An Unusual Cause of Obscure Gastrointestinal Bleeding

Abstract

Question: A 54-year-old man was referred to our hospital with a 1-month history of intermittent tarry to bloody stool. His medical history included hepatitis B–related liver cirrhosis and hepatocellular carcinoma (HCC). His hepatoma was diagnosed 1 year earlier (American Joint Committee on Cancer Staging T3aN0M0) , and he was treated with radiofrequency ablation and tumor embolization. The tumor recently progressed with portal vein tumor thrombosis (Figure A). He underwent sorafenib therapy; however, the drug was discontinued after the bleeding episode. Examination with upper endoscopy and colonoscopy failed to identify the cause of bleeding. Despite medical therapy, including a proton pump inhibitor and octreotide, the bleeding persisted, and he was referred to our hospital for deep enteroscopy. The laboratory examination revealed anemia (hemoglobin 9.1 g/dL), thrombocytopenia (platelet count, 131 × 109/L), and a normal prothrombin time. The calculated Model for End-stage Liver Disease score was 8 and the Child-Pugh class was B. Deep enteroscopy via the anal route was performed, and a lesion at 100 cm from the ileocecal valve was found (Figure B, Video Clip A). What are the findings of enteroscopy? What is the differential diagnosis? Look on page 361 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Enteroscopy revealed a bleeding submucosal tumor in the ileum (Figure B). Hemostasis via enteroscopy failed, and a submucosal tattoo was placed around the lesion. Review of the computed tomography examination revealed a previously unrecognized tumor in the ileum (Figure C, arrow). To control the bleeding, the patient decided to undergo laparoscopic tumor resection (Figure D). Pathologic examination revealed a 2.5-cm ulcerative tumor involving the whole layer of the small intestine with pleomorphic nuclei, coarse chromatin, prominent nucleoli, and abundant eosinophilic cytoplasm (Figure E) with positive staining for Hep-par-1 (Figure F). Metastatic HCC was diagnosed. After surgery, the bleeding was controlled, but the patient died of progressive liver failure after 6 weeks. HCC is the most common liver malignancy. Distant metastases from HCC usually involve the lung, regional lymph nodes, bone, or adrenal glands, and only 0.2% of metastatic HCC involve the gastrointestinal tract.1Chen L.T. Chen C.Y. Jan C.M. et al.Gastrointestinal tract involvement in hepatocellular carcinoma: clinical, radiological and endoscopic studies.Endoscopy. 1990; 22: 118-123Crossref PubMed Scopus (79) Google Scholar The mechanisms of gastrointestinal tract metastasis are direct invasion (82%), hematogenous metastasis (9%), and seeding (9%), and most cases are discovered at autopsy.2Yang C.W. Soon M.S. Chen Y.Y. et al.Synchronous metastasis to the oral cavity and proximal upper small intestine as an initial presentation of hepatocellular carcinoma: report of a case.Gastroenterol J Taiwan. 2009; : 318-320Google Scholar The present case was considered to have hematogenous spread because of portal vein tumor thrombus and no peritoneal dissemination or direct invasion. Endoscopic findings of gastrointestinal metastases from HCC included raised and centrally ulcerated lesions, polypoid tumors, and submucosal tumors.1Chen L.T. Chen C.Y. Jan C.M. et al.Gastrointestinal tract involvement in hepatocellular carcinoma: clinical, radiological and endoscopic studies.Endoscopy. 1990; 22: 118-123Crossref PubMed Scopus (79) Google Scholar, 2Yang C.W. Soon M.S. Chen Y.Y. et al.Synchronous metastasis to the oral cavity and proximal upper small intestine as an initial presentation of hepatocellular carcinoma: report of a case.Gastroenterol J Taiwan. 2009; : 318-320Google Scholar The treatment of HCC with gastrointestinal tract metastases comprises palliative care, minimally invasive surgery, or rarely, endoscopic resection.3Igawa A. Oka S. Tanaka S. et al.Small bowel metastasis of hepatocellular carcinoma detected by capsule endoscopy.Case Rep Gastroenterol. 2013; 7: 492-497Crossref PubMed Scopus (7) Google Scholar The prognosis is usually ominous with a median overall survival of 5 months, because gastrointestinal involvement is often a sign of advanced disease.2Yang C.W. Soon M.S. Chen Y.Y. et al.Synchronous metastasis to the oral cavity and proximal upper small intestine as an initial presentation of hepatocellular carcinoma: report of a case.Gastroenterol J Taiwan. 2009; : 318-320Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhMjYxNTVkZmZkYjU3NjRkYjlmMTAxZDc2NGRiZTZjZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDkzMTYzfQ.gdjzK2Nf51DgpOUxpyDVFJgvcc-1uFMg1xcGldDxkDRwgr2AgdFYgTWngJGS61kOUBpAhf3qRuJTNYKkDx9DkX4KQX1FYq5EUoWWRg4oFhL_VIZvDHAXfAtczZVEO_TVyrmguX12SRZFCnTd0_pMze0DJqL08Z_k3nG51b3-46KHlBbts1qKZhr-VGQc7NgQHuv82BEymLbZfKXCY2KT83UqeigxGVTnA9ZsR7pTF9-VSZXsRoEVxSEaITBsmO-1YUJK7065Zj4cFT4h5GgN9m3Zj7MSdf5DnK9DdvdxU-qhqGXXrhz11BUGr9XjiEo7YXaHKNQJ-q6s_jVcGsTqJA Download .mp4 (63.22 MB) Help with .mp4 files Video Clip