Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 2343 

CASE REPORT Table of Contents   
Year : 2009  |  Volume : 15  |  Issue : 4  |  Page : 264-267
Adenocarcinoma of the small bowel: A surgical dilemma

Department of Surgery, Padmashree Dr. D. Y. Patil Medical College and Rajawadi Municipal General Hospital, Ghatkopar, Mumbai - 400 077, India

Click here for correspondence address and email

Date of Submission09-Jun-2008
Date of Acceptance21-Feb-2009
Date of Web Publication30-Sep-2009


Malignant tumors of the small intestine are among the rarest types of gastrointestinal cancers. Due to their infrequent occurrence and the multitude of tumor types (viz, adenocarcinomas, carcinoids, sarcomas, and lymphomas), not much is known about their natural history and presentation, and there is often delay in the diagnosis. Adenocarcinoma is the commonest histologic type of small bowel cancer. There are no prospective randomized trials that have elucidated the best diagnostic and therapeutic options for this rare condition. In this article, a case of adenocarcinoma of the jejunum presenting as an abdominal lump is presented, along with a review of the literature.

Keywords: Small intestine, cancer, tumor, adenocarcinoma

How to cite this article:
Vagholkar K, Mathew T. Adenocarcinoma of the small bowel: A surgical dilemma. Saudi J Gastroenterol 2009;15:264-7

How to cite this URL:
Vagholkar K, Mathew T. Adenocarcinoma of the small bowel: A surgical dilemma. Saudi J Gastroenterol [serial online] 2009 [cited 2021 Feb 24];15:264-7. Available from:

Adenocarcinoma of the small bowel is a rare malignancy as compared to other malignancies of the gastrointestinal tract. However, it is the commonest amongst small bowel cancers. It is asymptomatic in the early stages and by the time it becomes symptomatic it has usually spread to other sites. Thus, the diagnosis is often delayed, with consequent poor prognosis.

   Case Report Top

A 47-year-old male presented with the complaint of an abdominal mass in the right lumbar region. He was admitted for evaluation. He did not have symptoms suggestive of intestinal obstruction and there had been no weight loss. There was no history of hematemesis or melena. Physical examination revealed an intra-abdominal mass that did not move with respiration. The mass was not ballottable.

CT scan revealed a circumferential growth involving the small bowel [Figure 1]. There were no hepatic metastases nor was there any free fluid in the peritoneal cavity. The patient underwent an exploratory laparotomy, at which the mass was seen encircling the jejunum [Figure 2]. The involved segment was resected [Figure 3]. Postoperative recovery was uneventful. Histopathology of the specimen revealed adenocarcinoma of the small intestine [Figure 4]. The resection margins were clear of tumor cells on histology and there was no evidence of lymph node involvement. The lesion was T3N0M0, i.e., stage II disease. Adjuvant chemotherapy was not given as the patient did not have metastases and the margins were clear. The patient has been followed up for 2 years and there has been no evidence of recurrence.

   Discussion Top

The small intestine constitutes about 90% of the mucosal surface area and 75% of the length of the gastrointestinal tract. Despite this, malignant neoplasms are uncommon in the small intestine, constituting only 20% of all the gut tumors. Many theories have been postulated to explain the low incidence of malignant tumors at this site. For example, it has been said that the large volumes of alkaline fluid in the small bowel, the presence of various enzymes, and the high immunoglobulin A levels cause dilution and detoxification of potential carcinogens and also prevent prolonged contact of such carcinogens with the mucosa. In addition, the small intestine has a very limited number of bacteria (as compared to the colon) that are capable of transforming potential procarcinogens into their active breakdown products. Since the incidence of small bowel carcinoma is very low, not much information is available regarding the molecular aspects of these tumors, which could be of help in the planning, prevention, diagnosis, and management of these tumors.

In general, small intestinal cancers have a low prevalence in Asian countries as compared to the West. Males have a higher predilection for these malignancies. Increasing age is associated with a higher incidence of small intestinal cancers.

Genetic factors have been strongly implicated in the etiology of adenocarcinoma of the small intestine. Patients suffering from familial adenomatous polyposis have a higher chance of developing duodenal adenocarcinoma. [1] These patients have high frequency of p53 overexpression. [2] Hereditary nonpolyposis colorectal cancer patients have a high likelihood of developing adenocarcinoma of the small bowel. [3] Environmental factors such as a diet rich in red meat, salt-cured or smoked foods, as well as intake of tobacco and alcohol, have been implicated in the etiology of this malignancy. [4]

Predisposing medical conditions are Crohn disease and celiac disease (nontropical sprue). Patients suffering from Crohn disease have a high risk of developing adenocarcinoma of the small bowel, whereas patients suffering from celiac disease have increased risk of developing small bowel lymphoma rather than adenocarcinoma. [5]

Approximately 64% of all small bowel tumors are malignant and 40% of the tumors are adenocarcinomas. [6] The remaining malignancies comprise GIST (gastrointestinal stromal tumors), carcinoids, and lymphomas). [7] These tumors have a resemblance to large bowel adenocarcinomas. Adenocarcinomas in the small bowel arise from premalignant adenomas. Through a stepwise accumulation of genetic mutations, these adenomas become dysplastic and progress to carcinoma in situ and then to invasive adenocarcinomas. They metastasize via the lymphatics or portal circulation to the liver, lung, bone, brain, and other distant sites. Small bowel adenocarcinomas tend to cluster away from the colon, toward the gastric end of the small intestine. [8] Approximately 50% arise in the duodenum, 30% in the jejunum, and 20% in the ileum. K-ras mutation and p53 overexpression are common in small bowel cancers. [2] Impaired small intestinal acyl coA thioesterase synthesis is probably related to the adenoma-carcinoma sequence of small intestinal epithelial tumors. [9] A significant number of small bowel tumors show moderate to strong COX-2 and c PLA 2 expression. [10]

Small bowel cancers are asymptomatic in the early stages. As the disease progresses, symptoms develop. The nature of symptoms is nonspecific and, as a result, there is a delay in diagnosis which averages 6-8 months. [11] Abdominal pain and weight loss are the commonest symptoms. Bleeding, vomiting, nausea, and obstruction are less common. Physical examination in the early stages is unremarkable. Rarely, a palpable abdominal mass or a tender abdomen, possibly with peritoneal signs, may be found due to obstruction or perforation.

Laboratory tests may show mild anemia due to chronic blood loss. Liver function test may reveal hyperbilirubinemia in case of duodenal tumors. Elevated transaminases may be found in case of liver metastasis. The diagnosis of small bowel adenocarcinomas may be elusive. Upper GI series, with small-bowel follow-through, shows abnormalities in 53.83% of patients with small bowel cancers. [12] Abdominal CT scan will reveal the exact site and extent of local disease as well as the presence of liver metastasis. [13] Upper GI endoscopy with small-bowel enteroscopy may allow identification and biopsy of lesions in the duodenum and jejunum. Videocapsule endoscopy has shown promise in the diagnosis of small bowel disorders. [14],[15]

Surgical resection provides the only hope for cure for adenocarcinoma of the small bowel. [16],[17] Patients with a lesion in the proximal duodenum should undergo pancreaticoduodenectomy. [17],[18] For lesions elsewhere in the small bowel, the treatment is wide resection. Surgery, in the form of a bypass for intestinal obstruction, may also be indicated for palliation in patients with symptomatic advanced disease. [17] Chemotherapy is of benefit as an adjuvant to surgery, especially when there is metastatic disease. Jigyasu et al. studied 14 subjects with metastatic small bowel adenocarcinoma treated with chemotherapy regimens, mostly containing 5-fluorouracil (5-FU). Two minor responses and one partial response occurred, with a median survival of 9 months. [19] Ouriel and Adams reported a mean survival of 10.7 months in 6 patients with metastatic disease treated with 5-FU-based regimens, compared with a mean survival of 4 months in 6 patients with metastatic disease who received no chemotherapy.[20] Crawley et al. reported eight patients with advanced small bowel adenocarcinoma treated with infusional 5-FU- based regimens and found a response rate of 37.5% and a median survival of 13 months. [21] Polyzos et al. reported minor responses, with improvement of symptoms, using salvage irinotecan therapy for 5-FU-refractory small bowel adenocarcinoma. [22] Bettim et al. found that the FOLFOX-4 regimen (which is a combination of infusional 5-FU, oxaliplatin, and leucovorin) could be safely administered as adjuvant chemotherapy in three subjects with resected small bowel adenocarcinoma associated with celiac disease. [23]

Veyrieves et al. reported an overall 5-year survival of 38%; with palliative treatment alone the 5-year survival was 0%, while it was 54% after curative resection. In patients undergoing curative resection, the 5-year survival was 63% when lymph nodes were not involved and 52% when they were, 57% when the serosa was not involved and 53% when it was, 56% when the tumor was well or moderately well differentiated and 40% when it was undifferentiated. Other factors influencing long-term survival were the emergency presentation, the site, the multiplicity, and the size of the tumor. [24]

In conclusion, primary small bowel tumors are rare and the prognosis is generally considered to be poor. Diagnosis is often difficult because of the infrequency of these tumors and the nonspecific symptoms. Aggressive surgical resection in an attempt to achieve complete tumor removal should be the aim. Large tumor size, advanced histological grade, and transmural invasion are associated with decreased survival. [25]

   References Top

1.Offerhaus GJ, Giardiello FM, Krush AJ, Booker SV, Tersmette AC, Kelley NC, et al. The risk of upper gastrointestinal cancer in familial adenomatons polyposis. Gastroenterology 1992;102:1980-2.  Back to cited text no. 1      
2.Arai M, Shimizu S, Imai Y, Nakatsuru Y, Oda H, Oohara T, et al. Mutations of the Ki-ras, p53 and APC genes in adenocarcinomas of the human small intestine. Int J Cancer 1997;70:390-5.  Back to cited text no. 2      
3.Rodriguez-Bigas MA, Vasen HF, Lynch HT, Watson P, Myrhψj T, Jδrvinen HJ, et al. Characteristics of small bowel carcinoma in hereditary nonpolyposis colorectal carcinoma. International Collaborative Group on HNPCC. Cancer 1998;83:240-4.  Back to cited text no. 3      
4.Neugut AI, Jacobson JS, Suh S, Mukherjee R, Arber N. The epidemiology of cancer of the small bowel. Cancer Epidemiol Biomarkers Prev 1998;7:243-51.  Back to cited text no. 4      
5.Chow WH, Linet MS, McLaughlin JK, Hsing AW, Chien HT, Blot WJ. Risk factors for small intestine cancer. Cancer Causes Control 1993;4:163-9.  Back to cited text no. 5      
6.Neugut AI, Marvin MR, Rella VA, Chabot JA. An overview of adenocarninoma of the small intestine. Oncology 1997;11:529-36.  Back to cited text no. 6      
7.Minardi AJ Jr, Zibari GB, Aultman DF, McMillan RW, McDonald JC. Small bowel tumors.J Am Coll Surg 1998;186:664-8.  Back to cited text no. 7      
8.O'Riordan BG, Vilor M, Herrera L. Small bowel tumors: An overview. Dig Dis 1996;14:245-57.  Back to cited text no. 8      
9.Gassler N, Schneider A, Kopitz J, Schnφlzer M, Obermόller N, Kartenbeck J, et al. Impaired expression of Acyl CoA Synthetase 5 in epithelial tumors of the small intestine. Hum Pathol 2003;34:1048-52.  Back to cited text no. 9      
10.Wendum D, Svrcek M, Rigau V, Boλlle PY, Sebbagh N, Parc R, et al. COX-2, inflammatory secreted PLA2, and cytoplasmic PLA2 protein expression in small bowel adenocarcinomas compared with colorectal adenocarcinomas. Mod Pathol 2003;16:130-6.  Back to cited text no. 10      
11.Maglinte DD, O'Connor K, Bessette J, Chernish SM, Kelvin FM. The role of the physician in the late diagnosis of primary malignant tumors of the small intestine. Am J Gastroenterol 1991;86:304-8.  Back to cited text no. 11      
12.Bessette JR, Maglinte DD, Kelvin FM, Chernish SM. Primary Malignant tumors of the small bowel a comparison of the small bowel enema and conventional follow through examination. AJR Am J Roentgenol 1989;153:741-4.  Back to cited text no. 12      
13.Buckley JA, Siegelman SS, Jones B, Fishman EK. The accuracy of CT staging of small bowel adenocarcinoma: CT/Pathologic correlation. J Comput Assist Tomogr 1997;21:986-91.  Back to cited text no. 13      
14.Costamagna G, Shah SK, Riccioni ME, Foschia F, Mutignani M, Perri V, et al. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology 2002;123:999-1005.  Back to cited text no. 14      
15.Chong AK, Taylor AC, Miller AM, Desmond PV. Initial experience with capsule endoscopy at a major referral hospital. Med J Aust 2003;178:537-40.  Back to cited text no. 15      
16.Bauer RL, Palmer ML, Bauer AM, Nava HR, Douglass HO Jr. Adenocarcinoma of the small intestine: 21 year review of diagnosis treatment and prognosis. Ann Surg Oncol 1994;1:183-8.  Back to cited text no. 16      
17.Blanchard DK, Budde JM, Hatch GF 3 rd , Wertheimer-Hatch L, Hatch KF, Davis GB, et al. Tumors of the small intestine. World J Surg 2000;24:421- 9.  Back to cited text no. 17      
18.Sohn TA, Lillemoe KD, Cameron JL, Pitt HA, Kaufman HS, Hruban RH, et al. Adenocarcinoma of the duodenum: Factors influencing long term survival. J Gastrointest Surg 1998;2:79-87.  Back to cited text no. 18      
19.Jigyasu D, Bedikian AY, Stroehlein JR. Chemotherapy for primary adenocarcinoma of the small bowel. Cancer 1984;53:23-5.  Back to cited text no. 19      
20.Ouriel K, Adams JT. Adenocarcinoma of small intestine. Am J Surg 1984;147:66-71.  Back to cited text no. 20      
21.Crawley C, Ross P, Norman A, Hill A, Cunningham D. The Royal Marsden experience of a small bowel adenocarcinoma treated with protracted venous infusion 5 fluorouracil. Br J Cancer 1998;78:508-10.  Back to cited text no. 21      
22.Polyzos A, Kouraklis G, Giannopoulos A, Bramis J, Delladetsima JK, Sfikakis PP. Irinotecan as Salvage Chemotherapy for advanced small bowel adenocarcinoma: A series of three patients. J Chemother 2003;15:503-6.  Back to cited text no. 22      
23.Bettini AC, Beretta GD, Sironi P, Mosconi S, Labianca R. Chemotherapy in small bowel adenocarcinoma associated with celiac disease: A report of three cases. Tumori 2003;89:193-5.  Back to cited text no. 23      
24.Veyriθres M, Baillet P, Hay JM, Fingerhut A, Bouillot JL, Julien M. Factors influencing long term survival in low cases of small intestine primary adenocarcinoma. Am J Surg 1997;173:237-9.  Back to cited text no. 24      
25.Chaiyasate K, Jain AK, Cheung LY, Jacobs MJ, Mittal VK. Prognostic factors in primary adenocarcinoma of the small intestine: !3 year single institution experience. World J Surg Oncolog 2008;3:12.  Back to cited text no. 25      

Correspondence Address:
Ketan Vagholkar
Annapurna Niwas, 229 Ghantali Road, Thane - 400 602, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-3767.56105

Rights and Permissions


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
1 Jejunal AdenocarcinomaA Case Report with Review
Priti Prasad Shah, Sudhir Kothari
Indian Journal of Surgery. 2011;
[VIEW] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded555    
    Comments [Add]    
    Cited by others 1    

Recommend this journal