Upper gastrointestinal bleeding secondary to renal tumor

Hemorragia digestiva alta secundaria a tumor renal

Key words: Upper gastrointestinal bleeding. Malignant duodenal ulcer. Metastatic renal carcinoma. Duodenal metastasis. Renal cell carcinoma.

Palabras clave: Hemorragia digestiva alta. Úlcera maligna duodenal. Metástasis de carcinoma renal. Metástasis duodenal. Carcinoma renal

We present the case report of a 66-year-old woman with no relevant medical history, presented with melenas for the last 5 days. She had been under study for asthenia, anorexia and diffuse abdominal pain for a few months. Physical examination was normal except low blood pressure and mild tachicardia. Blood test: hemoglobin 10.2 g/dl (MCV, 102 fl; MCH, 82 pg/c) and 29.9% hematocrit. Emergency gastroscopy was performed observing a large and deep duodenal ulcer with edematous raised borders at the second portion, that seemed to be malignant. Also showed an adhered blood clot, which could not be flushed out by intensive lavage. The histology of biopsy showed fragments of necrotic ulcer material and no evidence of atypical cells. A pelvic CT scan with intravenous contrast was performed (Fig. 1) showing the presence of a renal mass that measured 10 cm and that dependend of the right kidney lower pole. That mass showed a heterogeneous enhancement with hypodense areas inside (necrotic component) that vanished its limits in its inner border, forming a tumor magma which was migrating and intimately adherent to second portion of duodenum and the head of pancreas. It also showed presence of air bubbles near the area adjacent to the duodenum, suggesting contained duodenal perforation. Para-aortic adenopathies were also seen. Necrotic appearance and dilated coledocum and intrahepatic bile duct, conditioned by the compressive effect of the foresaid mass. Pulmonary nodules related to metastasis were identified. These findings, together with the description of the gastroscopy, suggested the presence of a T4 N2 M1 (1987 TNM classification) locally and regionally advance D stage IV metastatic right renal cell carcinoma, with infiltration of the pancreas, duodenum (Forrest IIb ulcer) and bile duct (secondary dilatation and cholestasis).

Discussion

Neoplasms of the small bowel (SB) represent only 1-2% of all gastrointestinal tumors. SB metastases of renal carcinoma (RC) are even more unusual (1). RC is incidentally diagnosed in more than half the cases (2) and it is not usually expressed clinically in the early stages. It presents as metastasis up to 25% of patients at the time of the diagnosis. The classical triad flank pain, hematuria and palpable renal mass is quite unusual and the initial symptoms are very nonspecific (fever, liver dysfunction or high blood pressure due to production of renin) (3), which makes an early diagnosis difficult. Another manifestation is upper gastrointestinal bleeding, although often not as the first clinic sign but in patients who had undergone nephrectomy some years previously. Another manifestation may be pain and bowel obstruction (4,5). Diagnosis is done through radiology and gastroscopy, where findings are not specific such as irregular and polypoid masses, ulcerated surface covered with a white/hematic exudate, and given that lesions are extraluminal, biopsies can be negative or usually associated to necrosis (5). Surgical resection of metastases improves survival in these patients but it would be recommended in cases of solitary metastasis or multiple pulmonary metastases which do not affect other organs.

Juana Gonzalo-Marín, Víctor Manuel Aguilar-Urbano, Francisco Muñoz-Castillo,
Cristobal Albandea-Moreno, Cristina Montes-Aragón and Carlos de-Sola-Earle
Department of Gastroenterology. USP Hospital Marbella. Málaga, Spain

References

1. Merino C, Molés JR, Rodrigo A, Ferrando J, García J, Primo J, et al. Unusual cause of upper gastrointestinal bleeding: Duodenal metastases from renal cell carcinoma. Gastroenterol Hepatol 2005;28:221-4.         [ Links ]

2. Campbell SC, Andrew CN. Renal Tumours. En: Campbell-Walsh, editors. Urology. Sounders Elsevier; 2007. p. 1582-605.         [ Links ]

3. Stefens J, Bock R, Braedel HU, Isenberg E, Bührle CP, Ziegler M. et al. M. Renin-producing renal cell carcinomas: clinical and experimental investigations on a special form of renal hipertensión. Urol Res 1992;20:111-5.         [ Links ]

4. Toh SK, Hale JE. Late presentation of a solitary metastasis of renal cell carcinoma as an obstructive duodenal mass. Postgrad Med J 1996;72:178-9.         [ Links ]

5. Theodors A, Sivak MV, Crey WD. Hypernephroma with metastasis to duodenum: Endoscopic features. Gatrointest Endosc 1980;26:48-51.         [ Links ]