Presentations

Abstract

Introduction:

Peritoneal carcinomatosis (PC) is a condition where malignant cells from a primary tumor, either intraperitoneal or extra-peritoneal, shed off and implant within the peritoneal cavity. PC associated with pancreatic malignancy is rare, has a poor prognosis, and has been reported less in the literature. We report a presentation of pancreatic PC as a colonic stricture.

Case Information:

An 87-year-old female with a past medical history of atrial fibrillation, chronic heart failure, aortic stenosis, and multiple abdominal surgeries presented to the emergency department with abdominal pain and constipation for several weeks. CT findings suggested transverse colonic stricture (Figure 1) and mild intra-abdominal ascites. General surgery and gastroenterology were consulted. Patient opted for colonoscopy with stent placement, underwent colonic stenting and was noted to have a benign appearing intrinsic stricture with ischemic changes in the distal colon on colonoscopy (Figure 2). She reported improvement in her symptoms and was discharged. A month later she developed suprapubic pain and non-bloody, non-bilious emesis for several days. CT scan at that time was concerning for possible small bowel obstruction without evidence of perforation. Patient required transfer to intensive care with hemodynamically unstable atrial fibrillation with rapid ventricular response requiring urgent cardioversion. Patient developed worsening abdominal pain and did not have bowel movements with bowel preparation. Examination was remarkable for rebound tenderness and absent bowel sounds. She underwent emergent exploratory laparotomy and was found to have multiple omental implants, mass-like structure by the splenic flexure that corresponded with the stricture location and a small perforation was noted proximal to colonic stent. Histopathological examination of implants confirmed pancreatic adenocarcinoma thus confirming the diagnosis of PC secondary to pancreatic adenocarcinoma. The patient had increasing pressor and inotropic requirements after the procedure and unfortunately passed away in ICU.

Discussion:

Diagnosis of PC is often very challenging, requiring advanced imaging and surgical exploration. PC has the same attenuation as normal peritoneum and bowel making radiological detection on CT difficult (1). PET and MRI have better sensitivity and specificity than CT, however, higher costs and limited availability restrict their widespread application (1). Treatment for PC secondary to pancreatic adenocarcinoma is currently limited. There is modest evidence for complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (2,3). Despite this overall survival is poor.

Conclusion:

PC is a complex, heterogenous disease that is difficult to diagnose and treat. Advanced imaging and surgical exploration should be considered for early diagnosis to improve chances of survival.