Mohammed Affan Guliyara1,2, Jenn Hian Koo1,2. 1. Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia. 2. South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.
A 53-year-old man with the background of hepatocellular carcinoma (HCC) and Child-Pugh A cirrhosis was hospitalized for melena and symptomatic anemia. Since his diagnosis in 2012, he had undergone liver resections and trialed sorafenib, lenvatinib, radiotherapy, and phase 1 trial agents with continued progression of his disease. The computed tomography mesenteric angiogram, gastroscopy, and colonoscopy failed to detect any bleeding source. He underwent a video capsule endoscopy (VCE), which identified abnormal mucosa in the mid-small bowel and a nodular mass in the distal small bowel (Figures 1 and 2). His subsequent antegrade double-balloon enteroscopy revealed a large exophytic mass in the proximal jejunum and another large circumferential mass in the distal jejunum (Figures 3 and 4). Histopathology of this lesion confirmed metastatic HCC. This is the fifth reported case in the English literature of the jejunal metastases from HCC presumably from hematogenous spread given multifocal deposits.[1,2] Compared with an abdominal computed tomography scan, the diagnostic yield from VCE and double-balloon enteroscopy is significantly higher in detecting small bowel tumors, irrespective of their size.[3] This case highlights the importance of early luminal examination of the small bowel with a VCE to ascertain the cause of obscure gastrointestinal bleeding in patients with HCC.
Figure 1.
Video capsule endoscopy (VCE) image showing abnormal mucosa within mid-small bowel seen at the 1:15:42 mark (highlighted with 2 green arrows).
Figure 2.
Video capsule endoscopy (VCE) image showing an infiltrative nodular mass within distal small bowel at the 2:27:47 mark (highlighted with 2 green arrows).
Figure 3.
Double balloon enteroscopy (DBE) image showing a large nonbleeding exophytic mass within the proximal jejunum.
Figure 4.
Double balloon enteroscopy (DBE) image showing a large nonbleeding partially circumferential infiltrative mass within the distal jejunum.
Video capsule endoscopy (VCE) image showing abnormal mucosa within mid-small bowel seen at the 1:15:42 mark (highlighted with 2 green arrows).Video capsule endoscopy (VCE) image showing an infiltrative nodular mass within distal small bowel at the 2:27:47 mark (highlighted with 2 green arrows).Double balloon enteroscopy (DBE) image showing a large nonbleeding exophytic mass within the proximal jejunum.Double balloon enteroscopy (DBE) image showing a large nonbleeding partially circumferential infiltrative mass within the distal jejunum.
DISCLOSURES
Author contributions: MA Guliyara collected the data, wrote the manuscript, and is the article guarantor. JH Koo edited the article.Financial disclosure: None to report.Informed consent was obtained for this case report.
Figure 1.
Figure 2.
Figure 3.
Figure 4.