Abstract

Melanoma is commonly known to metastasize to the gastrointestinal tract (GIT) with a predilection for the small bowel (SB). Early signs of melanoma in the GIT are iron deficiency anemia and abdominal pain with later findings including overt gastrointestinal bleeding (GIB), obstruction or intussusception. This case highlights a common presentation of metastatic melanoma requiring multiple endoscopic modalities for diagnosis. An 81 year-old male with a history of metastatic melanoma to the brain presented at an outside hospital with bright red blood per rectum. Initial work-up included an esophagoduodenoscopy (EGD) revealing non-erosive gastritis and a colonoscopy remarkable for large amounts of blood coming from the SB. A nuclear medicine tagged RBC scan did not localize a source of bleeding. He underwent a video capsule endoscopy (VCE), showing multiple non-bleeding SB arteriovenous malformations (AVMs), which he was transferred to our tertiary care center for further intervention and management. Due to report of SB AVMs, he underwent an antergrade single balloon enteroscopy revealing a 3 cm infiltrative, ulcerative, easily friable mass in the mid-jejunum (Figure A). Biopies were taken and pathology was consistent with metastatic melanoma (Figure B). Diagnosis and treatment of SB metastatic melanoma resolves the presenting complications but more importantly is associated with prolonged survival1. A randomized prospective study showed higher diagnostic yield of VCE compared to push enteroscopy (50% and 24% respectively) for obscure GIB. This paper cites other studies that collaborate this finding2. In this study, VCE did not miss lesions detected by enteroscopy while enteroscopy missed lesions detected by VCE in 26% of patients. Thus it is surprising that the large sized melanoma was not identified after a VCE, but instead identified with pursuant enteroscopy. This case illustrates the importance of using multiple endoscopic modalities, even in diagnosing lesions commonly presenting in the GIT, as no single modality is highly sensitive to evaluate for SB bleeding. As in our case, diagnosis of metastatic melanoma in the SB will potentially lead to further surgical treatments and increased survival.Figure 1Figure 2

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