A 73 yo man presented with a three day history of hematemesis.
Three days prior, he began vomiting red blood, progressively larger in quantity. His past medical history was most notable for CAD, atrial fibrillation (off coumadin), and renal cell carcinoma. 8 months prior to presentation the patient underwent embolization and right nephrectomy for his renal cell carcinoma. Of note, a CT scan, 1 month prior to presentation showed: a paraaortic and paracaval mass 6.7cm x 4.8cm in diameter, and paraaortic and paracaval lymphadenopathy.
On upper endoscopy, a large 2-3cm pulsating hematoma was found in the second portion of the duodenum; likely an erosion of an extrinsic mass into the duodenum. A mucosal defect at the tip of the hematoma was oozing blood intermittently. A side-viewing endoscope was advanced: the major papilla was noted nearby the mass but clearly separate and with clear bile output.
He was admitted to the ICU for monitoring and blood transfusions. A general surgery consult was obtained and commented the mass was intimately associated with the duodenum, pancreas head, IVC and aorta and therefore not amenable to surgery. IR embolization was discussed, but the patient deferred given risk of bowel ischemia and low likelihood of success given his vascular anatomy/supply to the area. He was discharged with hospice, and expired within one week.
Malignancy of the small bowel accounts for approximately 1-4% of upper GI bleeding. Renal cell carcinoma is thought to account for less than 10% of small bowel metastases. Renal cell carcinoma can behave unpredictably.
There have been several case reports of renal cell carcinoma metastases presenting as eroding vascular-enteric fistulas causing massive gastrointestinal hemorrhage. Management can be surgical, endoscopic (depending on location), radiologic (embolization, endovascular stent placement). Bleeding from metastases to the small bowel is relatively rare, yet it is important to keep this in mind especially in cases of obscure bleeding.
Cynthia Leung, MD, Palo Alto Veteran’s Hospital, Stanford University School of Medicine
Roy Soetikno, M.D., Palo Alto Veteran’s Hospital, Stanford University School of Medicine
Shai Friedland, M.D., Palo Alto Veteran’s Hospital, Stanford University School of Medicine