P-029 An Unusual Case of Metastatic Signet Cell Carcinoma Presenting as Crohn's Disease

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Crohn's disease (CD) can be difficult to diagnose because it can affect different parts of the gastrointestinal (GI) tract and symptoms may be non-specific. About half of CD patients present with strictures or fistulas within 20 years of diagnosis; 25% present with small bowel strictures and 10% with at least one colonic stricture.1 However, intestinal strictures may complicate other disease processes, including cancer. Signet ring cell carcinomas (SRCC) may be a more aggressive type of gastric cancer that generally occurs in younger individuals. Typically, primary gastric carcinoma is associated with local metastasis and rarely spreads to other parts of the intestine. A pediatric case of abdominal pain/distention revealed small bowel strictures and eventually SRCC of the ileum.2


We report a case of a 58-year-old woman who presented in May 2014 with epigastric tenderness and nausea. In July 2014, she was diagnosed with Helicobacter Pylori gastritis. She later experienced abdominal cramps and changes in bowel habits alternating between diarrhea and constipation. Diet changes helped; however, symptoms worsened to vomiting, bloating, early satiety and a 10-pound weight loss. An EGD performed March 2015 revealed gastric nodules and a gastric antral mass. Additionally, a colonoscopy revealed an inflamed non-patent sigmoid colon stricture. An abdominal/pelvis MRI revealed chronic inflammation in the sigmoid and transverse colon along with multiple skip segments of the small bowel, a pattern thought to be concerning for Crohn's disease. The pathology from the gastric nodules revealed high grade adenocarcinoma with signet ring cell features. The decision was made not to further surgically stage the signet cell adenocarcinoma with small bowel resection. In April 2015, she presented with vomiting and abdominal cramps. Imaging showed interval development of a small bowel obstruction secondary to a stricture within mid to distal small bowel. Stricture resection specimens subsequently revealed poorly differentiated adenocarcinoma with signet ring cell features.


Overall prognosis associated with this disease was reviewed and goals of therapy were primarily palliative. The patient passed away in November 2015.


After the patient's diagnosis of SRCC, the MRI imaging of intestinal strictures were thought to be concerning for a concomitant diagnosis of CD. CD is a diagnosis of exclusion and a new clinical diagnosis accounts for a patient's history, radiographic imaging, labs, and endoscopy with histology. To our best knowledge, there have been no cases of metastatic SRCC imitating Crohn's. Imaging is important for monitoring and treatment of IBD and cancer. In patients with SRCC, imaging suggesting intestinal inflammation should be evaluated for metastatic disease before a diagnosis of CD is made.

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