Mwinyogle Aubrey A, Bhatt Astha, Kapisoda Katarina, Somerville Justin, Cunningham Steven C
Department of Surgery, St Agnes Hospital, Baltimore, MD, USA.
Colorectal Surgery, St Agnes Hospital, Baltimore, MD, USA.
J Med Case Rep. 2019 May 17;13(1):148. doi: 10.1186/s13256-019-2068-x.
Multiple myeloma is a hematological malignancy that classically results in an abnormal clonal proliferation of plasma cells in the bone marrow. Extramedullary disease in the setting of multiple myeloma, referred to as secondary extramedullary plasmacytoma, is found in 7-17% of cases of multiple myeloma at the time of diagnosis and can involve any organ system. Small bowel obstruction is a rare but important gastrointestinal manifestation of multiple myeloma that should be considered in patients with multiple myeloma who present with concerning abdominal symptoms.
We present the case of a 52-year-old African-American man with a history of deep venous thrombosis (he is on anticoagulation) and pathologic fracture secondary to multiple myeloma diagnosed 4 months prior to our encounter. He presented with abdominal pain, constipation, nausea, and vomiting. An abdominal X-ray showed distended bowel loops concerning for bowel obstruction and a contrast-enhanced computed tomography scan of his abdomen and pelvis showed a 5.4 cm soft tissue mass involving a loop of distal ileum. He underwent laparoscopic exploration of his abdomen with small bowel resection and primary anastomosis for a small intussusception. He had an uneventful postoperative course and was discharged on postoperative day 6.
Multiple myeloma has myriad presentations. Gastrointestinal involvement, although rare, can manifest as small bowel obstruction for which early recognition and appropriate surgical management are key to improving outcome. Intussusception is the most common mechanism of obstruction from extramedullary plasmacytoma causing small bowel obstruction and this has been seen in five of six case reports, including this case. It is important to recognize and consider the risks of immunosuppression, venous thromboembolism, and malnutrition in the surgical management of gastrointestinal complications of multiple myeloma.
多发性骨髓瘤是一种血液系统恶性肿瘤，典型表现为骨髓中浆细胞异常克隆性增殖。多发性骨髓瘤患者出现的髓外病变，称为继发性髓外浆细胞瘤，在多发性骨髓瘤诊断时的发生率为7% - 17%，可累及任何器官系统。小肠梗阻是多发性骨髓瘤一种罕见但重要的胃肠道表现，对于出现相关腹部症状的多发性骨髓瘤患者应予以考虑。
我们报告一例52岁非裔美国男性病例，其有深静脉血栓形成病史（正在接受抗凝治疗），并在我们接诊前4个月被诊断为多发性骨髓瘤继发病理性骨折。他出现腹痛、便秘、恶心和呕吐症状。腹部X线显示肠袢扩张，提示肠梗阻，腹部和盆腔增强CT扫描显示一个5.4 cm的软组织肿块累及回肠末端肠袢。他接受了腹腔镜下腹部探查，行小肠切除及小肠套叠的一期吻合术。术后恢复顺利，术后第6天出院。
多发性骨髓瘤有多种表现形式。胃肠道受累虽然罕见，但可表现为小肠梗阻，早期识别和适当的手术治疗是改善预后的关键。套叠是髓外浆细胞瘤导致小肠梗阻最常见的梗阻机制，在包括本病例在内的六例病例报告中有五例出现这种情况。在多发性骨髓瘤胃肠道并发症的手术治疗中，认识并考虑免疫抑制、静脉血栓栓塞和营养不良的风险很重要。
