Small-Bowel Obstruction While on a Cruise
Background
A 57-year-old man with severe abdominal pain is evacuated from a cruise ship and presents to a local emergency department (ED).
The pain, which is most severe in the right lower portion of his abdomen, started soon after he boarded the cruise ship 2 days before presentation. Since onset, the pain has worsened, and the patient has noticed his abdomen becoming progressively "bloated." The pain is associated with nausea and vomiting, and the patient has not been able to have a bowel movement.
On further questioning, he reports having night sweats, low-grade fevers, intermittent abdominal discomfort with constipation, and a 30-lb weight loss over the past 2-3 months. He has no significant medical history, is not taking any medications, and is not on any weight-loss regimen. He does have a significant family history of colon cancer, soft tissue sarcoma, pancreatic cancer, chronic myeloid leukemia (CML), and prostate cancer.
On physical examination, the patient is alert and oriented. His temperature is 98.8°F (37.1°C), his pulse is 65 bpm, his respiratory rate is 18 breaths/min, and his blood pressure is 104/67 mm Hg. The abdominal examination reveals localized tenderness to palpation in the right lower quadrant (RLQ) with a palpable mass. He has generalized abdominal distention but no guarding, rebound, or percussion tenderness. His rectal examination reveals brown stool that is guaiac-positive. The findings from the respiratory and neurologic portions of the physical examination are unremarkable.
Laboratory investigations are ordered and reveal a hemoglobin value of 9.4 g/dL (94 g/l), with a corresponding hematocrit of 30.8% (0.308). His white blood cell (WBC) count is 6.2 × 103/μL (6.2 × 109/L), and his lactate dehydrogenase (LDH) level is elevated at 285 U/L.
The results of an electrolyte panel, liver function tests, and renal function tests are within normal limits. An abdominal computed tomography (CT) scan (see Figure 1) demonstrates a large mass in the patient's RLQ. The mass is causing a small-bowel obstruction, and several enlarged retroperitoneal and mesenteric nodes are noted (not pictured).On physical examination, the patient is alert and oriented. His temperature is 98.8°F (37.1°C), his pulse is 65 bpm, his respiratory rate is 18 breaths/min, and his blood pressure is 104/67 mm Hg. The abdominal examination reveals localized tenderness to palpation in the right lower quadrant (RLQ) with a palpable mass. He has generalized abdominal distention but no guarding, rebound, or percussion tenderness. His rectal examination reveals brown stool that is guaiac-positive. The findings from the respiratory and neurologic portions of the physical examination are unremarkable.
Laboratory investigations are ordered and reveal a hemoglobin value of 9.4 g/dL (94 g/l), with a corresponding hematocrit of 30.8% (0.308). His white blood cell (WBC) count is 6.2 × 103/μL (6.2 × 109/L), and his lactate dehydrogenase (LDH) level is elevated at 285 U/L.
What is the likely etiology leading to this small bowel obstruction?
Hint: Note the patient's strong family history of cancer.
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