To the Editor
We briefly present a case of a 58-year-old man with a 3-month history of dyspepsia, constipation, and tenesmus recently referred to our emergency department for evaluation of abdominal pain and recurrent vomiting.
Medical history did not show any relevant problems. On presentation to the emergency department our patient was afebrile, with all other vital signs within normal limits. On physical examination, his abdomen was mildly distended, with diffuse pain on palpation; there was no guarding or rebound tenderness. Rectal exploration revealed a hard, concentric stenosis 6 cm from the anal verge. Results of blood tests, chest radiography, and an ECG were normal. An abdominal computed tomography showed a thickening of the gastric antrum and, simultaneously, confirmed an extended concentric stenosis of the whole rectum from the sigmoid junction to the anal verge (Fig. 1a,b). Endoscopic evaluations detected a wide substenotic ulcerative lesion of the medium and distal thirds of stomach and a strict insuperable stenosis of lower rectum with apparently normal mucosa. The gastric biopsies revealed a signet-ring cell gastric adenocarcinoma and histopathological findings of the rectum samples did not show any sign of tumoral involvement. Magnetic resonance of the pelvis confirmed an asymmetric thickening of the proximal rectum and a symmetric concentric stenosis of the medium-distal rectum along with some lymphadenopathies within mesorectum and presacral space. Laparotomy was performed with a working diagnosis of non-metastatic locally advanced gastric cancer, but surgical findings also included a hardening of rectal and perirectal tissue below the peritoneum. A total gastrectomy and a lateral decompressive left colostomy, along with a number of biopsies of perirectal tissue, were performed. Histopathological findings were consistent with signetring cell adenocarcinoma of stomach (with muscular layer and nodal involvement) and with infiltration of signet-ring cell adenocarcinoma of the rectal wall. Subsequently, the patient was referred for adjuvant chemotherapy.
The rectal stenosis can be an atypical sign of gastric cancer and can to occur as a result of peritoneal dissemination of disease or, rarely, as result of lymphangitic spread of poorly differentiated signet-ring cell adenocarcinoma within the submucosa of the gastrointestinal tract (Schnitzler's metastasis). In published case reports, lymphangitic involvement of the rectum is associated with a widespread extension of disease and, more often, metachronously [1][2][3]. This is the first reported case with synchronous Schnitzler's metastasis associated with a (otherwise non-metastatic) primary gastric cancer.