MODULE 6: Small
Intestine & Appendix
CASE 4
Presented by:- Group 4B
Section:- MD 3H
Content
General Data
History of Present Illness
Physical Exam
Family History
Primary Impression
Differential Diagnosis
Diagnostic/Work-up
Interpretation of results
Final Impression
Case Discussion
General Data
NAME: NOT GIVEN
AGE: 47 YEARS OLD
GENDER : FEMALE
Chief complaint :melena and abdominal
pain
History of present illness:
4 months prior to admission - intermittent crampy
abdominal pain which was relieved with food intake
1 month prior to admission - complained of intermittent
crampy abdominal pain now associated with episodes
of black tarry stools
easily fatigued and had lost weight
Persistence of symptoms prompted patient to seek
consult.
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Past medical history:
Hypertensive for 1 year – maintenance medication of Losartan with good
compliance
S/P Excision biopsy of Left Breast mass (Fibroadenoma)
Personal and social history:
Occasional alcoholic beverage drinker
Smoker for 2 pack years
History of Metamphetamine use 20 years prior.
Physical Exam
Vital Signs:
* Blood Pressure (BP): 90/60 mmHg
* Heart Rate (HR): 100 beats per minute (tachycardia)
* Respiratory Rate (RR): 20 cycles per minute
* Temperature: 36.7°C
* Oxygen Saturation: 98% on room air
* Height : 5’2”
* Weight : 55kg
HEENT: anicteric sclerae, trachea at midline, no palpable
lymph nodes
C/L: clear breath sounds, equal chest expansion, equal
tactile fremitus
CV: adynamic pericardium, regular rate and rhythm
Abdomen: soft, (+) direct tenderness, RLQ on deep
palpation, (-)Rovsing’s sign, no palpable masses
Extremities: strong peripheral pulses, CRT <2 secs, Full
ROM all extremities
GUT: (-)KPS
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Primary impression
Upper Gastrointestinal bleeding likely from a distal small bowel
lesion (e.g., bleeding ileal polyp or adenoma with possible
malignant transformation)
Basis:
The patient had black tarry stools (melena), pointing to bleeding in the upper or small intestine.
She had crampy abdominal pain for months, relieved by food, suggesting a lesion in the small bowel.
She also experienced fatigue and weight loss, which are signs of chronic blood loss.
On Physical exam, she had low blood pressure and fast heart rate, supporting anemia or volume loss.
Tenderness in the lower right abdomen points to a problem in the distal ileum.
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Differential Diagnosis
DISEASE RULE IN RULE OUT
Weight loss No palpable abdominal mass
Melena No vomiting, overt anorexia, or overt
GASTRIC CARCINOMA Age >40 lymphadenopathy,
Smoking history No overt epigastric
Occasional alcohol use tenderness or fullness
melena,
crampy abdominal pain releive by no history of NSAID or h.pylori,
duodenal ulcer food(classic for duodenal ulcer), no hematemesis(not always present).
occasional alcohol intake.
Differential diagnosis
DISEASE RULE IN RULE OUT
chronic abdominal pain no sign of obstruction
SMALL BOWEL weight loss (vomiting,distention),
NEOPLASM melena requires small bowel
RLQ pain endoscopy.
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Diagnostic/Work-up
Lab
1. CBC - To access any anemia or inflammation
2. Liver and Kidney Function Tests - To assess organ function.
3. Fecal Occult Blood Test (FOBT) - Find any bleeding in the Gl
tract.
4. Tumor Markers (CEA, CA 19-9) - May help monitor cancer.
Diagnostic/Work-up
Diagnostic Tools
1. Endoscopy (EGD) - To find any bleeding or polyp in the ileum.
2. Colonoscopy - To rules out any large bowel causes.
3. CT Scan (Abdomen) - To find any polyp or swollen lymph nodes.
4. Biopsy
5.chest CT-To rule out lung metastatis
6.Capsule Endoscopy - If more small bowel detail or cancer spread is unclear.
Interpretation of Results
1. CBC:
• Hemoglobin 9 g/dL, Hematocrit 32% → Anemia due to chronic GI blood loss (melena).
• WBC 11 → Mild leukocytosis, possibly reactive.
• Platelets normal → No thrombocytopenia.
2. Electrolytes and Renal Function:
• Normal Na, K, Creatinine, and BUN → No renal dysfunction or electrolyte imbalance.
3. Liver Function Tests:
• ALT 50 U/L → Mild elevation; non-specific.
• Albumin 3.5 g/dL, Cholesterol 100 mg/dL → May indicate chronic disease or malnutrition.
• Normal bilirubin and ALP → No liver or biliary obstruction.
Interpretation of Results
4. Fasting Blood Sugar:
• FBS 118 mg/dL → Mildly elevated; possibly prediabetes.
6. Histopathology:
• Villous adenoma with adenocarcinoma invading muscularis propria → Confirms
malignancy (likely T2 stage).
CT Scan:
• 2-cm polyp in distal ileum, no
lymphadenopathy → Identifies lesion
Normal chest x ray
location and suggests no metastasis.
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Final Impression
invasive adenocarcinoma of the
distal ileum
Case Discussion
Defination
SMALL BOWEL ADENOCARCINOMA IS A RARE MALIGNANT
TUMOR ARISING FROM GLANDULAR EPITHELIUM OF THE SMALL
INTESTINE, MOST COMMONLY AFFECTING THE DUODENUM, BUT
MAY ALSO OCCUR IN THE JEJUNUM OR ILEUM.
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Anatomy
THE ILEUM IS THE TERMINAL PORTION OF THE SMAll INTESTINE.
IT CONNECTS TO THE LARGE BOWEL AT THE ILEOCECAL VALVE.
SUPPLIED BY THE SMA; DRAINED BY MESENTERIC VEINS.
LINED BY ABSORPTIVE MUCOSA WITH VILLI; SITE
OFWATER/ELECTROLYTE ABSORPTION
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Pathophysiology
Genetic Mutations (e.g., APC, KRAS) cause uncontrolled epithelial cell growth in
the small intestine, leading to formation of a villous adenoma, aprecancerous
polyp.
Progressive dysplasia develops within the adenoma due to accumulation of
furthermutations (e.g., p53), eventually leading to malignant transformation.
The tumor invades through the muscularis
. propria, classifying it as invasive
adenocarcinoma.
The lesion becomes friable and vascular, resulting in chronic bleeding, which
manifests as melena and iron-deficiency anemia.
Tumor activity and bleeding cause fatigue, weight loss, and abdominal
pain,while cytokine release may contribute to systemic symptoms like anorexia
and cachexia.
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Management
Surgical Resection : Standard of care
Segmental resection of distal ileum with wide
margins + mesenteric lymphadenectomy
Management
Steps:
1. Exploratory Laparotomy or Laparoscopy:
Examine entire small bowel for other lesions.
Assess liver, peritoneum, and nodes for metastasis.
2. Segmental Resection:
Resect the portion of distal ileum containing the tumor, ensuring:
At least 5-10 cm margins on either side.
Preserve ileocecal valve if oncologically safe.
If lesion is very near the ileocecal valve, perform right
hemicolectomy.
Management
3. Mesenteric Resection:
Dissect and submit at least 8–12 lymph nodes for staging.
4. Anastomosis:
Side-to-side or end-to-end anastomosis of healthy ileal
segments (or ileocolic if hemicolectomy done).
5. Postoperative Care:
Pain control, early mobilization, DVT prophylaxis.
Gradual return to oral diet.
Histopathologic confirmation of final staging
Management
Adjuvant Treatment (post-surgery):
If final pathology confirms T2N0M0 with clear margins, only
observation and surveillance no chemo may be needed.
If nodes are positive (T3-4, Any N) lesions with high-risk
features then adjuvant chemotherapy:
FOLFOX (5FU leucovorin, oxaliplatin) for 3-6 months OR
CAPEOX (Capecitabine, Oxaliplatin) for 6 monthsadjuvant
chemotherapy (e.g., FOLFOX) is considered.
Management
Follow up and Surveillance:
History and PE every 3-6 months for 2 years, then every 6
months for a total of 5 years.
CEA and/or CA 19-9 every 3-6 months for 2 years, then every 6
months for a total of 5 years.
Chest/Abdominal/Pelvic CT every 6-12 months for 2 years, then
every 12 months years 3-5.
PET/CT scan not indicated.
Routine capsule endoscopy is not indicated.
Nutritional evaluation, especially for small bowel resections.
Thank you
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