Recurrent small bowel obstruction in a 60-year-old celiac patient: a rare entity of a common disease
A 60-year-old woman was referred to our gastroenterology clinic for evaluation of two episodes of abdominal pain and distention that started 3 months prior to her first presentation. Her abdominal pain was colicky, originated in the left lower quadrant and was followed by vomiting and abdominal distention. Each episode lasted for approximately 2 weeks and resolved spontaneously.\nHer past medical history consisted of celiac disease, diagnosed at the age of 10 years, and anxiety. Her medical treatment contained citalopram and tibolone. The patient did not follow a strict gluten-free diet. Her father died at the age of 60 due to colon cancer.\nThe patient was examined in the emergency department during the second episode. Her physical examination demonstrated left abdominal tenderness without peritoneal signs. Her white blood count was 12.05 K/mcL (4-10.8), with a left shift (absolute neutrophils count of 8.72 K/mcL, normal: 1.8-7.7) and her hemoglobin level was 14.5 g/dL (11.7-15.7). Blood chemistry results were unremarkable, and C-reactive protein level was 8.9 mg/L (normal range 0-5). A computed tomography scan of the abdomen demonstrated dilatation of several small bowel loops, up to 41 mm (). The patient was treated conservatively with gradual resolution of her complaints. After she was referred for our consultation, the patient underwent upper and lower endoscopies, which were normal. Biopsies from the proximal small bowel, taken to diagnose the activity of celiac disease, demonstrated partial shortening of the villi with increased number of intraepithelial lymphocytes, compatible with grade 3 Marsh classification. Anti-endomysial antibody was positive. We decided to further evaluate the small bowel by a video capsule. A single large ulceration, with partial occlusion of the lumen in the middle of the small bowel was demonstrated. Antegrade and retrograde double-balloon enteroscopies failed to reach the desired region, and the patient was sent for laparotomy. A firm lesion was palpated in the proximal ileum. The lesion was excised, and pathology revealed ulcerated, well to moderately differentiated adenocarcinoma invading the entire thickness of the small bowel wall into the mesentery. Surgical margins were free of tumor cells, and regional nodes were not involved. The tumor was classified as pT3, N0, Mx. The patient was prescribed capecitabine for 6 months. After one year the patient is free of any symptoms or evidence of recurrence.