American Journal of Emergency Medicine 31 (2013) 1622.e3-1622.e4

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American Journal of Emergency Medicine

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Case Report

A unique presentation of renal cell carcinoma: both upper and lower gastrointestinal bleeding

Abstract

Renal cell carcinoma (RCC) constitutes 3% of all adult malignancies and may present with various symptoms due to local growth, metastasis, and paraneoplastic syndrome. Gastroin- testinal hemorrhage because of RCC is a very rare event and more commonly seen as a recurrence of RCC many years after nephrectomy. Both upper and lower gastrointestinal bleeding due to direct invasion of RCC has not been reported yet in the literature. Herein, we report a case of 78-year-old man with both massive upper and lower gastrointestinal bleeding as a presenting symptom of RCC.

A 78-year-old man presented to our emergency department with massive Upper gastrointestinal bleeding and a 1-week history of melena. There was no recent history of taking anti-inflammatory medications or alcohol use. He had a 52-pack year history of smoking. No signs of Chronic liver disease were noted.

On physical examination, the patient was orthostatic and had generalized abdominal tenderness. His blood pressure was 70/50 mm Hg, and his heart rate was 112 beats per minute. laboratory investigations revealed microcytic hypochromic anemia, with hemo- globin level of 5.3 g/dL and hematocrit of 16%. The patient’s Liver enzymes and urinalysis were all within the normal range.

After Initial resuscitation and a blood transfusion, esophagogas- troduodenoscopy was performed. An actively bleeding, 5-cm irregu- lar, ulcerative mass was noted in the second part of the duodenum. Biopsies were obtained from this mass, and endoscopic interventions controlled the bleeding.

Further investigations included a computed tomographic scan of the abdomen, which revealed an ill-defined mass measuring 57 x 40

x 70 mm in the inferior pole of the right kidney, with direct invasion to the second part of the duodenum (Fig. 1). chest X-rays showed 2 opacity nodules, suggestive of lung metastasis of renal cell carcinoma (RCC) (Fig. 2).

The patient underwent Roux-an-Y gastrojejunal reconstruction and right nephrectomy. Histology from the resected specimen confirmed a grade 3 clear cell variant of RCC.

Renal cell carcinoma is one of the most lethal of the urologic cancers [1]. Gastrointestinal bleeding is a very rare presenting symptom of RCC, which is more commonly seen as a recurrence many years after nephrectomy [1]. Here, we present a unique case of RCC where the Primary presentation of the disease was symptoms of both upper and lower gastrointestinal bleeding due to direct invasion of the RCC of the duodenum. To our knowledge, this is the first case of both upper and lower gastrointestinal bleeding related to direct invasion of RCC. Imaging has a significant role in early detection and planning further therapy of patients with such a very rare manifestation of RCC.

Tumay Bekci MD Department of Radiology University of Ondokuz Mayis

Faculty of Medicine, Samsun, Turkey E-mail address: [email protected]

Ramazan Aydin MD

Department of Radiology Physical Medicine & Rehabilitation Hospital

Samsun, Turkey

Kerim Aslan MD

Department of Radiology University of Ondokuz Mayis Faculty of Medicine

Samsun, Turkey

http://dx.doi.org/10.1016/j.ajem.2013.06.022

Reference

[1] Tiwari P, Tiwari A, Vijay M, Kumar S, Kundu AK. Upper gastro-intestinal bleeding- rare presentation of renal cell carcinoma. Urol Ann 2010;2:127-9.

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1622.e4 T. Bekci, R. Aydin / American Journal of Emergency Medicine 31 (2013) 1622.e3-1622.e4

Fig. 1. Computed tomographic scan of the abdomen demonstrating an ill-defined mass measuring 57 x 40 x 70 mm in the inferior pole of the right kidney (arrowheads), with direct invasion to the second part of the duodenum (arrow). A, Axial view. B, Sagittal view. C, Coronal view.

Fig. 2. Computed tomography and roentgenogram of the chest showing Pulmonary nodules (arrows) suggestive of lung metastasis of RCC.