Jejunal Adenocarcinoma

Extremely rare place to be affected with adenocarcinoma, nevertheless it is possible. Small bowel is rarely affected by cancer, possibly due high mobility and peristaltic movement of the gut which propels any potential carcinogen forward.( Chandrasoma and Taylor)

Jejunal adenocarcinoma frequently presents with a gastritis like symptoms: upper abdominal pain, vomitting, food intolerance and abdominal distension. Taken together with its statistics, nobody would have thought about jejunal adenocarcinoma at its initial presentation.

A section of the jejunum showing a fungating mass measuring 4cmX3cm in the wall of jejunum. Biopsy reveals jejunal adenocarcinoma.( Lee and Polger: Jejunal Ca with metastasis to Liver)

The symptoms will progress to those of intestinal obstruction, such as billious projectile vomiting, severe abdominal distension, colicky abdominal pain and constant belching. Lost of weight and appettite which is present at this time is attributed to the obstruction, not to what obstruct it. At this point, surgeons will come into play and still, jejunal adenocarcinoma will be low in the list of differentials. Among the differentials are Colon adenocarcinoma(far more common), Gastric Ca, gallstones and jejunal volvulus.

Various imaging methods will be commenced. Unfortunately at early stage nothing much can be seen. At later stage, there may be metastatic lesions to the liver, reproductive organs and peritoneum. OGDS and Colonoscope detects nothing (do you wonder why?)
An upper GI series with small bowel follow-through was also performed in 1988 prior to the patient's surgery. This showed a 6 cm ulcerating and nodular mass in the proximal jejunum just distal to the ligament of Trietz (Lee and Polger: Jejunal Ca with metastasis to the liver)

Only at laparatomy can the biopsy and definitive diagnosis be made. At this point of time, the tumor might have caused adhesion among the loops of the small bowel, it might have spread to mesenteric nodes and even to the peritoneum and ovaries.

Biopsy of a part of the jejunal showing malignant gland-forming cells in the submucosa of the wall of the jejunum. Nucleus is darkly stained and cells are pleomorphic. (Ajay H Bhandarwar, Shivkumar S Utture, Sunderraj Ellur, Tanuj Shrivastava : Adenocarcinoma of the Jejunum Presenting with Intestinal Obstruction)

Chemotherapy will be commenced post-surgery. There is no specific chemo treatment for jejunal adenocarcinoma because it is so rare. Treatment for colon cancer is extrapolated to treat jejunal adenocarcinoma. One case report states that "the role of chemotherapy and radiotherapy in small bowel adenocarcinoma is not clearly defined"(Ajay H Bhandarwar, Shivkumar S Utture, Sunderraj Ellur, Tanuj Shrivastava: Adenocarcinoma of the Jejunum Presenting with Intestinal Obstruction)

Screening for jejunal adenocarcinoma is difficult. A case report suggest that Barium contrast studies have an accuracy of 83%. However, the method of choice suggested is Enteroclysis.

When the cancer is terminal, please warn the patients that there will be "magic" people out there who claim to be able to cure this disease. Money will be spent, only for the patient's condition to deteriorate.

The moral of the story is, although a disease is rare, please do not exclude it. As 1 of my Professor told me last time, "in practicing the art of medicine, never say never".