Obscure Overt Gastrointestinal Bleeding Secondary to Jejunal Metastasis of Urothelial Cell Carcinoma Diagnosed by Deep Enteroscopy

Abstract

Introduction: Metastatic urothelial cell carcinoma (previously referred to as transitional cell carcinoma) is a very rare cause of gastrointestinal bleeding. We present a case of obscure overt gastrointestinal bleeding from metastatic urothelial cell carcinoma to the jejunum. Case Report: A 57 year old male presented with the onset of hematochezia and hematemesis after 2 days of epigastric pain with hemoglobin of 6 g/dL and INR of 15. Twenty months prior, he had been diagnosed with urothelial cell carcinoma of the urinary bladder (T3N1M0). The initial staging CT scan did not have evidence of distant metastases but noted an incidental pulmonary embolus for which he was anticoagulated. A repeat CT of the abdomen revealed a 3.7 × 5 cm jejunal mass, a 2.6 × 2.7 cm mass at the ileojejunal junction and a 3.4 × 3.5 cm mass in distal descending colon. After resuscitation and correction of coagulopathy, an EGD was performed and found LA Grade C esophagitis that was thought to be the likely source of symptoms. After stopping anticoagulation and placing an IVC filter, he was discharged. He was readmitted 6 weeks later with melena and microcytic anemia with hemoglobin of 5.9 g/dL. Repeat CT of the abdomen had no change in the intestinal findings. Push enteroscopy showed resolution of esophagitis and no identifiable source of melena. Colonoscopy could not be completed due to severe angulation and extrinsic compression on the sigmoid. An antegrade double-balloon enteroscopy was performed and a large, fungating and ulcerated mass oozing blood was found in the distal jejunum. Oozing was stopped with argon plasma coagulation. Biopsies showed metastatic urothelial carcinoma histologically and immunohistochemically compatible with the initial bladder malignancy. He stabilized and was discharged for further outpatient management. Within 2 weeks, he was readmitted for melena. At laparotomy, the jejunal mass was found adherent to and compressing the sigmoid colon. Resection was performed and pathology confirmed metastatic urothelial carcinoma with inflammatory adhesions. He had no further overt bleeding or anemia while hospitalized. Conclusion: To our knowledge, there are no other reported cases of urothelial cell carcinoma metastatic to the jejunum causing gastrointestinal bleeding; in fact, there are only 4 reported cases of symptomatic small bowel lesions (2 duodenal, 2 ileal). Despite this scarcity, there is a 13% prevalence of metastases to the gastrointestinal tract in autopsy series and in the appropriate setting should be considered in the differential diagnosis of obscure overt gastrointestinal bleeding.