Small bowel adenocarcinomas (SBA) are rare malignancies with exceedingly low survival rates, with different presentation in Crohn’s disease (CD). CD-induced SBA poses diagnostic challenges given overlapping presentation with stricturing CD and lack of diagnostics for early detection. Moreover, guidance is lacking on the impact of recently approved therapeutics in CD on SBA management. Here, we aim to highlight the future of CD-induced SBA management and discuss the potential merit of balloon enteroscopy and genetic testing for earlier detection.

We report the case of a 60-year-old female with longstanding Crohn’s ileitis, presenting with acute obstructive symptoms attributed to stricturing phenotype. Her obstructive symptoms were refractory to intravenous (IV) steroids, with further investigation via computed tomography enterography not providing additional diagnostic yield. Ultimately, surgical resection revealed SBA in the neoterminal ileum, with oncologic therapy plan created. However, this therapy plan could not be initiated due to continued obstructive symptoms attributed to active CD. Ultimately, infused biologic therapy was initiated, but her obstructive symptoms continued to remain dependent on IV corticosteroids. Review of diagnostics by a multidisciplinary care team suggested metastatic disease in the peritoneum, lending to a shift in the goals of care to comfort.

With the diagnostic and therapeutic challenges of concurrent SBA and CD, multidisciplinary care and algorithmic management can optimize outcomes.

• Crohn’s disease
• Small bowel adenocarcinoma
• Management
• Diagnosis
• Case report

• Crohn’s disease
• Inflammatory disorders
• Small bowel adenocarcinoma

Crohn’s disease (CD) is a chronic remittent idiopathic disease. Although the early phase of the disease is commonly characterized by inflammation-driven symptoms, such as diarrhea, the frequency of fibrostenotic complications in patients with CD increases over the long-term course of the disease. This review presents the current diagnostic options for assessing CD-associated strictures. In addition to the endoscopic evaluation of CD strictures, this review summarizes the currently available imaging modalities, including ultrasound and cross-sectional imaging techniques. In addition to stricture detection, differentiating between the primarily inflammatory strictures and the predominantly fibrotic ones is essential for selecting the appropriate treatment strategy (anti-inflammatory medical treatment vs endoscopical or surgical approaches). Therefore, recent imaging advances, such as contrast-enhanced ultrasound and ultrasound elastography, contribute to the development of non-invasive non-radiating imaging of CD-associated strictures. Finally, novel magnetic resonance imaging techniques, such as diffusion-weighted, motility and magnetization transfer imaging, as well as ¹⁸F-FDG PET/CT, molecular imaging approaches and biomarkers, are critically reviewed with regard to their potential role in assessing stricturing CD.

• Crohn’s disease
• Inflammatory bowel disease
• Intestinal stricture
• Endoscopy
• Magnetic resonance imaging
• Ultrasound
• Computed tomography
• ¹⁸F-FDG PET/CT CEUS
• Elastography

• Constriction, Pathologic
• Crohn Disease/complications
• Crohn Disease/diagnosis
• Diagnostic Imaging/methods
• Endoscopy, Gastrointestinal/methods
• Humans
• Intestinal Obstruction/diagnostic imaging
• Intestinal Obstruction/etiology
• Intestines/diagnostic imaging
• Predictive Value of Tests
• Prognosis

This review of the literature on small bowel carcinoma associated with Crohn’s disease specifically addresses the incidence, risk factors, and protective factors which have been identified. It also reviews the clinical presentation, the current modalities of diagnosis, the pathology, treatment, and surveillance. Finally, the prognosis and future direction are addressed. Our experience with small bowel adenocarcinoma in Crohn’s disease is reported. Readers will be provided with a better understanding of this rare and often poorly recognized complication of Crohn’s disease.

• Crohn’s disease
• Small bowel adenocarcinoma
• Cancer risk
• Cancer malignancy
• Incidental carcinoma
• Late complications of Crohn’s disease
• Inflammatory bowel disease

• Adenocarcinoma/diagnosis
• Adenocarcinoma/epidemiology
• Adenocarcinoma/therapy
• Crohn Disease/diagnosis
• Crohn Disease/epidemiology
• Crohn Disease/therapy
• Humans
• Incidence
• Intestinal Neoplasms/diagnosis
• Intestinal Neoplasms/epidemiology
• Intestinal Neoplasms/therapy
• Intestine, Small/drug effects
• Intestine, Small/pathology
• Intestine, Small/surgery
• Predictive Value of Tests
• Prognosis
• Protective Factors
• Risk Assessment
• Risk Factors

• Adaptation
• Atrophy
• Enteroscopy
• Ileum
• Jejunum
• Small intestine

• Animals
• Humans
• Intestinal Diseases/pathology
• Intestinal Mucosa/pathology

• Crohn’s disease
• device-assisted enteroscopy
• enteroscopy
• inflammatory bowel disease
• review

Cancer of the small intestine is very uncommon. There are 4 main histological subtypes: adenocarcinomas, carcinoid tumors, lymphoma and sarcoma. The incidence of small intestine cancer has increased over the past several decades with a four-fold increase for carcinoid tumors, less dramatic rises for adenocarcinoma and lymphoma and stable sarcoma rates. Very little is known about its etiology. An increased risk has been noted for individuals with Crohn’s disease, celiac disease, adenoma, familial adenomatous polyposis and Peutz-Jeghers syndrome. Several behavioral risk factors including consumption of red or smoked meat, saturated fat, obesity and smoking have been suggested. The prognosis for carcinomas of the small intestine cancer is poor (5 years relative survival < 30%), better for lymphomas and sarcomas, and best for carcinoid tumors. There has been no significant change in long-term survival rates for any of the 4 histological subtypes. Currently, with the possible exceptions of obesity and cigarette smoking, there are no established modifiable risk factors which might provide the foundation for a prevention program aimed at reducing the incidence and mortality of cancers of the small intestine. More research with better quality and sufficient statistical power is needed to get better understanding of the etiology and biology of this cancer. In addition, more studies should be done to assess not only exposures of interest, but also host susceptibility.

• Cancer of the small intestine
• Histology
• Incidence
• Risk factors
• Survival