Laparoskopischer Zufallsbefund bei inkomplettem Ileus: Adenokarzinom des Dünndarms als Erstmanifestation eines Morbus Crohn

Zusammenfassung

Die vorliegende Fallstudie soll auf die niedrige Inzidenz eines Adenokarzinoms des Dünndarms bei Morbus Crohn hinweisen. Bis dato finden sich weltweit in der Literatur weniger als 100 solcher Fälle. Epidemiologische Untersuchungen zur Pathogenese des Dünndarmkarzinoms deuten auf eine positive Korrelation zu Zucker-, Kohlenhydrat-, Fett- und Alkoholkonsum hin. Diskutiert wird auch eine Adenom-Karzinom-Sequenz-Theorie wie beim kolorektalen Karzinom und die Prädisposition verschiedener Zustände wie Ileostoma, Ileumconduit, Morbus Crohn und Zöliakie. Immunhistochemie und Onkogenese lassen keine für den klinischen Alltag verwertbaren Ergebnisse erkennen. Das Dünndarmkarzinom weist kein spezifisches abdominelles Beschwerdebild auf. Die Abgrenzung eines Anfangsstadiums zu einem entzündlichen Schub oder einer progredienten Stenose bei bereits bekanntem Morbus Crohn ist ohne invasive Diagnostik unmöglich. Nach sonografischer, endoskopischer (Enteroskopie, Ileoskopie, Kapselendoskopie) und radiologischer Diagnostik (Sellink-Passage, Computertomografie, MR-Sellink, Ileografie) ist eine diagnostische Laparoskopie (ggf. explorative Laparotomie) anzuschließen. Nur so lässt sich die Erkrankung in einem Frühstadium erkennen und nach den Radikalitätsprinzipien therapieren. Die Prognose bleibt weiterhin schlecht mit einem hohen Anteil nicht-resezierbarer und metastasierter Erkrankungen und einer 5-Jahres-Überlebensrate zwischen 20 und 50 Prozent.

Abstract

The case-study reminds of adenocarcinoma of the small intestine as a rare complication of Crohn's disease. A few more than 100 of these cases have been published. Epidemiological studies concerning small bowel carcinoma showed consumption of sugar and carbohydrates as pathogenetic factors, other conditions like ileostoma, ileumconduit, Crohn's disease and coeliac disease have been identified to some extent. An adenoma-carcinoma sequence as in large intestine carcinoma has been discussed. Immunohistochemical and oncogenetic findings failed to demonstrate any result of practical clinical value. Diagnosis of early stages of adenocarcinoma of the small intestine is very difficult and thus might be impossible to differentiate from exacerbation or progressive stenosis of preexisting Crohn's disease. If non-invasive diagnostic measures (ultrasound, small bowel enema, CT-scan, intestinoscopy, radiography, NMR-Sellink, capsule-endoscopy) fail to clear the situation a diagnostic laparoscopy or even laparotomy should not be delayed. This constitutes the only chance to discover early stages which can possibly be cured in accordance with oncosurgical principles. Otherwise the prognosis remains poor with a high percentage of late stages and a 5-year-survival-rate between 20 and 50 percent.

Schlüsselwörter

Adenokarzinom des Dünndarms - Morbus Crohn - Enteritis regionalis - laparoskopische Chirurgie

Key words

adenocarcinoma of the small intestine - Crohn's disease - regional enteritis - laparoscopic surgery

Literatur

• 1 Amano M, Imai Y, Hashimoto T, Saito Y. et al . Primary cancer of the small intestine and mutational analysis of the K-ras and p53 genes.  J Gastroenterol. 1998;  33 397-401
• 2 Barraya R, Benhamiche A M, Rassiat E, Phelip J M. et al . Incidence of treatment modalities for cancer of the small intestine in Burgundy (France).  Gastroenterol Clin Biol. 1999;  23 215-220
• 3 Bastug D F, Cochran R C, Caldwell R, Foster D. Adenocarcinoma of the small intestine in Crohn's disease: a unique finding.  W V Med J. 1991;  87 295-298
• 4 Bernstein C N, Blanchard J F, Kliewer E, Wajda A. Cancer risk in patients with inflammatory bowel disease: a population-based study.  Cancer. 2001;  91 854-862
• 5 Collier P E, Turowski P, Diamond D L. Small intestinal adenocarcinoma complicating regional enteritis.  Cancer. 1985;  55 516-521
• 6 Delvaux M, Gerard G. Capsule endoscopy in 2005: facts and perspectives.  Best Pract Res Clin Gastroenterol. 2006;  20 23-39
• 7 Ersoy O, Sivri B, Arslan S, Batman F, Bayraktar Y. How much helpful is the capsule endoscopy for the diagnosis of small bowel lesions?.  World J Gastroenterol. 2006;  12 3906-3910
• 8 Fields S, Libson E. CT-guided aspiration core needle biopsy of gastrointestinal wall lesions.  J Comput Assist Tomogr. 2000;  24 224-228
• 9 Hidalgo L, Villanueva A, Soler T, Matias Guiu X, Capella G. Molecular changes in adenocarcinoma of the small intestine associated with Peutz-Jeghers syndrome.  Rev Esp Enferm Dig. 1996;  88 137-140
• 10 Hirai A, Hibi K, Nakamura H, Fujikake Y. et al . Findings of genetic changes in small intestinal carcinomas.  Gan To Kagaku Ryoho. 1997;  24 Suppl 2 332-336
• 11 Hutchins R R, Bani Hani A, Kojodjojo P, Ho R, Snooks S J. Adenocarcinoma of the small bowel.  ANZ J Surg. 2001;  71 428-437
• 12 Iwafuchi M, Watanabe H, Ishihara N, Enjoji M. et al . Neoplastic endocrine cells in carcinomas of the small intestine: histochemical and immunohistochemical studies of 24 tumors.  Hum Pathol. 1987;  18 185-194
• 13 Kaerlev L, Teglbjaerg P S, Sabroe S, Kolstad H A. et al . Is there an association between alcohol intake or smoking and small bowel adenocarcinoma? Results from a European multi-center case-control study.  Cancer Causes Control. 2000;  11 791-797
• 14 Kaerlev L, Teglbjaerg P S, Sabroe S, Kolstad H A. et al . Medical risk factors for small-bowel adenocarcinoma with focus on Crohn disease: a European population-based case-control study.  Scand J Gastroenterol. 2001;  36 641-646
• 15 Keuchel M, Hagenmuller F. Small bowel endoscopy.  Endoscopy. 2005;  37 122-132
• 16 Kirshstein B, Roy-Shapira A, Lantsberg L, Avinoach E, Mizrahi S. .  Surg Endosc. 2005;  19 464-467
• 17 Koga H, Aoyagi K, Hizawa K, Iida M. et al . Rapidly and infiltratively growing Crohn's carcinoma of the small bowel: serial radiologic findings and a review of the literature.  Clin Imaging. 1999;  23 298-301
• 18 Kronberger I E, Graziadel I W, Vogel W. Small bowel adenocarcinoma in Crohn's diesease: a case report and review of literature.  World J Gastroenterol. 2006;  12 1317-1320
• 19 Lagergren J, Ye W, Ekbom A. Intestinal cancer after cholecystectomy: is bile involved in carcinogenesis?.  Gastroenterology. 2001;  121 542-547
• 20 Lien G S, Mori M, Enjoji M. Primary carcinoma of the small intestine. A clinicopathologic and immunohistochemical study.  Cancer. 1988;  61 316-323
• 21 Lowenfels A B. Why are small bowel tumors so rare?.  Lancet. 1973;  6 24-26
• 22 Napolitano L, de Nicola P, Di Bartolomeo N, Aceto L, Liddo G, Angelucci D, Innocenti P. A case of perforated small bowel adenocarcinoma as first symptom of Crohn's disease.  G Chir. 2005;  26 212-214
• 23 Negri E, Bosetti C, La Vecchia C, Fioretti F. et al . Risk factors for adenocarcinoma of the small intestine.  Int J Cancer. 1999;  82 171-174
• 24 Neugut A I, Marvin M R, Rella V A, Chabot J A. An overview of adenocarcinoma of the small intestine.  Oncology. 1997;  11 529-536 ,  discussion 545, 549-550
• 25 North J H, Pack M S. Malignant tumors of the small intestine: a review of 144 cases.  Am Surg. 2000;  66 46-51
• 26 Ojha A, Zacherl J, Scheuba C, Jakesz R, Wenzl E. Primary small bowel malignancies: single-center results of three decades.  J Clin Gastroenterol. 2000;  30 289-293
• 27 Onuma E K, Amenta P S, Jukkola A F, Mohan V. et al . A phenotypic change of small intestinal epithelium to colonocytes in small intestinal adenomas and adenocarcinomas.  Am J Gastroenterol. 2001;  96 2480-2485
• 28 Piercecchi-Marti M D, Desjeux A, Liprandi A, Farisse J. et al . Crohn's disease and small intestine adenocarcinoma.  Rev Med Interne. 2001;  22 749-752
• 29 Ribeiro M B, Greenstein A J, Heimann T M, Yamazaki Y, Aufses Jr  A H. Adenocarcinoma of the small intestine in Crohn's disease.  Surg Gynecol Obstet. 1991;  173 343-349
• 30 Rodriguez Ramos C, Guillen P, Palomo M J, Porcel A. et al . Small intestine adenocarcinoma with Crohn's disease.  Rev Esp Enferm Dig. 1997;  89 321-324
• 31 Ryan J C. Premalignant conditions of the small intestine.  Semin Gastrointest Dis. 1996;  7 88-93
• 32 Schippers E, Langer S, Flosdorff W, Hilber U. Das primäre Dünndarmmalignom.  Chirurg. 1982;  53 364-369
• 33 Sellner F. Hypothesis on the existence of an adenoma-carcinoma sequence in the small intestine.  Z Gastroenterol. 1987;  25 151-165
• 34 Shenderey R L, Thompson N, Mansfield J C, Rees C. Adenocarcinoma as a complication of small bowel Crohn's disease.  Eur J Gastroenterol Hepatol. 2005;  17 1255-1257
• 35 Soeda J, Sekka T, Hasegawa S, Ishizu K, Ito E, Saguti T, Ogosi K, Makuuchi H. A case of primary small intestinal cancer diagnosed by laparoscopy.  Tokai J Esp Clin Med. 2004;  29 159-162
• 36 Solem C A, Harmsen W S, Zinsmeister A R, Loftus Jr E V. Small intestinal adenocarcinoma in Crohn's disease: a case-controll study.  Inflamm Bowel Dis. 2004;  10 32-35
• 37 Uesugi H, Mitomi H, Sada M, Takahashi H. et al . A case of adenocarcinoma of the small intestine in a Japanese patient with Crohn disease: a report with immunohistochemical and oncogenic analyses.  Scand J Gastroenterol. 1999;  34 1162-1167
• 38 Umschaden H W, Szolar D, Gasser J, Umschaden M, Haselbach H. Small-bowel disease: comparison of MR enteroclysis images with conventional enteroclysis and surgical findings.  Radiology. 2000;  215 717-725
• 39 Wu A H, Yu M C, Mack T M. Smoking, alcohol use, dietary factors and risk of small intestinal adenocarcinoma.  Int J Cancer. 1997;  70 512-517