2595 Metastatic Urothelial Carcinoma to the Duodenum: An Unusual Cause of Duodenal Stenosis

Abstract

INTRODUCTION: Bladder cancer typically presents within the confines of the bladder wall with less than 4% of cases spreading to distant lymph nodes and organs. We present a unique case of gastric outlet obstruction with early satiety and weight loss secondary to usual mass effect from metastatic bladder cancer in the duodenum. CASE DESCRIPTION/METHODS: An 81-year-old male presented with two weeks of bilious vomiting, early satiety, and 20 lb weight loss. Medical history significant for prostate cancer status post prostatectomy with biochemical recurrence and bladder cancer status post radical cystectomy. On physical exam, he had mild epigastric tenderness. Labs were significant for metabolic alkalosis, acute kidney injury, and normal liver function tests. MRI of the abdomen showed diffuse thickening of the duodenal wall. He subsequently underwent an esophagogastroduodenoscopy (EGD), which revealed gastric outlet obstruction at the second portion of the duodenum. An endoscopic ultrasound (EUS) was performed which revealed no pancreatic head mass. However, a two centimeter hypoechoic thickening of the second portion of the duodenum with resultant peri-duodenal biopsies via fine needle aspiration revealed metastatic urothelial carcinoma. Patient was managed conservatively with nasogastric tube placement. With gradual improvement to a soft diet, he was discharged home with plans for outpatient palliative chemotherapy. However, he was readmitted two weeks later with similar complaints and underwent an exploratory laparotomy and palliative gastrojejunostomy. The patient was discharged on a soft diet and plans for platinum chemotherapy. DISCUSSION: Bladder cancer ranks as the ninth most frequently-diagnosed cancer worldwide. It typically spreads via the lymphatic and hematogenous routes with the most common sites involving: regional lymph nodes, liver, lung, and bone. Metastasis to the duodenum is extremely rare and to the best of our knowledge is only reported in 4 cases in the literature to date. Three of these cases presented as duodenal obstruction and one case presented as a massive upper GI bleeding. We describe an uncommon presentation of gastric outlet obstruction from bladder metastasis to the duodenum in a patient whose cancer was in remission. Tumor metastasis should be considered in a patient with a history of cancer and presenting with gastric outlet obstruction despite a normal EGD. We also highlight the utility of EUS as a safe and minimally invasive procedure to establish the diagnosis.