NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Figure 8-18: A pedunculated small bowel carcinoid tumor causing a small bowel obstruction.

Case Variation 8.16.2. A 2.2-cm diameter, yellow firm mass at the base of the appendix ◆ ◆ This is most likely a larger carcinoid tumor that involves the base of the cecum. Excision, not biopsy, is appropriate. ◆ ◆ A carcinoid tumor with a size of 2 cm or more or involvement of the base of the appendix or cecum suggests malignant behavior and is an indication to perform a right colectomy. ◆ ◆ An adenocarcinoma may appear similar, although the color is different. Colectomy may require an extension of the incision cephalad for adequate exposure. Reanastomosis of the ileum and colon can usually be performed safely. Case Variation 8.16.3. A 3-cm round pedunculated mass in the terminal ileum that appears to be obstructing the lumen (Fig. 8-18) ◆ ◆ Carcinoid tumors and adenocarcinomas of the small intestine can manifest as peduncu- lated masses that cause intermittent small bowel obstruction that may mimic appendicitis. It is necessary to remove the involved ileum and regional lymph nodes. Examination of the remaining bowel for other lesions is also appropriate because of a significant incidence of multiple carcinoid tumors in the bowel . The pathology for the appendiceal mass returns as carcinoid tumor. Q: What management plan is appropriate? A: For each of the carcinoid tumors (Case Variations 8.16.1 and 8.16.2), it is necessary to obtain a baseline urinary 5-hydroxyindoleacetic acid (5-HIAA) and serum serotonin level. The principal determinants of malignancy involve the biologic behavior of the tumor . Thus, long-term follow-up of patients with such tumors is appropriate. If there is a question of recurrence, a CT scan of the abdomen and an octreotide scan, which localizes to neuro- endocrine tumors, is warranted. SAMPLE

Case 8.17 Complications of a Ruptured Appendix

A 60-year-old patient with a ruptured appendix recovers from surgery and is discharged. One week later, the patient presents with fever, chills, anorexia, and malaise.