2572 Metastatic Renal Cell Carcinoma to the Small Bowel: A Rare Cause of Gastrointestinal Hemorrhage

Abstract

INTRODUCTION: We present a case of overt gastrointestinal blood loss which after thorough investigation, was found to be a manifestation of metastatic renal cell carcinoma (RCC). CASE DESCRIPTION/METHODS: A 55 year-old female with a history of clear cell RCC removed with nephrectomy and breast cancer on chemotherapy presented with melena and abdominal pain. The patient was assessed in the ED and was hemodynamically stable. On exam she had tenderness in her left lower quadrant. She was found to have a hemoglobin of 8.2 g/dL. CT revealed active diverticulitis, but no obvious masses were noted. Gastroenterology evaluated the patient and recommended admission and EGD for further evaluation. The EGD was obtained which did not reveal any source of bleeding, which prompted colonoscopy. The colonoscopy demonstrated sigmoid diverticulosis, patchy segmental inflammation of the sigmoid colon, but no active bleeding. Approximately one week later, the patient was readmitted for worsening fatigue and continued melena. A capsule endoscopy was done which revealed a bleeding mass in the proximal and distal small bowel. A push enteroscopy was advanced to the jejunum but no bleeding was found. MRE was completed, which revealed a 1.9 × 1.6 cm nodule in the left pelvic small bowel, diverticulitis as well as a 3.2 × 2.2 cm left lower pole renal mass. The patient later went for an exploratory laparotomy with resection of two segments of small bowel. Pathology showed a diagnosis of metastatic renal cell carcinoma. DISCUSSION: Renal cell carcinoma is a common urological malignancy that can have many systemic complications. RCC presents with metastasis in as many as 30% of cases, however some signs may not lead physicians to timely diagnosis. RCC metastasizes to the small bowel in less than 0.5% of cases. Of these cases, gastrointestinal bleeding occurs in 1% of cases with <1% of cases coming from the small bowel. Small bowel involvement is rare and there are only a few case reports reporting this presentation. GI bleeding from metastatic RCC is an underdiagnosed disease and can cause increased morbidity and mortality. Being able to diagnose metastatic cancer and small bowel bleeding can be difficult. When it causes potentially life threatening symptoms, it becomes a priority to diagnose it. Prompt treatment requires knowledge of complications of RCC. Being able to identify these complications will not only allow us to improve outcomes in patients, but to better understand and anticipate future complications for our future patients.