Brooklyn Hospital Center Brooklyn, NY, United States
Jamil M. Shah, MD1, Sarah Huang, MD2, Manan A. Jhaveri, MD1, Eric O. Then, MD1, Pratyusha Tirumani Setty, MD1, Ali Aamar, MD1, Yingxian Liu, MD1, Derrick Cheung, MD1, Denzil Etienne, MD1, Madhavi Reddy, MD, FACG1 1Brooklyn Hospital Center, Brooklyn, NY; 2NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
Introduction: Carcinoid tumors, or well-differentiated neuroendocrine tumors (NETs), are rare tumors of the GI tract, lungs, GU tract, and pancreas. Among patients with small bowel well-differentiated GI NETs (GINETs) who do not have carcinoid syndrome, the most common symptoms are abdominal pain and intestinal obstruction. An uncommon manifestation is GI bleeding. We report a case of severe GI bleeding due to a proximal ileum carcinoid tumor in the setting of dual antiplatelet therapy.
Case Description/Methods: 67 y/o Bengali man, with PMH of HTN, HLD, DM, CAD (s/p RCA stent x2 in 4/2020, on aspirin and prasugrel), and OSA on CPAP, presented with multiple episodes of rectal bleeding x 1 day. Dark red blood filled the toilet bowl and was mixed with the stool. No family history of colorectal cancer. No prior EGD or colonoscopy. Initial vital signs and physical exam were unremarkable. He declined a rectal exam. Initial labs showed Hb 10.2 g/dL (baseline Hb ~13 g/dL) and MCV 80. Aspirin and prasugrel were held. IV PPI bolus, PPI infusion, and IV fluids were started. Over two days, he underwent EGD with push enteroscopy, ileocolonoscopy, and capsule endoscopy. Dark red blood, believed to be old blood, was present in the entire colon and distal ileum. No active bleeding site was identified. CT angiogram showed no active bleeding, nor any acute pathology. During the hospital course, he continued to have rectal bleeding. He was transferred to the medical ICU. The Hb dropped to 7.9, 7.5, and 7.6 g/dL, requiring a total of 5 units of PRBCs. Ultimately, the rectal bleeding improved and resolved, and he was discharged. A few weeks later, elective video capsule endoscopy showed an ulcerated lesion in the distal small bowel. Single balloon-assisted lower enteroscopy showed a 10-mm ulcerated non-bleeding lesion in the proximal ileum–possibly the source of prior GI bleeding (Fig 1A). The ileum lesion biopsy showed neuroendocrine tumor (Fig 1B, C). A Gallium scan showed localized carcinoid tumor and no metastatic spread. He then underwent successful segmental small bowel resection of the tumor
Discussion: NETs comprise 2% of all GI tract tumors and tend to grow slowly. The most common site for small bowel GINETs is the ileum. GI bleeding is a rare manifestation. Surgical resection of the primary tumor is the treatment of choice. The estimated 5-year survival rate is 67-97%. This case reveals a unique presentation of small bowel carcinoid tumor and the diagnostic challenges due to inadequate mucosa visualization from GI bleed
Figure: Figure 1A. Image from single balloon-assisted lower enteroscopy. A 10-mm ulcerated non-bleeding subepithelial-appearing lesion was seen in the proximal ileum. This was likely the source of prior GI bleeding.
Figure 1B, C. H&E 40x, and 100x: Clusters of carcinoid tumor cells in the submucosa of the ileum. The tumor cells were positive for synaptophysin and chromogranin.
Jamil Shah indicated no relevant financial relationships.
Sarah Huang indicated no relevant financial relationships.
Manan Jhaveri indicated no relevant financial relationships.
Eric Then indicated no relevant financial relationships.
Pratyusha Tirumani Setty indicated no relevant financial relationships.
Ali Aamar indicated no relevant financial relationships.
Yingxian Liu indicated no relevant financial relationships.
Derrick Cheung indicated no relevant financial relationships.
Denzil Etienne indicated no relevant financial relationships.
Madhavi Reddy indicated no relevant financial relationships.
Jamil M. Shah, MD1, Sarah Huang, MD2, Manan A. Jhaveri, MD1, Eric O. Then, MD1, Pratyusha Tirumani Setty, MD1, Ali Aamar, MD1, Yingxian Liu, MD1, Derrick Cheung, MD1, Denzil Etienne, MD1, Madhavi Reddy, MD, FACG1. P0485 - Ileal Carcinoid Tumor: A Rare and Unusual Cause of Severe Gastrointestinal Bleeding, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.