Adenokarcinom dvanaesnika u oboljelog od celijakije: prikaz bolesnika

Branko Bakula, Ivan Zoričić, Marko Sever, Marinko Marušić, Rosana Troskot-Perić, Martin Grbavac, Domagoj Štritof

Adenokarcinom dvanaesnika izrazito je rijetka bolest i zaslužan je za samo oko 1,3% gastrointestinalnih tumora odnosno oko 0,2% svih malignih tumora u čovjeka. Najčešći maligni tumori tankog crijeva jesu karcinoid (44%) i adenokarcinom (33%). Nešto više od polovine adenokarcinoma tankog crijeva nalazi se u duodenumu. Bolesti koje povisuju rizik od nastanka ovoga rijetkog malignoma jesu obiteljska adenomatozna polipoza (FAP), nasljedni nepolipozni kolorektalni karcinom (HNPCC), Peutz-Jeghersov sindrom, Crohnova bolest te celijakija. Prikazujemo 43-godišnjeg muškarca kojemu je još u djetinjstvu dijagnosticirana celijakija, a primljen je u našu bolnicu zbog intenzivnog povraćanja i do 30 puta na dan unatrag nekoliko dana, gubitka težine od oko 20 kg unatrag godinu dana uz nalaz blaže anemije. Tijekom hospitalizacije rendgenogramom pasaže želudca, MSCT-om, enteroskopijom te PHD-om verificiran je opstruktivni adenokarcinom horizontalnog segmenta dvanaesnika. Tumor je uklonjen Whippleovom operacijom. Adenokarcinom duodenuma, iako rijetka, kobna je komplikacija celijakije. Rizik od razvoja karcinoma viši je u pacijenata koji se nisu pridržavali bezglutenske dijete, kao i kod onih kojima je bolest otkrivena kasno. Danas smo svjedoci neprihvatljivo malenom postotku rano otkrivenih adenokarcinoma tankog crijeva u pacijenata s celijakijom. Želimo naglasiti važnost redovitoga kliničkog praćenja bolesnika s celijakijom i njihova educiranja o dijeti, uz nizak prag za indiciranje dodatnih endoskopskih ili slikovnih pretraga pri promjeni kliničkog stanja ili slabom odgovoru na primijenjeno liječenje.

Duodenal adenocarcinoma is extremely rare and is responsible for only about 1.3% of gastrointestinal or about 0.2% of all malignant tumors in humans. Most common malignant tumors of the small intestine are carcinoid (44%) and adenocarcinoma (33%). More than half of adenocarcinoma of the small intestine can be found in the duodenum. Diseases that increase the risk of this rare malignancy are familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC), Peutz-Jeghers syndrome, Crohn’s disease and celiac disease. We present the case of a 43-year-old man, in childhood diagnosed with celiac disease, who was admitted to our hospital because of intense vomiting, up to about 30 times a day over the last few days, with weight loss of about 20 kg in a previous year and with the finding of minor anemia. Upper GI series, abdominal MSCT and enteroscopy revealed obstructing adenocarcinoma of horizontal duodenal segment. The tumor was resectable and the Whipple procedure was performed. Duodenal adenocarcinoma, although rare, is a fatal complication of celiac disease. Patients who did not adhere to a gluten-free diet and those with late diagnosis of celiac disease have a greater risk of developing cancer. Today we are witnessing an unacceptably low percantage of early diagnosed
patients with small bowel adenocarcinoma. We wish to emphasize the importance of a regular follow-up by experts as well as proper diet education, with low threshold for indicating additional endoscopic and imaging investigations in the case of worsening of symptoms or in the case of a noncompliant patient.