Hepatocellular Carcinoma Masquerading As A Bleeding Gastric Ulcer

Abstract

Purpose: To report an atypical presentation of hepatocellular carcinoma (HCC), mimicking a bleeding stomach ulcer, controlled by transcatheter arterial embolization (TAE). Clinical vignette: 72 year old African American male with a history of alcohol abuse presents with hematemesis and anemia. Endoscopy revealed an extrinsically compressed stomach with outlet obstruction and a small bleeding ulcer with a protruding central lesion (Figure 1). Endoscopic hemostasis was unsuccessful. Angiography was performed revealing prominent neoplastic vascularity fed by the left gastric artery (LGA), at the site of the obstructed gastric air column, corresponding to the endoscopic site of bleeding (Figure 2). TAE of the LGA was performed achieving hemostasis. A dynamic computed tomography of the abdomen with intravenous contrast showed a large 16 cm mass in the left dome of the liver that was fused to the stomach. Alfa fetoprotein level was 227,308 ng/ml, thus establishing the diagnosis of HCC. No recurrence of bleeding occurred during the hospital stay and the hemoglobin remained stable. Discussion: HCC is the twelfth most common cancer in the United States. Bleeding from the upper gastrointestinal tract in patients with HCC can occur as a sequelae of portal hypertension. Locoregional invasion of the stomach leading to upper gastrointestinal hemorrhage has been rarely reported in the literature, with diagnosis and hemostasis achieved by surgical approach (Table 1). Our case illustrates the efficacy of TAE in controlling HCC tumor bleeding resulting from gastric wall invasion. This method should be attempted as first line approach given the high surgical risk and the poor prognosis associated with locally advanced HCC.FigureFigure