Gastric Outlet Obstruction as the Initial Presentation of Locally Advanced Urothelial Carcinoma

Abstract

Gastric outlet obstruction (GOO) is often the first sign of advanced upper gastrointestinal neoplasms. The most common neoplastic causes include gastric, pancreatic, and biliary tract cancers. Urothelial carcinoma (UC) is among the top 10 most common cancers in the United States. Approximately 5-10% of all UC arise from the upper urinary tract, which includes the renal pelvis and ureter. Unlike UC in the bladder, these upper urinary tract urothelial carcinomas (UTUC) spread more often by direct invasion and extension, and via the lymphatic system. We report a case of a patient with GOO who was found to have locally advanced urinary tract urothelial carcinoma. An 80-year-old female with a history of GERD and hypothyroidism initially presented with right-sided flank pain. CT scan showed right renal pelvis dilation with inflammatory changes surrounding the ureter. Cystoscopy revealed a right ureteral stricture and thus a ureteral stent was placed. Cytologic analysis of the urine and ureteral brushings were negative for malignancy. Her symptoms improved and she was discharged home. She then presented two months later with diffuse abdominal pain, nausea, and vomiting for five days and obstipation for two days. She was afebrile and hemodynamically stable. Her exam was notable for right upper quadrant and epigastric pain with hypoactive bowel sounds. Laboratory studies revealed a mild leukocytosis and bacteriuria with normal liver function tests. CT scan showed a mass in the right renal pelvis compressing the duodenum leading to gallbladder distention and common bile duct dilation (12mm). Small bowel series confirmed partial obstruction of the second portion of the duodenum. CT-guided biopsy of the renal mass was performed which revealed poorly differentiated urothelial carcinoma. A percutaneous endoscopic jejunostomy tube was placed. Following neoadjuvant chemotherapy, the duodenal obstruction resolved. Symptoms of GOO are often nonspecific and include abdominal pain, early satiety, weight loss, and vomiting. This patient presented with a rare cause of malignant GOO secondary to locally invasive urinary tract urothelial carcinoma. The time lag between onset of initial symptoms to the onset of clinically significant GOO demonstrates the difficulty of diagnosing this disease. A review of the literature revealed two earlier instances of UTUC as a cause of GOO and thus our case represents a very rare presentation of UC presenting as gastric outlet obstruction.2685_A Figure 1. Significant distension of the stomach and proximal duodenum with wall thickening of the second and third parts of the duodenum along with gallbladder distension and biliary ductal dilatation.2685_B Figure 2. Significant distension of the stomach and proximal duodenum with wall thickening of the second and third parts of the duodenum along with gallbladder distension and biliary ductal dilatation.2685_C Figure 3. Urothelial carcinoma invading into renal parenchyma (hpf)