ORIGINAL REPORTS
Invasive Pancreatic Cancer Presenting as Gastrointestinal Hemorrhage—A Case Report Aislinn Vaughan, MD, and JoAnn Lohr, MD Section of Vascular Surgery, Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio Upper gastrointestinal hemorrhage is not uncommonly seen by the surgical practitioner. We present a case of a patient who presented with melena and syncope, who was subsequently found to have invasive metastatic pancreatic cancer as his source of bleed. (Curr Surg 61:390-392. © 2004 by the Association of Program Directors in Surgery.) KEY WORDS: pancreatic cancer, pancreas, gastrointestinal hemorrhage, invasive
CASE REPORT A 67-year-old man presented to the hospital with melena and an episode of syncope. He was admitted and found to be anemic with a hemoglobin of 10, which subsequently drifted down to 7. At that facility, he was treated with pantoprazole and octreotide continuous intravenous infusions and underwent upper endoscopy, which initially showed a large clot on the gastric fundus, but no active bleeding (Fig. 1). The patient required a total of 6 units of packed red blood cells overnight, and repeat upper endoscopy the next morning showed a submucosal gastric mass to be the source of the bleeding. The patient was then transferred to our hospital for surgical intensive care observation. On arrival, the patient developed hypotension and was taken urgently to the operating room for exploration. At the time of surgery, the patient had a presumed diagnosis of a bleeding gastric leiomyoma or possibly leiomyosarcoma eroding into the gastric mucosa. At exploration, the patient was found to have metastatic peritoneal implants and liver nodules in addition to a large mass in the retroperitoneum adherent to the stomach, tail of the pancreas, and spleen. Wedge resection of one of the peripheral liver nodules was performed and sent for frozen pathology analysis, which confirmed metastatic adenocarcinoma. The patient then underwent a partial gastrectomy, splenectomy, partial pancreatectomy, and placement of a feeding jejunostomy tube. The patient had a CA 19-9 level drawn on postoperative day 3, which came back markedly ele-
Correspondence: Inquiries to Aislinn Vaughan, MD, c/o Joy Rusche, Hatton Research-11J, Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH 45220; fax: (513) 872-1549; e-mail:
[email protected]
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FIGURE 1. Preoperative esophagogastroduodenoscopy picture shows clot overlying ulcerated mass indenting lumen of stomach.
vated at 1286. Final pathology revealed the liver section to be metastatic mucinous adenocarcinoma. Capsular plaques of poorly differentiated mucinous adenocarcinoma involving the serosal surface and wall of the stomach were evident in the spleen and portions of the stomach and pancreas. Carcinoma was also found at the margins of resection. In an attempt to determine whether the primary site was stomach versus pancreas, immunoperoxidase stains were performed using antibodies to cytokeratin-7 and cytokeratin-20. The adenocarcinoma was diffusely positive with cytokeratin-7 and in part positive with cytokeratin-20. This pattern of reactivity is present in two-thirds of pancreatic adenocarcinoma and in approximately one-tenth of gastric adenocarcinomas. The patient’s course was complicated by a postoperative abdominal abscess in his left upper quadrant, which was percutaneously drained with computed tomography (CT) guidance (Fig. 2). The patient died approximately 4 months after diagnosis with liver and kidney failure.
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FIGURE 2. Postresection abdomen/pelvis CT shows multiple liver metastases and residual left upper quadrant phlegmon.
DISCUSSION An extensive literature search was performed, and very few cases of invasive pancreatic cancer presenting as massive gastrointestinal hemorrhage were found. Many references to postoperative gastrointestinal hemorrhage in patients with pancreatic cancer were identified, but this entity was not relevant to our patient’s presentation. One review of 859 endoscopies done in patients with gastrointestinal bleeding revealed 3 patients with pancreatic tumors invading into the duodenum.1 Overall, 1% to 2% of patients with acute major upper gastrointestinal hemorrhage are found to have advanced tumors of the stomach and duodenum. Some of these are amenable to endoscopic therapies like electrocoagulation. Unfortunately, they frequently rebleed and require surgical treatment for palliation. Gastric stromal tumor was the preoperative diagnosis based on initial endoscopic findings. These have associated upper gastrointestinal hemorrhage in 40% to 65% of patients. The frequency of bleeding increases as these tumors enlarge and subsequently ulcerate.2-5 One potentially helpful tool would be a preoperative abdominal and pelvic CT. This would not normally be part of the preoperative evaluation for upper gastrointestinal bleed. However, with a suspicion of a gastric mass, further characterization regarding size, involvement of other structures, and evidence of metastases may help with preoperative planning. Invasive pancreatic cancer as a cause of massive gastrointestinal hemorrhage is exceedingly rare. Only one paper directly addressing gastrointestinal hemorrhage as the initial symptom of pancreatic carcinoma was located. The authors discussed 8 patients in their review. Seven of the patients had tumors directly invading the gastrointestinal tract. One patient had a metastatic bleeding lesion in the sigmoid colon. Four of the 8 required urgent exploratory laparotomy, and all died during the initial hospitalization.6-9 Angiography with embolization would perhaps have prevented an operation in this patient. This would be beneficial, CURRENT SURGERY • Volume 61/Number 4 • July/August 2004
particularly in known cancer patients whose tumors are too far advanced to allow for surgical cure.10-12 One article looking at arterial embolization for multiple causes of upper gastrointestinal hemorrhage was encouraging. Embolization was successful in 62% of their 29 patients.13 Another paper looking at angiographic treatment of massive nonvariceal upper gastrointestinal bleeding had similar results. Contrast extravasation was seen in 25 of 64 patients. In these 25 patients, 13 patients were successfully treated with either arterial embolization or intraarterial vasopressin and avoided operation. Arteries treated included the left gastric artery, common hepatic artery, gastroduodenal artery, inferior pancreaticoduodenal artery, and right gastric artery. This angiographic intervention could be potentially lifesaving in patients who are very high risk for surgical intervention.14 An additional test to consider would be endoscopic ultrasound to assess depth of tumor invasion; however, its utility in a symptomatic patient is questionable. This unusual case of upper gastrointestinal hemorrhage is presented to remind the readers to keep more obscure origins of gastrointestinal hemorrhage in mind in their differential diagnoses when the source of bleed is not straightforward.
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