Published online Mar 26, 2023. doi: 10.12998/wjcc.v11.i9.2021
Peer-review started: November 14, 2022
First decision: January 12, 2023
Revised: January 25, 2023
Accepted: March 3, 2023
Article in press: March 3, 2023
Published online: March 26, 2023
Small bowel adenocarcinomas (SBA) are rare malignancies with exceedingly low survival rates, with different presentation in Crohn’s disease (CD). CD-induced SBA poses diagnostic challenges given overlapping presentation with stricturing CD and lack of diagnostics for early detection. Moreover, guidance is lacking on the impact of recently approved therapeutics in CD on SBA management. Here, we aim to highlight the future of CD-induced SBA management and discuss the potential merit of balloon enteroscopy and genetic testing for earlier detection.
We report the case of a 60-year-old female with longstanding Crohn’s ileitis, presenting with acute obstructive symptoms attributed to stricturing phenotype. Her obstructive symptoms were refractory to intravenous (IV) steroids, with further investigation via computed tomography enterography not providing additional diagnostic yield. Ultimately, surgical resection revealed SBA in the neoterminal ileum, with oncologic therapy plan created. However, this therapy plan could not be initiated due to continued obstructive symptoms attributed to active CD. Ultimately, infused biologic therapy was initiated, but her obstructive symptoms continued to remain dependent on IV corticosteroids. Review of diagnostics by a multidisciplinary care team suggested metastatic disease in the peritoneum, lending to a shift in the goals of care to comfort.
With the diagnostic and therapeutic challenges of concurrent SBA and CD, multidisciplinary care and algorithmic management can optimize outcomes.
Core Tip: The prognosis of Crohn’s disease-induced small bowel adenocarcinomas (SBA) depends largely on staging at diagnosis, with early detection resulting in potentially improved outcomes. A multidisciplinary approach with gastroenterology, colorectal surgery, and radiology is key to this early diagnosis. Initially, a thorough family history can aid in decision-making with earlier intervention in those with stricturing phenotype and suggestion of higher colorectal cancer risk or syndrome. If imaging shows atypical features such as a mass, retrograde balloon enteroscopy should not be delayed. Finally, when surgical resection is considered in strictures refractory to medical therapy, lymph node sampling can aid in surgical staging of the SBA.