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CASE REPORT GASTRIC ADENOCARCINOMA PRESENTING WITH INTESTINAL PSEUDOOBSTRUCTION, SUCCESSFULLY TREATED WITH OCTREOTIDE SANJAY SHARMA, UDAY C. GHOSHAL, GANESH BHAT, GOURDAS CHOUDHURI
ABSTRACT
m rf o d s a o tion l n a w o blic d Key words: Gastric tumor, intestinal obstruction, somatostatin analogue, treatment e Pu ). e r w m f r o owith IPO that responded to adenocarcinoma Intestinal pseudoobstruction (IPO) is a o n .c f octreotide. symptom complex of ineffective intestinal k e l ed ow propulsion due to absent or reduced intestinal b n peristalsis in absence of mechanical a MCASEkREPORT l i obstruction. Though it can be primary, a moreby ed v often it is secondary to a wide a varietyd of mA 65-year-old man presented in September causes, including malignantistumors.e It is . 2004 with dysphagia, predominantly to solids; t w epigastric discomfort for 15 days; he had thought to result fromF paraneoplastic s o wwa malena 15 days ago for 4 days. He had neuropathy or myopathy. Octreotide, D h ( P thas somatostatin analogue, been used diffuse distension of abdomen and obstipation e s i i successfully in the treatment idiopathic for 4 days before presentation. He complained s IPO.of Octreotide h and scleroderma-associated of anorexia of 15 days’ duration. He denied T a Intestinal pseudoobstruction has been reported as a paraneoplastic manifestation of several cancers, including those of gastrointestinal tract. Octreotide, a somatostatin analogue, has been used successfully in the treatment of idiopathic and sclerodermaassociated intestinal pseudoobstruction. We report a 65-year-old man with carcinoma stomach presenting with intestinal pseudoobstruction, which responded to octreotide.
[1]
[2]
[3]
stimulates migratory motor complex, which is known to be absent in IPO.[4,5] We report on an unusual patient with gastric Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India Correspondence U. C. Ghoshal, Dept. of Gastroenterology, SGPGI, Lucknow - 226 014, India. E-mail:
[email protected]
having pain on swallowing and had no hematemesis, jaundice or loss of weight. There was no history of dyspepsia. He denied family history of gastric malignancy. He had been suffering from non-insulin dependent diabetes mellitus (NIDDM) for 5 years, which was well controlled on dietary restrictions alone. There was no evidence of target organ damage secondary to NIDDM. Examination Indian J Med Sci, Vol. 60, No. 11, November 2006
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GASTRIC ADENOCARCINOMA PRESENTING WITH INTESTINAL PSEUDOOBSTRUCTION
revealed pallor but no icterus or pedal edema. Abdominal examination revealed distended abdomen with absent bowel sounds and without any palpable lump or organomegaly. Investigations revealed hemoglobin, 86 g/ L (normal 110-140 g/L); total leukocyte count, 14.2 × 10 9/L (normal 4-11 × 109 /L); neutrophils, 90%; lymphocytes, 6%; eosinophils, 1%; monocytes, 4%; platelets, 212 × 10 9 /L (normal > 1 × 10 9 /L); prothrombin time, 13.0 s (control 12.3); bilirubin, 12.5 µmol/L (normal 2-18 µmol/L); alanine and aspartate aminotransferase, 87 and 99 IU/L respectively (normal up to 40 IU/L); alkaline phosphatase, 137 IU/L (normal 80-160 IU/L); and serum protein and albumin, 68 and 31 g/L (normal 60-84 and 35-55 gm/L) respectively; serum calcium, 2.4 µmol/L (normal 2.2-2.6 µmol/L); creatinine, 84 µmol/L (50-110); fasting and 2-h post-lunch blood sugar, 6.1 mEq/L and 9.3 mEq/L respectively; serum potassium and sodium, 4.2 mEq/L and 136 mEq/L respectively. Abdominal X-ray revealed dilated small and large bowel loops with gas in rectum and irregular filling defect in fundal gas shadow [Figure 1] and multiple fluid levels on erect skiagram. Upper gastrointestinal endoscopy revealed a friable, ulceroproliferative nodular growth in fundus and cardia of the stomach, infiltrating gastroesophageal junction. Biopsy showed gastric adenocarcinoma. Contrast-enhanced computerized tomographic scan of abdomen showed growth in proximal stomach, with multiple lymph nodes in hepatoduodenal ligament and loss of vascular planes between mass and aor ta [Figure 2]. The lesion w as
m rf o d s a o tion l n a w c do ubli e rf e w P m). r fo kno .co le ed ow b la M dkn i a by e v a si ted w.m F os w D P te h (w unresectable. With a diagnosis of IPO and is si h unresectable gastric adenocarcinoma, the T a patient was treated with intravenous fluids, Figure 1: Supine abdominal X-ray with dilated small and large bowel loops with gas in rectum and irregular filling defect in fundal gas shadow
Figure 2: Contrast-enhanced computerized tomographic scan of abdomen showing growth in proximal stomach with multiple lymph nodes in hepatoduodenal ligament
nothing per mouth and subcutaneous octreotide (50 µg three times a day for 1 week). IPO resolved, as documented by disappearance of abdominal distension, passage of flatus and feces, appearance of normal bowel sounds and radiological improvement. Patient started taking normal diet without any deterioration.
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DISCUSSION IPO was described first in Ogilvie in 1948 in severely ill hospitalized patients. Chronic IPO is often associated with a wide variety of conditions, including visceral myopathy and neuropathy, metabolic diseases, cerebral disorders, infections, collagen disease and drugs. Many authors reported an association of IPO with underlying neoplasm, such as small cell carcinoma of lung; carcinoma of pancreas, esophagus, gallbladder; cholangiocarcinoma; carcinoid and retroper itoneal sarcoma. [3,6] The suggested mechanism leading to paraneoplastic pseudoobstruction includes muscular or neuronal disruption by tumor, ‘auto vagotomy’ secondary to micrometastasis and possible autoimmune phenomenon resulting from cross reaction between tumor antigens and myenteric neuronal cells.[6,7] Octreotide, a long-acting somatostatin analogue, has been shown in many case reports and small case series to improve IPO and mechanical obstruction associated with inoperable neoplasm by reducing secretions and increasing phase III of migrating motor complex in intestine.[4,8]
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a strong stimulant of migratory motor complex of small intestine. However, octreotide is also known to affect neuroendocrine tumors and some adenocarcinomas of the stomach may have neuroendocr ine differentiation . We cannot comment on the role of such neuroendocrine differentiation in causation of IPO or effect of octreotide on it as immunohistochemistry of tumor was not done for this purpose.
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GASTRIC ADENOCARCINOMA PRESENTING WITH INTESTINAL PSEUDOOBSTRUCTION
1991:100:137-42. 8. Sorhaug S, Steinshamn SL, Waldum HL. Octreotide treatment for paraneoplastic intestinal pseudoobstruction complicating SCLC. Lung Cancer 2005;48:137-40. 9. Iwahasi N, Tame E, Nagasaka T, Furuta M, Nagashima H, Nirmura Y. Massive hemorrhage and
pseudoobstruction of small intestine caused by primary AL amyloidosis associated with gastric cancer : A repor t of a case. Surg Today 2004;34:871-4.
Source of Support: Nil, Conflict of Interest: None declared.
m rf o d s a o tion l n a w c do ubli e rf e w P m). r fo kno .co le ed ow b la M dkn i a by e v a si ted w.m F os w D P te h (w This repor t descr isibes asipatient with IPO h associated with carcinoma stomach a T encroaching gastroesophageal junction.
m rf o d s a o tion l n a w c do ubli e rf e w P m). r fo kno .co le ed ow b Author Help: Online Submission ofathe Manuscriptsn il y M dk For online submission articles should be Articles can be submitted online from a http://www.journalonweb.com. varticle file).b Images eshould be submitted separately. prepared in two files (first page file and a d .m 1) First Page File: s e i t acknowledgement, w etc., using a word processor program. All information Prepare the title page, covering letter, s w which can reveal yourF identity should be here. o w Use text/rtf/doc/pdf files. Do not zip the files. D 2) Article file: h ( The main text ofPthe article, beginning from Abstract till References (including tables) should be in this file. e t Do not include is any information si (such as acknowledgement, your names in page headers, etc.) in this file. h Use text/rtf/doc/pdf files. Do not zip the files. Limit the file size to 400 kb. Do not incorporate images in the file. If T file size isa large, graphs can be submitted as images separately without incorporating them in the
Although IPO has been described in association with neoplasms of gastrointestinal tract, association with carcinoma stomach has been rarely reported.[9] This report also confirms previous findings that octreotide improves paraneoplastic IPO. Octreotide is known to be
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REFERENCES
1. Faulk DL, Anuras S, Christensen J. Chronic intestinal pseudoobstruction. Gastroenterology 1978;74:922-31. 2. Ghoshal UC, Sachdeva S, Sharma A, Gupta D, Misra A. Cholangiocarcinoma presenting with severe gastroparesis: A case report. Indian J Gastroenterol 2005;24:167-8. 3. Verne GN, Earker EY, Hardy E, Snisky CA. Effect of Octreotide and Erythromycin on Idiopathic and scleroderma-associated intestinal pseudoobstruction. Dig Dis Sci 1995;40:1892-901. 4. Haruma K, Wiste JA, Camilleri M. Effect of octreotide on gastrointestinal pressure profiles in health and in functional and organic gastrointestinal disorders. Gut 1994;35:1064-9. 5. Greydanus MP, Camilleri M. Abnormal postcibal antral and small bowel motility due to neuropathy or myopathy in systemic sclerosis. Gastroenterology 1989;96:110-5. 6. Gerl A, Storck M, Schalhorn A, Muller-Hocker J, Jauch KW, Schildberg FW, et al. Paraneoplastic chronic intenstinal pseudoobstruction as a rare complication of bronchial carcinoid. Gut 1992;33:1000-3. 7. Lennon VA, Sas DF, Busk MF, Scheithauer B, Malagelada J R, Camilleri M, et al. Enteric neuronal auto-antibodies in pseudo-obstruction with smallcell lung carcinoma. Gastroenterology
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