P-0257 - Challenges in Management of Malignant ileocecal ulcers
|Date||28 June 2014|
|Event||World GI 2014|
|Topics|| Colon Cancer
|Citation||Annals of Oncology (2014) 25 (suppl_2): ii14-ii104. 10.1093/annonc/mdu165|
J. Toshniwal1, R. Chawlani2, S. Mukewar1, M. Sachdeva2
Up to 45% of Intestinal diseases occur in Ileo-cecal (IC) region; of which ulcerative disease account for 50%. Etiological diagnosis of ileocecal ulcers in tropics is challenging in view of variety of diseases affecting this region including Infections (Tuberculosis, Amoebiasis and Enteric fever); Inflammatory bowel diseases and Malignancies. The aim of this prospective study was to evaluate the clinical, colonoscopic and treatment profile of the patients with malignant ileocecal ulcers.
Of the colonoscopies performed at a tertiary care referral center patient with ulceration in ileo-cecal region were enrolled and the colonoscopic biopsies were obtained from these ulcerated lesions; of which patients with biopsy proven malignancy on histopathological examination formed the study group. Clinical features, Colonoscopic findings and treatment profile and outcome of these patients were studied.
Out of 1654 colonoscopies performed during Jan 2011 to Dec 2012, 104 patients had ulcerations in ileocecal region; of which 10 patients had malignancy on histological examination. These 10 patients compiled the study group; of which 6 were male. Patients were in age group of 46-76 years. Pain abdomen, vomiting, and anorexia were most common manifestations noted in 6 patients followed by altered bowel habit in form of diarrhea and constipation noted in 2 and 3 patients respectively. Duration of presentation was in range of 1-12 months. Haemoglobin less than 7gm% was noted in 5 patients. Stool for occult blood was positive in 2. On colonoscopy cecum, ileum and cecum, and ileo-cecal valve showed multiple ulcerations in 4 patients each, while ileum alone was involved in 2 patients. Colonic biopsy revealed Diffuse Large B-Cell Lymphoma (DLBCL) in 7 and Adenocarcinoma in 3-of which 2 were moderately differentiated and 1 was poorly differentiated. The later was unresectable and the patient expired after 3 months of diagnosis. The former two had resectable tumor and were also treated with chemotherapy. However, one patient with moderately differentiated adenocarcinoma had severe anaemia and was diagnosed after 9 months of clinical symptoms due to delay in referal for colonoscopy. 2 patients of DLBCL were misdiagnosed as colonic Tuberculosis and were treated with anti-tubercular drugs for 6 months. Similarly 2 patients of DLBCL needed repeated Colonoscopic biopsy as the biopsy report was non-specific ulcers during first attempt. 1 patient with DLBCL had relapse with Hepatic involvement after treatment with CHOP regimen of Chemotherapy and the patient expired after 4 months of relapse. Also 2 patients of DLBCL were lost to follow-up after receiving the first cycle of chemotherapy.
Malignant Ileo-cecal ulcers account for great mortality and morbidity too. Management i.e., diagnosis and treatment of malignant ileo-cecal ulcers still remains a challenge especially in Tropics, in view of delay in Colonoscopic examination due to delayed referal, histopathological mis-diagnosis, high prevalance of Tuberculosis affecting Ileo-cecal region, disease relapse and irregular follow-up. This study indicates that malignancies do occur in Ileo-cecal region and that too in extent of 10%! So, its high time to make medical community aware that every ulcer in ileo-cecal region should be suspected as lesion with malignant potential; especially in Tropics.