Metastatic invasive lobular breast cancer with emergency surgery for bowel obstruction

What happened, in summary

A 68-year-old woman had invasive lobular carcinoma of the left breast with known metastases to the peritoneum and ovaries. She was receiving hormonal therapy and had already required right ureteric stenting because a metastatic pelvic mass was compressing the ureter. She came to the emergency department with 24 hours of right flank pain, constipation, and nausea. She had no vomiting at first, and her abdomen was soft, non-distended, and not tender. Blood tests did not show leukocytosis or high C-reactive protein, and kidney and liver function were normal, though mild hyponatremia and hypoalbuminemia were present. Early X-rays did not show free air or clear air-fluid levels, and bedside ultrasound showed mild right kidney collecting-system fullness and minimal pelvic ascites. She was initially managed with bowel rest, intravenous fluids, and symptom control. About 12 hours after admission, her condition changed: she developed repeated vomiting and colicky abdominal pain, and nasogastric decompression drained bilious fluid. CT of the abdomen and pelvis then showed dilated jejunal loops, fecalized small bowel contents, and a transition point at the jejuno-ileal junction, suggesting a closed-loop small bowel obstruction. She underwent emergency exploratory laparotomy. Surgeons found 2 jejunal loops herniated through a 6 cm by 3 cm defect in the transverse mesocolon. The bowel looked congested but viable, so no resection was needed. They reduced the bowel and closed the defect. A large pelvic mass was seen, with metastatic deposits on the liver surface, mesentery, and omentum. She restarted oral intake on postoperative day 2, had bowel function by day 3, and was discharged stable on day 5.