Small bowel carcinoid is typically aggressive, with transmural invasion, extensive fibrosis, and mesenteric involvement. Patients with mesenteric carcinoid are difficult to manage surgically, as these deposits are often large, cicatrize the mesentery and encase the mesenteric vasculature.
A 73 year-old gentleman was referred to us with worsening abdominal pain and imaging confirming a mesenteric carcinoid mass. He complained of progressive abdominal pain over two years which occurred after oral intake associated with bloating. He lost 12kg during this time. He also complained of 4-5 loose bowel motions per day but denied cutaneous flushing.
Prior to admission, a computed tomography(CT) revealed a mass in the root of the mesentery with cicatrizing, radiating bands of fibrosis typical of mesenteric carcinoid. The tumour encased the mesenteric vasculature. His proximal small bowel was dilated and distal terminal ileum was collapsed.
On clinical examination, his abdomen was mildly distended, diffusely tender but soft. He was anaemic with a haemoglobin of 108g/L. His renal and liver function were normal, and his albumin was 32g/L.
After discussion with the patient and family, we proceeded with a laparotomy with palliative intent. At operation, his proximal small bowel was thickened and chronically dilated with a transition point at commencement of four discrete small bowel tumours in the mid-ileum. The terminal ileum was collapsed. Handling of the mesentery resulted in the bowel becoming instantly pale and markedly cool to touch consistent with vasocactive amine release. A side-to-side ileo-ileal bypass was performed. One small bowel tumour was resected for pathological assessment. Histology confirmed a neuroendocrine small tumour (WHO G1 – carcinoid). Immunohistochemistry was synaptophysin positive and chromogranin positive, MIB1 <1%.
He recovered well from his operation, was able to tolerate a diet and was discharged.
Mesenteric carcinoid can present late, with a long history of abdominal symptoms. There is often a primary small bowel tumour, and where possible, mechanical obstruction should be palliated to enable oral intake.