bowel obstruction is a common surgical admission around the world usually resulting from post surgical adhesions or abdominal hernias .
conversely , small intestinal tumors , such as midgut carcinoids , are uncommon neoplasms and an infrequent cause of intestinal obstruction . although the small bowel is the most common site for these tumors , the overall incidence is still less than two per 100,000 of all medical or surgical admissions , however the actual reported incidence is closer to eight per 100,000 based on autopsy studies .
a preexisting small bowel neoplasm can prohibit the passage of an accidentally ingested foreign object and produce an obstruction that neither the neoplasm nor the foreign body could have produced alone .
we hereby report an interesting case in which a small piece of foreign material accidentally ingested by a patient lead to the detection of an asymptomatic midgut carcinoid in the proximal ileum that would have otherwise eluded detection for several years .
a previously healthy , 39-year - old male presented to the emergency department ( ed ) with a less than 24 hour complaint of severe cramping abdominal pain and two episodes of emesis within the past five hours .
his past medical history is significant only for hypertension for which he was noncompliant and not taking any medication .
social history was relevant for cigarette smoking of one pack per day and for beer drinking several times per week but he denied ever being intoxicated .
his last drinking event was a couple of cans of beer two days prior to his presentation .
review of systems was negative except for the gastrointestinal complaint resulting in his emergency room ( er ) visit .
the patient was employed as a mechanic and had previously been active until the onset of his current symptoms . at presentation ,
his pulse was 98 beats / min , his blood pressure was 186/88 and his temperature was 99.0 degrees fahrenheit .
his chest was clear to auscultation , heart sounds were regular and without murmur , and he had no peripheral edema or cyanosis .
his bowel was diffusely tender to deep palpation , without focal tenderness ; and no ventral or inguinal hernias were found .
the patient displayed mild voluntary guarding however ; there were no obvious rebound or other peritoneal signs .
his laboratory analysis was remarkable only for a white blood count of 19.810 with left shift ( 28% bands ) .
plain films of the abdomen showed dilated small bowel loops with multiple air fluid levels , highly characteristic of a distal small bowel obstruction . a computed tomography ( ct ) scan of the abdomen with iv and po contrast revealed dilated , contrast - filled , small bowel loops , a short segment of small bowel with thickened bowel wall , and a small metallic ring within the lumen ( figure 1 ) . the colon was collapsed and mesenteric adenopathy was noted ( figure 2 ) . 

figure 1metallic piece in the lumen of the thickened small bowel . 
  metallic piece in the lumen of the thickened small bowel . 

the patient was resuscitated with 2 liters of intravenous lactated ringer 's and then taken to the operating room ( or ) for an exploratory laparotomy . upon entering the abdomen , dilated loops of small bowel were immediately encountered that had a tapioca - like studding pattern , particularly around the proximal jejunum . an obvious stricture was noted in the distal jejunum / proximal ileum which displayed the characteristics of a transition point in which the distal bowel segment was decompressed , and the proximal segment was dilated and edematous .
palpationrevealed a patchy , white , firm , napkin - ring - like deformity in the bowel wall with thickening and contracture of the surrounding mesentery ( figure 3 ) .
a hard , subcentimeter nodule with surrounding desmoplastic reaction was visualized , this was consistent with a metastatic mesenteric lymph node .
several other lymph nodes were firm and easily palpable or visible within the remainder of the small bowel mesentery .
running the entire length of the bowel revealed two more palpable subserosal masses within the jejunum / ileum just distal to this site , each measuring less than one centimeter .
a segmental en bloc small bowel resection to include all three lesions and the mesentery was performed .
the adjacent remaining mesentery was then carefully explored and dissected for any additional metastatic lymph nodes , three were identified and removed . a cholecystectomy was also performed without difficulty . 

the specimen was immediately dissected in the pathology lab ( figure 4 ) . upon opening the bowel wall a dense , intraluminal mass , with an associated tight luminal obstruction
additionally , a tab from a beer can was seen immediately proximal to the intraluminal mass ( figure 5 ) .
figure 4specimen opened to reveal the primary carcinoid tumor and the adjacent beer can lid induced mucosal damage . 
 
specimen opened to reveal the primary carcinoid tumor and the adjacent beer can lid induced mucosal damage . 

figure 5beer can lid retrieved from the small bowel lumen adjacent to the carcinoid tumor . 
 
the final pathology revealedx a multifocal , low - grade neuroendocrine tumor ( carcinoid ) with multiple drop metastases throughout the segment of intestine and metastatic mesenteric lymph nodes .
both the intraluminal mass and lymph nodes stained positive for chromogranin and synaptophysin , but were negative for ki-67 .
the patient 's recovery was uneventful with the return of normal bowel function on the fourth postoperative day .
he was discharged home on the fifth postoperative day . upon questioning at a postoperative visit
, the patient recalled that two days prior to his admission he had dropped a beer tab into the beer can that he was drinking and he must have swallowed it without knowing . his 24 hour urine was collected and submitted for analysis of 5-hiaa levels , this was within normal limits .
carcinoids are rare neoplasms , first reported by langhans in 1867 and first described by lubarsch in 1888 .
the term carcinoid ( karzinoide , meaning cancer - like in german ) was originally given by oberndorfer to this tumor for its ' histological malignant appearance , but benign and indolent clinical course when compared to that of other cancers .
patients with midgut carcinoid commonly present with vague and non - specific symptoms , which often results in clinical detection being delayed for years .
as time progresses , the most common presenting symptom is intense , episodic , abdominal pain , which is typically indicative of advanced disease .
this pain may be due to intermittent intussusceptions of an affected segment , mesenteric ischemia due to buckling of the fibrosed mesentery or arterial elastosis , or frank obstruction .
unlike other cancers , the size of the primary tumor does not necessary correlate with presence of metastatic disease ( with the exception of appendiceal carcinoids ) .
often times , the diagnosis is made only after the development of carcinoid syndrome ( flushing , wheezing , and diarrhea ) due to the serotonin produced escaping hepatic clearance when cancer cells metastasize to the liver or retro - peritoneum strictures .
admission for intestinal obstruction can be due to a variety of causes and is a frequent event in hospitals around the world . in one series intestinal obstructions
accounted for 3% of all surgical admissions and up to 20% of all acute abdominal conditions requiring admission by other observers .
post surgical adhesions are the most common etiology of acute mechanical obstruction of the small bowel ( sbo ) and account for 6080% of all cases of intestinal obstruction in the developed world .
hernias are recognized as the second most common etiology of mechanical small bowel obstruction in developed countries .
malignant small bowel obstruction is the third , and a much less frequent , cause of hospital admission in developed countries . in one series
, it accounted for less than 5% of small intestinal obstructive cases , but can make up to 7.4% of all admissions for small bowel obstructions .
although most small bowel tumors found at autopsy are benign ( 75% ) , those that present with symptoms or are found during surgery are usually malignant .
the most common tumor of the small bowel is an adenoma , which is generally asymptomatic .
several theories attempt to explain the low incidence of tumorigenesis in the small bowel including rapid turnover of mucosal cells , rapid transit of luminal contents , low bacterial counts , and the alkalinity of chime .
population clusters do exist , but potential risk factors for the development of malignant disease of the small intestine are poorly defined .
masses causing intraluminal obstruction or extrinsic compression are rarely obstructive in the small intestine due to the liquid nature of the small bowel enteric contents .
even a very small luminal channel is sufficient for the passage of all residuals of digestion , with the exception of an indigestible non - yielding foreign object . in this patient , a preexisting and previously undetected , asymptomatic small intestinal neoplasm caused the retention of a foreign body resulting in the complete obstruction of the small bowel .
such an unusual combination of factors resulting in a bowel obstruction has not widely been reported in literature due to the rarity of such a condition . a foreign object that is small enough to pass through
the esophagus and pylorus is unlikely to cause obstruction anywhere else along the lower gastrointestinal tract .
therefore , when a foreign object is found to be obstructing at the mid portion of the small bowel , suspicions of a preexisting small bowel neoplasm should be raised and a timely exploratory surgery should be conducted .
 bowel obstruction is a common surgical admission around the world . on the other hand , small intestinal tumors , such as midgut carcinoid , 
 are uncommon neoplasms and an infrequent cause of intestinal obstruction leading to hospitalization . 
 a foreign body is an extremely rare cause of intestinal obstruction and when ingested , foreign bodies most often lodge in the narrowest portion of the gastrointestinal tract . 
 narrowing of the small bowel due to a neoplasm can prohibit the passage of an accidentally ingested foreign object and produce an obstruction that neither the neoplasm nor the foreign body could have produced alone . 
 we hereby report a case in which an accidentally ingested piece of foreign material leads to the finding of a small , early stage , asymptomatic , midgut carcinoid cancer in the proximal ileum that would have otherwise eluded detection for several years . 
Introduction
Case Report
Discussion