2666 Disseminated Renal Cell Carcinoma Presented as Obscure Gastrointestinal Bleeding

Abstract

INTRODUCTION: Metastatic disease to the gastrointestinal tract is frequently observed in patient with known disseminated malignancies. Among those, melanoma, breast and lung cancer are commonly reported. Renal cell carcinoma (RCC) metastasis to small bowel is rare and the presentation varies from obstructive symptoms, intussusception, as well as, gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 85 years old male with medical history of pulmonary embolism on apixaban and progressive stage IV RCC despite multiple lines of therapy on lenvatinib, presented with progressive fatigue and melenic stools. Denied abdominal pain, change in bowel habits, prior episodes of bleeding, or NSAIDs use. Vital signs were unremarkable. Physical exam was pertinent for non-tender abdomen, no distention, active bowel sounds, no rebound or guarding, and a rectal exam that revealed melenic stools. Labs: Hemoglobin of 6.8 g/dL (Baseline 10.3 g/dl), electrolytes, kidney and liver function tests were unremarkable. Computerized tomography (CT) of the abdomen and pelvis revealed multiple hepatic, retroperitoneal and mesenteric metastases. He received two units of packed red blood cells with appropriate response. Apixaban was held and he was admitted for workup of gastrointestinal bleeding. Esophagogastroduodenoscopy was unrevealing, while colonoscopy showed a few non-bleeding colonic and rectal angioectasias. A subsequent capsule endoscopy demonstrated an actively bleeding jejunal lesion (Figure 1). He continued to have large melenic bowel movements, and his hemoglobin decreased to 5.5 g/dL. A computed tomography angiography showed a blush of contrast in the jejunum, near the site of a tumor implant (Figures 2 and 3). An interventional radiology embolization was performed, with successful hemostasis. DISCUSSION: One autopsy series reported that only 2 out of 44 metastatic tumors to the small intestine were duodenal implants of RCC. In recent years, however, the number of published reports of RCC small bowel metastasis has been increasing. Retrograde venous spread to the paravertebral vessels has been propose as the route of dissemination of RCC to the intestine and solitary, bulky hypervascular lesions might be diagnostic if seen on CT scan. Luminal evaluation may localize the bleeding and offer potential treatment, however, angiography with embolization is the preferred therapeutic approach for small intestine lesions. Small bowel metastases must be considered as an etiology of bleeding when patients with RCC present with melena.