/268570




  Introduction Top


The leading cause of small-bowel obstruction (SBO) is postsurgical intervention-related intraperitoneal adhesion.[1],[2] Inflammatory and malignancy diseases are rarely associated with SBO, with malignant bowel obstruction accounting for <10% of cases.[1] In most such cases, the small intestine is obstructed by extrinsic compression or local invasion of advanced gynecologic or gastrointestinal malignancies.[1],[3]

The initial management of SBO comprises nothing by mouth, fluid resuscitation, placement of a nasogastric (NG) tube for decompression, and administration of analgesia or antiemetic, depending on the clinical condition. Symptoms in most patients resolve within 3 days after nonoperative treatment. A previous study reported successful symptoms resolution without peritonitis in 65%–81% of cases with nonoperative management of partial intestinal obstruction.[4]

Herein, we report one case of a patient who experienced recurrent partial SBO caused by metastatic urothelial cell carcinoma (UCC) to the distal ileum complicated with bowel paralysis. Such cases of partial SBO are very rare and difficult to manage.


  Case Report Top


A 71-year-old male presented with abdominal pain for days, with no passage of stool for about 1 week. Tympanic sounds could be heard on percussion of the abdomen, and there were no signs of peritonitis. An abdominal plain radiograph revealed intestinal obstruction [Figure 1]a.
Figure 1: (a) Abdominal plain radiograph before admission. Fecal material retention along the length of the colon is seen, with continuous bowel loop dilatation, indicating an intestinal obstruction. (b) Abdominal plain radiograph after gastrografin administration for 24 h. Continuous bowel loop dilatation with a stack of coins' sign (arrows) is observed at the proximal jejunum, indicating an intestinal obstruction

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The patient had been diagnosed with UCC of the left ureter 1.5 years previously, which presented as painless gross hematuria. Hand-assisted retroperitoneoscopic nephroureterectomy with excision of the bladder cuff and left pelvic lymph node dissection had been performed. The pathologic diagnosis was found to be high-grade UCC, pT3N1M0, and Stage IV. The tumor had been found to invade the periureteric fat, the cut end of the ureter, and the paraexternal iliac lymph nodes. Lymphovascular space invasion (LVSI) had also been noted. Postoperative adjuvant chemotherapy with carboplatin/gemcitabine had been administered, and up to this presentation, follow-up with abdominal magnetic resonance imaging and cystoscopy had not shown any evidence of a recurrent lesion.

The patient's symptoms improved with fasting and NG tube insertion with decompression, but an abdominal plain radiograph still showed a stack of coins' sign [Figure 1]b. Due to the poor response to medical treatment for 19 days, the patient received surgery to relieve the obstruction.

During the operation, no peritoneal carcinomatosis was noted, but a distended small intestine [Figure 2]a and one tumor-like lesion at the distal ileum which near the previous surgical area [Figure 2]b were noted. There was involvement of paraexternal iliac lymph nodes. The tumor-like lesion was resected, and immunohistochemical staining confirmed the expression of UCC-specific markers [Figure 2]c and d]. UCC metastasis to the distal ileum was confirmed, and palliative chemotherapy with paclitaxel was administered. However, the patient died 5 months after the diagnosis of metastatic UCC complicated with refractory SBO.
Figure 2: (a and b) Exploratory laparoscopy with lysis of the adhesion and segmental resection of the small intestine. Severe distension of the ileum and jejunum (a). The tumor is seen invading the distal ileum (30 cm distal to the ileocecal valve) (b). (c and d) Pathological findings of the resected small intestinal tissue. Immunohistochemical staining showed that the small intestinal tissue was positive for cytokeratin 7 (c) and cytokeratin 20 and weakly positive for uroplakin (d)

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  Discussion Top


Transitional cell carcinoma, more correctly known as UCC, is the most common type of bladder cancer (>90%) affecting the genitourinary (GU) tract. UCC is typically diagnosed in old male patients, with incidence peaks in the sixth and seventh decades of life.[5] UCC is associated with the highest recurrence rate and multiplicity among cancers. High-grade UCC refers to a high level of genetic instability, with similar biological properties to those of invasive UCCs and a higher risk of recurrence and progression.[6] During the later stages of this disease, tumors may metastasize to the common iliac chain and paraaortic lymph nodes, which are reflected as distant metastasis. When UCC metastasis to the GU tract occurs through the hematogeneous route, the lung, bones, liver, and adrenal glands are most commonly affected.[5] In the present case, the patient had high-grade UCC with regional lymph node invasion and LVSI, and hence, the risk of recurrence or distant metastasis was very high. Disease progression with common iliac chain invasion and distal ileum metastasis was likely the cause of the recurrent SBO.

UCC with distant metastasis to the gastrointestinal tract is very rare. Ten cases of UCC with small intestinal metastasis in Asia have been reported [Table 1].[7] Nine patients were male and one was female, aged between 60 and 80 years. Four patients, including the one reported here, had primary lesions in the ureter and had undergone nephroureterectomy. In our case, the patient presented with SBO caused by small intestinal metastasis of UCC, 1.5 year after he was diagnosed with high-grade UCC. Although postsurgical adhesion is the most common cause of intestinal obstruction, malignant bowel obstruction should also be considered in the differential diagnosis if the patient has a history of cancer.
Table 1: Metastatic small intestinal tumor of the urothelial cell carcinoma cases[7]

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Malignant SBO (MSBO) is a harrowing complication of cancer disease which denotes a poor prognosis and poor life quality of patients. However, how to improve patient's quality of life, relieve abdominal symptoms, and adequate nutrition support need to be considered. Hu and Yureported that the use of small-bowel decompression tubes can ameliorate nutritional status, relieve symptoms, and decrease complications in patients with MSBO.[8] Jiang et al. stated that percutaneous needle decompression can be useful for the palliative treatment of MSBO.[9] On the other hand, Prost À la Denise et al. suggested that surgical intervention must be considered quickly after the failure of medical management of SBO. The authors found that less than half of the patients with a previous history of cancer whose SBO belonged to the malignant cause. They reported some meaningful predictors of a MSBO including: (I) incomplete obstruction, (II) acute onset, (III) temporary abdominal pain, (IV) a shorted time between primary cancer surgery and the first episode of obstruction, and (V) a known cancer recurrence.[10] In our patient, he presented with sudden onset, partial intestinal obstruction, and intermittent abdominal pain. These factors were maybe the hint of MSBO. A more conservative treatment may consider rather than surgery.


  Conclusion Top


We describe a case of intractable SBO due to UCC with distal ileum metastasis, which was complicated with intestinal paralysis. Although very rare, the possibility of UCC metastasis to the gastrointestinal tract should be considered in the differential diagnosis of refractory intestinal obstruction and who had a history of UCC. Rigorously, history taking, physical examination, and image study can let clinicians figure out significant risk factors for SBO and help make decision to treatment direction.

Patient consent

The authors certify that appropriate patient consent was obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Miller G, Boman J, Shrier I, Gordon PH. Etiology of small bowel obstruction. Am J Surg 2000;180:33-6.  Back to cited text no. 1
    
2.
Abbas S, Bissett IP, Parry BR. Oral water soluble contrast for the management of adhesive small bowel obstruction. Cochrane Database Syst Rev 2007;18:CD004651.  Back to cited text no. 2
    
3.
Miller G, Boman J, Shrier I, Gordon PH. Small-bowel obstruction secondary to malignant disease: An 11-year audit. Can J Surg 2000;43:353-8.  Back to cited text no. 3
    
4.
Diaz JJ Jr., Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma 2008;64:1651-64.  Back to cited text no. 4
    
5.
Vikram R, Sandler CM, Ng CS. Imaging and staging of transitional cell carcinoma: Part 1, lower urinary tract. AJR Am J Roentgenol 2009;192:1481-7.  Back to cited text no. 5
    
6.
Montironi R, Lopez-Beltran A. The 2004 WHO classification of bladder tumors: A summary and commentary. Int J Surg Pathol 2005;13:143-53.  Back to cited text no. 6
    
7.
Hoshi A, Tokunaga M, Usui Y, Yamashita H, Sasaki H, Kobayashi Y, et al. Metastatic small intestinal tumor associated with transitional cell carcinoma: A report of 2 cases and review of cases in Japan. Hinyokika Kiyo 2005;51:41-4.  Back to cited text no. 7
    
8.
Hu LJ, Yu SY. Management of malignant bowel obstruction with decompression tubes. Eur Rev Med Pharmacol Sci 2014;18:2798-802.  Back to cited text no. 8
    
9.
Jiang TH, Sun XJ, Chen Y, Cheng HQ, Fang SM, Jiang HS, et al. Percutaneous needle decompression in treatment of malignant small bowel obstruction. World J Gastroenterol 2015;21:2467-74.  Back to cited text no. 9
    
10.
Prost À la Denise J, Douard R, Malamut G, Mecheri F, Wind P. Small bowel obstruction in patients with a prior history of cancer: Predictive findings of malignant origins. World J Surg 2014;38:363-9.  Back to cited text no. 10
    


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