Malignant tumors of the small bowel are unusual and account for only 1% to 5% of all gastrointestinal tract malignancies. Thirteen cases of malignant tumors of the small bowel identified at the VAMC in Puerto Rico from January 1999 to September 2001 and a review of the literature are presented. The mean age of our cases was 67 (range: 45-78). Vague abdominal pain, nausea, vomiting, and melena were the most frequently reported symptoms. The average time from first symptoms to diagnosis was 3.2 months. A positive test for occult blood or hypochromic microcytic anemia was invariably present. Hyperbilirubinemia and increased alkaline phosphatase were warning signs that allowed earlier diagnosis in patients with duodenal tumors. Fifty-four percent of the lesions were detected by endoscopic examination while 46% relied on radiographic studies. Eleven had carcinomas and two malignant gastrointestinal stromal tumors. Neither carcinoids nor lymphomas were identified. Our report of thirteen cases of malignant small bowel tumors is unusual and exhibits differences with the previously reported data. The cases were identified in a limited Hispanic population in a short period of time. Aggressive evaluation and a high suspicion of these malignancies should be entertained whenever subtle symptoms and unexplained gastrointestinal blood loss are assessed.

Chronic intestinal pseudo-obstruction is a rare syndrome with high morbidity and mortality. The pathophysiology is not well understood, although it is postulated that it involves some sort of neuropathic and/or myopathic dysfunction resulting in intestinal dysmotility. We present the first case of chronic intestinal pseudo-obstruction secondary to a paraneoplastic syndrome associated with a primary small cell prostate cancer.

INTRODUCTION: Paralytic ileus presents similarly to mechanical obstruction; however, there is absence of a culprit anatomic lesion. It is commonly due to surgical intervention, peritonitis, trauma, medications, electrolyte disturbances, or intestinal ischemia. CASE DESCRIPTION/METHODS: This is the case of an 86-year- old male with past medical history of Parkinson's Disease and hypertension who was admitted at IM ward due to complicated UTI and bacteremia. During hospitalization, the patient developed abdominal distention and referred not having a bowel movement in 5 days. Physical exam was remarkable for a distended, tympanic, and non-tender abdomen. Labs displayed improving leukocytosis, normocytic-normochromic anemia, and absence of electrolyte disturbances. KUB was ordered, which revealed a very dilated stomach with gaseous distention in the stomach and small intestine as well as moderate amount of stool in the colon. As a result, Miralax, a sodium phosphate enema, and a nasogastric tube with intermittent suction were recommended. However, no bowel movements were reported as a result. Therefore, mineral oil was recommended the following day. Given lack of significant improvement, half a gallon of polyethylene glycol (golytely) was added to therapy. Two large bowel movements were achieved as a result. However, the patient's abdomen continued distended and tympanic for which CT abdomen with contrast was done. CT results showed no evidence of mechanical obstruction. Given lack of improvement despite interventions, trihexyphenidyl, which patient had recently started for Parkinson's Disease, was discontinued. Patient was not on opioid or other constipation inducing medications. Five bowel movements were reported in the 24-hours that followed removal of medication. The following day KUB displayed improvement and physical exam was remarkable for positive bowel sounds in all 4 quadrants and a non- tender, non-distended abdomen. DISCUSSION: Rapid resolution of symptoms suggests trihexyphenidyl as culprit. It is important to note that although anti-cholinergics are known to cause or precipitate paralytic ileus, few cases have been reported as a result of trihexyphenidyl use. Trihexyphenidyl is prescribed with frequency for the treatment of Parkinson's Disease, being aware of its side effects may lead to prompt diagnosis and better outcomes.

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