ELECTRONIC IMAGE OF THE MONTH Colon Cancer Presenting as an Upper Gastrointestinal Bleed Daniel J. Waintraub,* Patrick J. Toth,‡ and David M. Felig§ *Department of Medicine, Beth Israel Medical Center, New York, New York; and ‡Department of Radiology and §Department of Medicine, Hackensack University Medical Center, Hackensack, New Jersey
74-year-old man with no significant past medical history presented with hematemesis and melena. The patient had no prior colonoscopy and he denied any lower gastrointestinal (GI) symptoms. Upper endoscopy showed varices in the gastric body (Figure A) and in the duodenal bulb. No esophageal varices were seen. No ulcer or mass was seen in the upper GI tract. For further evaluation of the varices and bleeding, a computed tomography (CT) scan of the abdomen and pelvis was obtained and showed a nodular liver with a mass in the portal vein, suggestive of tumor thrombus (Figure B, arrow). The CT scan did not show any abnormalities in the colon. A CTguided transhepatic fine-needle aspiration of the portal vein mass was performed. The cytology showed adenocarcinoma (Figure C). The cells stained negative for keratin 7, type II (Figure D), positive for keratin
A
20, type I (Figure E), and positive for caudal type homeobox 2 (Figure F). These findings were suggestive of metastatic colon adenocarcinoma. The patient subsequently had a colonoscopy that showed a nonobstructing cancer in the sigmoid colon. The patient currently is being treated with folinic acid, fluorouracil, and oxaliplatin for stage IV colon cancer. There are rare reports in the literature of colon cancer presenting as an upper GI bleed, typically as a result of tumor eroding from the colon directly into the upper GI tract.1,2 Colon cancer metastatic to the portal vein also has been described previously.3 It is extremely unusual for colon cancer to present with upper gastrointestinal bleeding caused by tumor thrombus in the portal vein and ectopic varices in the stomach and duodenum. This case report highlights the fact that upper GI bleeding occasionally can be the initial presentation of lower GI pathology.
Clinical Gastroenterology and Hepatology 2015;13:e125–e126
ELECTRONIC IMAGE OF THE MONTH, continued References 1.
Thorpe B, Applebaum B, Esquivel RF, et al. Colon cancer presenting as upper-GI bleeding. Gastrointest Endosc 2006; 63:343–345.
2.
Schlabel SI, Rogers CI, Rittenberg GM. Duodeno-duodenal fistula: a manifestation of carcinoma of the colon. Gastrointest Radiol 1978;3:15–17.
e126
3.
Tada K, Kokudo N, Seki M, et al. Hepatic resection for colorectal metastasis with macroscopic tumor thrombus in the portal vein. World J Surg 2003;27:299–303.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.03.015
74-year-old man with no significant past medical history presented with hematemesis and melena. The patient had no prior colonoscopy and he denied any lower gastrointestinal (GI) symptoms. Upper endoscopy showed varices in the gastric body (Figure A) and in the duodenal bulb. No esophageal varices were seen. No ulcer or mass was seen in the upper GI tract. For further evaluation of the varices and bleeding, a computed tomography (CT) scan of the abdomen and pelvis was obtained and showed a nodular liver with a mass in the portal vein, suggestive of tumor thrombus (Figure B, arrow). The CT scan did not show any abnormalities in the colon. A CTguided transhepatic fine-needle aspiration of the portal vein mass was performed. The cytology showed adenocarcinoma (Figure C). The cells stained negative for keratin 7, type II (Figure D), positive for keratin
A
20, type I (Figure E), and positive for caudal type homeobox 2 (Figure F). These findings were suggestive of metastatic colon adenocarcinoma. The patient subsequently had a colonoscopy that showed a nonobstructing cancer in the sigmoid colon. The patient currently is being treated with folinic acid, fluorouracil, and oxaliplatin for stage IV colon cancer. There are rare reports in the literature of colon cancer presenting as an upper GI bleed, typically as a result of tumor eroding from the colon directly into the upper GI tract.1,2 Colon cancer metastatic to the portal vein also has been described previously.3 It is extremely unusual for colon cancer to present with upper gastrointestinal bleeding caused by tumor thrombus in the portal vein and ectopic varices in the stomach and duodenum. This case report highlights the fact that upper GI bleeding occasionally can be the initial presentation of lower GI pathology.
Clinical Gastroenterology and Hepatology 2015;13:e125–e126
ELECTRONIC IMAGE OF THE MONTH, continued References 1.
Thorpe B, Applebaum B, Esquivel RF, et al. Colon cancer presenting as upper-GI bleeding. Gastrointest Endosc 2006; 63:343–345.
2.
Schlabel SI, Rogers CI, Rittenberg GM. Duodeno-duodenal fistula: a manifestation of carcinoma of the colon. Gastrointest Radiol 1978;3:15–17.
e126
3.
Tada K, Kokudo N, Seki M, et al. Hepatic resection for colorectal metastasis with macroscopic tumor thrombus in the portal vein. World J Surg 2003;27:299–303.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.03.015
