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Indian Journal of Medical Sciences, Vol. 60, No. 11, November, 2006, pp. 467-470 Case Report Gastric adenocarcinoma presenting with intestinal pseudoobstruction, successfully treated with octreotide Sharma Sanjay, Ghoshal UdayC, Bhat Ganesh, Choudhuri Gourdas Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Code Number: ms0609 Abstract 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 scleroderma-associated intestinal pseudoobstruction. We report a 65-year-old man with carcinoma stomach presenting with intestinal pseudoobstruction, which responded to octreotide. Keywords: Gastric tumor, intestinal obstruction, somatostatin analogue, treatment Intestinal pseudoobstruction (IPO) is a symptom complex of ineffective intestinal propulsion due to absent or reduced intestinal peristalsis in absence of mechanical obstruction.[1] Though it can be primary, more often it is secondary to a wide variety of causes, including malignant tumors.[2] It is thought to result from paraneoplastic neuropathy or myopathy. Octreotide, a somatostatin analogue, has been used successfully in the treatment of idiopathic and scleroderma-associated IPO.[3] Octreotide stimulates migratory motor complex, which is known to be absent in IPO.[4],[5] We report on an unusual patient with gastric adenocarcinoma with IPO that responded to octreotide. Case report A 65-year-old man presented in September 2004 with dysphagia, predominantly to solids; epigastric discomfort for 15 days; he had malena 15 days ago for 4 days. He had diffuse distension of abdomen and obstipation for 4 days before presentation. He complained of anorexia of 15 days' duration. He denied 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 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 x 109/L (normal 4-11 x 109/L); neutrophils, 90%; lymphocytes, 6%; eosinophils, 1%; monocytes, 4%; platelets, 212 x 109 /L (normal > 1 x 109 /L); prothrombin time, 13.0 s (control 12.3); bilirubin, 12.5 µmol/L (normal 2-18 mmol/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 mmol/L (normal 2.2-2.6 mmol/L); creatinine, 84 mmol/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 aorta [Figure - 2]. The lesion was unresectable. With a diagnosis of IPO and unresectable gastric adenocarcinoma, the patient was treated with intravenous fluids, 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. 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 retroperitoneal 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] This report describes a patient with IPO associated with carcinoma stomach encroaching gastroesophageal junction. 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 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 neuroendocrine 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. References
Copyright 2006 - Indian Journal of Medical Sciences The following images related to this document are available:Photo images[ms06069f2.jpg] [ms06069f1.jpg] |
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