Jejunal tumor complicated by perforation: clinical case

Abstract

Background. The tumors of the small intestine are rare; they represent only 1-5% of the total gastrointestinal neoplasms and have a large histopathological variety. In the early stages they have modest and non-specific symptoms. Despite the recent technological advances, these pathological conditions remain the “poor relative” of imaging explorations, which are often inconclusive. As a consequence, the diagnosis is usually late, in the stage of severe evolutionary complications, such as a bleeding, obstruction or, less often, perforation. Case report. Patient P, a 78-year-old woman, was admitted urgently at the Department of General Surgery, Municipal Hospital nr.1, with diffuse abdominal pain that appeared suddenly, nausea and marked weakness. The abdominal pain had appeared about 6 hours ago, initially located periumbilical, followed by a tendency to extend throughout the whole abdomen. Patient had the 3-month history of diffuse non-Hodgkin's lymphoma with the big cell “B”. Physical examination revealed a supple abdomen, which does not participate in respiratory movements, spontaneous diffuse pain and muscular tenderness during palpation, with the maximum intensity around umbilicus. Laboratory tests had shown a normal range of leukocytes – 8.2x109/mm3, but with marked shift to the left (immature forms – 31%). Chest and abdominal radiograph were non-diagnostic. She underwent emergency surgery, started by diagnostic laparoscopy, and followed by conversion to median laparotomy, due to diffuse fibrinous peritonitis, probably caused by perforation of hollow viscus. Intraoperatively the induration and perforation of jejunum with a diameter of 0.8 cm with leakage of intestinal contents into peritoneal cavity was found. Segmental resection of the perforated jejunum with enteroenterostomy with lavage and drainage of the peritoneal cavity was performed. Initial postoperative diagnosis was as follows: Idiopathic perforation of the jejunum complicated by diffuse serous-fibrinous peritonitis. However, postoperative histopathological study of resected specimen suggested the malignant tumor (appearance similar to neuroendocrine carcinoma or a form of extranodal lymphoma). Uneventful postoperative evolution.Conclusions. The tumors of the small intestine are rare and have a modest and non-specific symptomatology, as well as obscure imaging presentation. Usually they are diagnosed as accidental intraoperative findings, or in advanced stages of disease, when acute complications occur.