Solitary metastatic malignant stricture of the ileum : a rare cause of small bowel obstruction (a case report).
Small bowel obstruction due to metastatic neoplastic stricture is uncommon and mostly occurs as a part of generalised carcinomatosis., Rarely however, it selectively affects the small bowel in the form of an isolated metastatic stricture. We report below such a case of an isolated metastatic stricture of the terminal ileum.
A 35 year old female presented with symptoms of colicy pain in the central abdomen, persistent vomiting and constipation of 15 days' duration. In addition, she also gave history of bleeding per vaginum. The general physical examination of the patient revealed severe dehydration, tachycardia and palor. No lymphadenopathy was detected.
Abdominal examination showed central abdominal distension and ladder pattern peristalsis. There was no organomegaly or free fluid in the peritoneal cavity. Bowel sounds were exaggerated.
The per vaginal examination revealed a hard fixed nodular growth of the cervix which bled or. touch suggestive of malignancy.
Except for anaemia, the haemogram and urine analysis did not show any abnormalities. Plain skiagram of the abdomen in standing position showed multiple air fluid levels. Skiagram of the chest was normal.
On exploration, she was found to have an impassable single stricture in the terminal ileum about 5 cm proximal to the ileo-caecal junction with a hard nodule on the serosal aspect. The bowel proximal to the stricture was dilated. Mesenteric and para-aortic lymph nodes were hard and enlarged. There was no evidence of visceral metastasis, peritoneal seedlings or ascites. A right hemicolectomy with end-to-end ileotransverse anastomosis was performed. A biopsy was taken from the cervical growth also. Postoperatively, the patient made an uneventful recovery.
Histopathological examination of the ileal stricture [Fig. 1] revealed it to be a metastatic squamous cell carcinoma and the one from cervix showed moderately differentiated squamous cell carcinoma. Lymph nodes from the mesentery of resected bowel did not show any evidence of metastasis.
Secondary involvement of the small intestine in the malignant disease is rare and seen almost always as a part of the generalised spread with multiple seedlings in the peritoneal cavity and frequently with ascites. Rarely, the secondary tumour of the ileum may be a solitary nodule. DeCastro et al, in 1957, reported 26 cases of solitary metastasic nodules of the small bowel. Farmer and Hawk found only 14 cases of discrete lesions of the small bowel in a series of 87 metastasic carcinoma patients.
The metastasis may come (in the order of frequency) from primary carcinoma of the cervix uteri, cutaneous melanoma, other parts of the gastro-intestinal tract (stomach, colon), and kidney.,, In the present case, the metastasis was from a moderately differentiated squamous cell carcinoma of the cerviy. Hendrikson quoted ileal involvement in 3.2%, of untreated and 1.2% of treated fatal cases of carcinoma cervix.
The route of metastasis to the ileum depends upon the site of the primary lesion., When the primary is in the abdomen or pelvis, the ileal involvement may occur via one of the following routes:
1. Retrograde lymphatic spread following initial blockade of paraaortic or mediastinal lymph nodes.
2. Peritoneal seedlings.
3. Direct extension by continuity or by permeation of the lymphatic spaces in the connective tissues.
In the present case, a retrograde lymphatic flow appeared to be the most likely route of metastasis due to the following reasons:
(i) Absence of any peritoneal seedlings including the pelvic floor.
(ii) Absence of direct extension of cervical growth to the site of metastasis in the terminal ileum.
(iii) Presence of metastasis to the paraaortic lymph nodes.
In the present case, the lesion was in the form of an annular stricture with mucosal ulceration.
The most common presenting clinical picture of the metastasic small bowel tumour is that of partial or complete small bowel obstruction,, as seen in the present case also. Less often, the patient may present with perforation of the bowel or haemorrhage from the lesion. Diagnosis of intestinal obstruction due to a metastasis should be suspected if, in addition, there are symptoms pertaining to a primary lesion or if the patient gives a history of having received treatment for a primary malignancy in the past.
Treatment is essentially in the form of either a palliative intestinal resection or a bypass surgery to relieve intestinal obstruction as done in the present case. The prognosis is better than the cases where ileal involvement occurs as a part of generalised carcinomatosis.