Upper Gastrointestinal Bleed: An Unusual Presentation of Pancreatic Cancer

Abstract

Pancreatic cancer is the 4th leading cause of deaths related to cancer. Most common presenting clinical signs and symptoms include abdominal pain, loss of appetite, weight loss, and jaundice. Unusual signs of pancreatic cancer include depression, thrombophlebitis, and skin manifestations. We demonstrate a case of pancreatic cancer with an uncommon presentation, upper gastrointestinal bleeding. A 73 year old female with hypertension, diabetes mellitus, chronic kidney disease presented to the Emergency Department (ED) for hypoglycemia (blood glucose of 36), decreased appetite and a 2 week history of right upper quadrant abdominal pain. Vital signs revealed a blood pressure of 96/58, pulse 71, temp 97.3, with 97% O2 saturation on room air. Examination revealed scleral icterus and significant jaundice. Stool was guaiac positive. Blood tests revealed a normocytic anemia with hemoglobin of 7.6, transaminitis with AST 267 and ALT 128 with elevated total bilirubin at 6.5. Right upper quadrant ultrasound was concerning for pancreatic mass. Magnetic resonance cholangiopancreatography (MRCP) revealed an ill-defined soft tissue thickening in distal common bile duct, pancreatic head, and first and second portion of duodenum concerning for infiltrative neoplasm. Before ERCP could be performed, patient experienced massive upper GI bleed requiring transfer to medical intensive care unit. Mesenteric angiogram revealed bleeding in the gastroduodenal artery which was subsequently embolized. Once patient was stabilized, ERCP was performed with pathology revealing mucin producing adenocarcinoma. In addition, gastric outlet obstruction of the duodenum was noted. Patient was referred to outside facility for endoscopic choledocogastrostomy stent insertion and gastrojejunostomy stent placement. However, patient expired approximately one month after discharge. Gastrointestinal bleeding is a rare complication in patients with pancreatic cancer. Pancreatic cancer presenting as GI bleed is reported to be as low as 2-3% and is associated with late stage disease and poor long term prognosis. With development of improved chemotherapy agents that prolong survival, it is likely GI bleed in pancreatic cancer will become more common, thus it is important to raise awareness of this uncommon, but potentially catastrophic complication. It is vital that physicians do not miss pancreatic cancer as a possible cause of GI bleeding.