Case Presentation: Fibrosis is a consequence of inflammation in response to injury which results in regeneration of the damaged tissue and deposition of connective tissue. The development of post-surgical or radiation-induced gastrointestinal fibrosis is a chronic process that can surface months to years after treatment. We present a case of duodenal fibrosis mimicking a neoplastic obstruction in the setting of Lynch Syndrome. A 61-year-old male with a history of Lynch syndrome status post duodenal resection and adjuvant radiotherapy for previous stage IV metastatic colon cancer was admitted for evaluation of a ten-month history of progressive fatigue, anorexia, and dark urine. His presentation was further concerning for complaints of unintentional 30lb weight loss associated with a constant dull epigastric pain and pale diarrhea in the last 6 months. Initial lab evaluation was significant for markedly elevated alkaline phosphatase (1,217), GGTp (995), and lipase (1,992). His presentation and initial serology were concerning for obstructive hepatopathy with possible neoplastic process warranting radiographic imaging. Abdominopelvic CT showed markedly intrahepatic and extrahepatic bile ducts in addition to a dilated pancreatic duct. No evidence of pancreatitis was noted on imaging. At that time, an interventional gastroenterologist was consulted for further evaluation and the patient underwent ERCP. Endoscopy showed evidence of a previous surgical duodenojejunostomy, numerous sessile polyps in the duodenal region yet without evidence of mass obstruction. However, the patient did have evidence of advanced fibrosis of the duodenal region with high-grade biliary obstruction noted on cholangiogram and compression of the ampulla of Vater. EUS guided transgastric biliary drain was then placed and no further endoscopy was conducted. Following his interventional procedures, the patient reported improvement and eventual resolution of his epigastric abdominal pain two days following his procedure. Lipase, alkaline phosphatase, bilirubin, and liver transaminases subsequently trended downwards to within normal limits. He was discharged after a four-day admission to follow up outpatient with his primary care physician and gastroenterologist within one week.
Discussion: Duodenal fibrosis is a rare finding in the setting of Lynch Syndrome. The progression of this complication is attributed to the interventions associated with Lynch syndrome including intestinal resections, anastomoses, and radiation therapy. In the case of our patient, the most likely source of his fibrosis was both his previous history of radiation to the abdomen and his duodenojejunostomy as much of the fibrosis appeared to centralize from this surgical site. Intestinal fibrosis is an irreversible process and management of duodenal fibrosis is largely based upon surgical resection (often via Whipple procedure), palliative stenting, or drain placement.
Conclusions: Patients with Lynch Syndrome are exposed not only to the immediately neoplastic complications of their conditions but also the complications associated with interventions. Although fibrosis is a possible complication, duodenal fibrosis remains a rare complication. Early recognition and intervention of obstructive complications are effective at reducing immediate mortality during the inpatient period. A team-based approach between hospitalists, consultants, and patients is useful for reducing admission length and patient morbidity.