Massive Gastrointestinal Bleed from Gastric Carcinoid Tumor

Abstract

Purpose: Gastric carcinoid tumors are rare, constituting less then 1% of all gastric tumors. A third of patients are diagnosed incidentally, while anemia is not an uncommon presentation. However, massive gastrointestinal (GI) bleeding is a rare presentation. We report a case of gastric carcinoid presenting with massive upper GI bleed. Methods: Case Report Results: A 70-year-old female presented with hematemesis and hematochezia associated with a near syncopal event. She denied using nonsteroidal anti-inflammatory medications, prior ulcer disease, or history of GI bleeding. Following aggressive resuscitation, she was normotensive, but still tachycardic. Hemoglobin was 7.8 g/dL. Emergent endoscopy noted a 1 cm nodular mass with central erosion located on the posterior wall of the greater curvature of the stomach. A massive pulsating arterial bleed originated from this lesion. Hemostasis was unsuccessful with epinephrine (1:10,000) and heater probe application, but ultimately achieved with argon plasma coagulation (APC). No other polyps or masses were noted in the stomach. A total of seven units of packed red cells were required before hemodynamic stability occurred. Repeat endoscopy with biopsy of the lesion and antrum performed three days later revealed nests of carcinoid cells without evidence of atrophic gastritis or Heliobacter pylori infection. Work up for multiple endocrine neoplasia and hypergastrinemia was negative. Abdominal CT was negative for local lymphadenopathy or metastasis. Endoscopic ultrasound (EUS) performed one month later revealed irregularity confined to the mucosa and repeat deep biopsy was negative. She is asymptomatic at 6 months of follow up. Conclusion: Gastric carcinoids can be classified into three different types. Type I and II tumors are associated with hypergastrinemia (primary or secondary) or multiple endocrine neoplasia and usually have a benign clinical course. Type III tumors, however, are sporadic and have malignant potential. Infrequently, small carcinoids (1–1.5 cm size) can be associated with arterial vascular anomalies that can erode and result in massive GI bleeding typically requiring surgical treatment for hemostasis. In our case, a type III gastric carcinoid presented with massive GI bleed and was successfully treated entirely endoscopically with hemostasis achieved with APC. Despite risk of metastasis in type III carcinoid, favorable prognostic factors (size < 2 cms, lack of submucosal invasion on EUS) have allowed us to follow this patient endoscopically.