GS07 - Case report: Malignant Bowel Obstruction with cecal perforation secondary to invasive pancreaticobiliary adenocarcinoma

Introduction/Purpose: Gallbladder adenocarcinoma is rare and usually detected at late stages of the disease. This is a case report of an interesting presentation of malignant bowel obstruction from advanced pancreaticobiliary mass causing cecal perforation.

Methods or Case Description: 86 year old male, with history of laparoscopic sigmoidectomy with primary anastomosis for sigmoid volvulus, presented with generalized abdominal pain found to have pneumoperitoneum with imaging findings of dilated small bowel loops, distended right colon and transverse colon, and possible right abdominal mass. Patient underwent exploratory laparostomy and was found to have a small cecal perforation due to a hard biliary mass encompassing the hepatic flexure of colon causing complete obstruction. Stomach, duodenum, and lesser sac were grossly normal. Patient had an extended right hemicolectomy, open subtotal cholecystectomy, and primary side to side ileocolic anastomosis.

Outcomes: The partial gallbladder pathology demonstrated poorly differentiated adenocarcinoma with signet cell features involving mucosa, lamina propria, submucosa, muscularis mucosa, and serosa. On pathology review of the right colon it demonstrated poorly differentiated carcinoma cells in muscular propria and pericolonic adipose tissue and colonic mucosa with necroinflammatory changes. Transverse colon mucosa with reactive changes and acute serositis and adhesions. Patient is Stage IVb, pT3, Nx, M1, grade 3 with a mass of pancreaticobiliary origin.

Postoperatively, patient developed a prolonged course of postoperative ileus and then later developed obstructive jaundice. ERCP was attempted to relieve biliary obstruction, however was unable to cannulate past the pylorus secondary to mass effect. Patient was transferred to tertiary care center for transhepatic biliary drainage and hepatopancreaticobiliary surgical management of potential mass invasion into the common bile duct.

Conclusion: Although gallbladder cancer is rare, it is a differential diagnosis that should be taken into consideration for cause of hollow viscus perforation from distal malignant obstruction. In this case, the patient remained vitally stable and a primary ileocolic anastomosis after resection of the obstruction was opted in this emergent case.