S3439 Not All That Bleeds Is of Gastrointestinal Origin: Hemorrhagic Anemia From the Nasopharynx

Abstract

INTRODUCTION: There is a vast differential diagnosis as to the underlying etiology for acute blood loss anemia, and gastrointestinal hemorrhage is often the culprit. When signs and symptoms are unclear and initial routine endoscopy is unremarkable, capsule endoscopy can be a beneficial test to better ascertain the location of the bleed. While capsule endoscopy is often utilized to identify occult gastrointestinal bleeding, it can also pinpoint alternative etiologies to blood loss. This case highlights the importance of maintaining a broad differential when approaching acute blood loss anemia. CASE DESCRIPTION/METHODS: A 62-year-old female with a history of chronic pain on daily non-steroidal anti-inflammatory medication presented to the emergency room with weakness and malaise. Initial hemoglobin was 3.4 g/dL, down-trending to 2.8 g/dL with concern for acute blood loss. Further studies revealed iron deficiency anemia with an iron level less than 15 and a ferritin of 12.6; occult blood testing was negative. Esophagogastroduodenoscopy demonstrated a hiatal hernia, Schatzki’s ring, and poor dentition with loose teeth, but no active bleed was identified. Colonoscopy showed mild sigmoid diverticulosis and distal colitis, however no bleeding was located to account for the patient’s profound anemia. Capsule endoscopy revealed an active bleed from the mouth (Figure A) with bright red blood in the esophagus and stomach along with dark blood in the small intestine without active bleed. These findings suggested acute blood loss from hemorrhagic gingivitis versus traumatized gingiva around the teeth. Computed tomography of the neck with contrast identified an ulcerated malignancy occluding the nasopharyngeal airway. Positron emission tomography confirmed the large nasopharyngeal mass without distant metastatic disease (Figure B), and subsequent biopsy revealed a non-keratinizing squamous cell carcinoma secondary to human papillomavirus sixteen (Figure C). Though deemed a poor surgical candidate, the patient underwent chemoradiation and was eventually discharged to a skilled nursing facility and continues to do well several months later. DISCUSSION: This case reveals the importance of maintaining a broad differential diagnosis as to the underlying etiology for acute blood loss anemia, especially when initial suspected gastrointestinal hemorrhage workup is unremarkable. Capsule endoscopy is a useful tool in the evaluation of anemia when upper and lower endoscopy do not reveal the underlying etiology for anemia.Figure 1.: Capsule endoscopy identifying the underlying mass accounting for the hemorrhage.Figure 2.: Positron emission tomography highlighting the nasopharyngeal mass.Figure 3.: H&E of the non-keratinizing squamous cell carcinoma at 200 magnification.