Duodenal Invasion of Pancreatic Cancer and Hematemesis

Abstract

Gastrointestinal bleeding (GIB) is a commonly encountered issue requiring hospitalization. Pancreatic cancer is an uncommon etiology of GIB but has been described when the cancer invades the GI tract, though presentation with hematemesis is exceedingly rare. We present a patient who was admitted with hematemesis, and endoscopy revealed fistulization of pancreatic cancer into the duodenum. A 58-year-old woman undergoing chemotherapy for pancreatic cancer presented after an episode of hematemesis. Her hemoglobin of 7.6 g/dL on admission reduced further to 4.5 g/dL, requiring multiple blood transfusions. Pantoprazole infusion was initiated. IR arteriography was performed due to hemodynamic instability, but it did not reveal any extravasation or contrast pooling. However, it was concerning for involvement of the superior mesenteric artery by the pancreatic uncinate mass. Esophagogastroduodenoscopy showed hematin throughout the upper GI tract without any bleeding or potential bleeding sources. Further, more distal examination revealed a large, friable ulcerated mass in the fourth part of the duodenum. The mass appeared to have been bleeding previously with no active bleeding at the time of examination. It was also noted to be partially obstructing the lumen of the GI tract, and as such this area could not be traversed. CT scan of the abdomen revealed increase in size of the mass of the pancreatic uncinate process, extending into the root of the small bowel mesentery suggesting fistulization to the distal duodenum. External beam radiotherapy to the pancreatic mass with short-term palliation of bleeding was initiated. Malignant pancreatic tumors rarely cause luminal GIB; presentation with bleeding usually indicates a poor prognosis due to tumor extension. When such bleeding does occur, it typically manifests as melena or hematochezia and is rarely described to present with hematemesis. GIB usually results from invasion of the duodenum, as the thicker gastric wall makes gastric invasion unlikely to bleed. In this patient, the endoscope was advanced into the fourth part of the duodenum as no active bleeding could be identified in the proximal GI tract, resulting in finding the source of the patient's hematemesis. This suggests that patients with GIB and negative evaluation of the esophagus, stomach and proximal duodenum should undergo further examination in all parts of the duodenum, especially in the setting of known pancreatic malignancy.Figure: Duodenum reveals congested mucosa with luminal narrowing on EGD.Figure: Ulcerated mass in the fourth part of the duodenum on EGD.