Massive upper gastrointestinal hemorrhage due to invasive hepatocellular carcinoma and hepato-gastric fistula

Abstract

A 36-year-old male Asian immigrant with a history of hepatitis B and hepatitis C related unresectable hepatocellular carcinoma in the left lobe of the liver presented with hematemesis and severe anemia. He was diagnosed with a liver mass that was resected 8 years ago described as a benign tumor in his home country. He had received trans-arterial chemoembolization (TACE) four months ago after subsequent diagnosis of unresectable hepatoma, and currently was receiving chemotherapy with Sorafenib. After resuscitation, a contrast enhanced computerized tomography was performed which showed fistulization of hepatocellular carcinoma into adjacent stomach. This finding was confirmed during endoscopy with direct visualization of the fistulous opening. Hepatocellular carcinoma (HCC) invading the gastrointestinal (GI) tract is rare. We present a case and literature review of HCC with local invasion of the stomach causing massive upper GI bleeding after receiving TACE.

Upper Gastrointestinal Hemorrhage as an Unexpected Feature of Hepatocellular Carcinoma

“…Metastatic spread of HCC can be hematogenous, lymphatic or by direct invasion of the tumor into adjacent organs. 4 In our case the abdominopelvic CT performed showed local invasion of the first part of the duodenum ( Fig. 3 B and C) making the direct tumor invasion of the gastrointestinal tract the most likely process.…”

“…Common etiologies include peptic ulcer disease, variceal bleeding due to portal hypertension from underlying cirrhosis, tumor invasion of portal vein causing thrombosis and portal hypertensive gastropathy. 1 , 2 , 3 , 4 The direct invasion of tumor to gut is considered a rare cause among patients with a non-variceal source of upper digestive hemorrhage with an estimated incidence of 0.05–2%. 5 , 6 , 7 The authors describe a 63 year-old male patient with a diagnosis of HCC who presented with melenic stool and epigastric pain.…”

Hepatogastric fistula: a rare complication of pyogenic liver abscess

“…Angioembolisation is recommended if there is hematemesis 2 10. Operative strategies include open drainage of abscess with excision of fistula and en bloc resection of the involved portions of the stomach and the liver.…”

Hepatogastric Fistula following Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

“…The most common site of direct tumor invasion is the stomach followed by the duodenum and colon [5]. Most metastases to the gastrointestinal tract (GIT) are found incidentally secondary to their asymptomatic presentation, but bleeding from the upper GIT is the most common initial presentation [6, 7].…”