Adenocarcinoma of an Ileostomy in a Case of Hirschprung’s Disease with Retroviral Disease
A 55-year old male patient of Indian origin presented to the Emergency Department with complaints of decreased stoma output, abdominal pain, distension and vomiting for two days. He had a history of Hirschprung’s disease for which he underwent a pull-through procedure at Day 10 of life along with a temporary transverse colostomy. Efforts to close the transverse colostomy at ten years of age failed as the patient developed bowel obstruction and a second temporary loop colostomy was performed. At 25 years of age, the patient underwent right hemicolectomy with an end ileostomy as second surgery since closure of loop colostomy was not possible because of the patient’s case hisotry. No medical records of previous surgical interventions were available.\nThe patient was positive for retroviral infection and had been on retroviral therapy for the past seven years. His CD4 count was 490. Abdominal x-ray was suggestive of small bowel obstruction with multiple air fluid levels which was managed conservatively. Digital rectal examination showed a stricture in the rectum. On abdominal examination, there was a proliferative growth involving the mucocutaneous junction of the ileostomy site (). However, no regional lymphadenopathy was seen on clinical examination. The sprout of the ileostomy site was thickened. Biopsy from the lesion was suggestive of adenocarcinoma. Computed tomography of the abdomen did not reveal metastasis to pelvic lymph nodes (). Levels of the tumor markers carcinoembryonic antigen (CEA) and alpha feto protein were normal. The patient underwent en bloc wide local excision of the ileostomy along with the adjacent anterior abdominal wall with a 3 cm margin () and re-siting of the ileostomy. On pathological examination, grossly the tumor measured 3x2.5x2 cm and on microscopic examination moderately differentiated adenocarcinoma was seen (). Margins were tumor free. The patient did not receive any adjuvant therapy and is asymptomatic after one year of follow up.