Obscure gastrointestinal bleeding requires a thorough examination of the entire gastrointestinal tract, including the small bowel.1 Suspected small bowel gastrointestinal bleeding is defined as the lack of obvious etiology for bleeding after upper endoscopy and colonoscopy.1 Video capsule endoscopy should be the next step in evaluation; deep enteroscopy can be considered if video capsule endoscopy is either contraindicated, unrevealing, or when endoscopic intervention is necessary. Computed tomography (CT) enterography should be considered before other procedures if obstruction or malignancy is suspected. In any acutely unstable patient, angiography is an option.2 Clear cell renal cell carcinoma is the most common renal malignancy.3 A small number of case reports of clear cell renal cell carcinoma involved in gastrointestinal bleeding4–11 have been published in the past, but this is yet a poorly understood and underappreciated phenomenon.
A 75-year-old man with a history of diabetes mellitus, paroxysmal atrial fibrillation not on anticoagulation but taking daily low-dose aspirin, sinus node dysfunction with pacemaker in place, chronic kidney disease, and clear cell renal cell carcinoma involving the right kidney diagnosed several before years, status after a radical right nephrectomy, with recurrence and spread of the disease to lung bases, retroperitoneum, abdominal lymph nodes, and omentum on active treatment with pembrolizumab presented for a second opinion regarding frequent melena of approximately 9-month duration, with resultant anemia requiring intermittent but frequent transfusions (10 red blood cell units) and multiple weekly iron infusions. Before this evaluation, he had undergone an extensive workup, including an upper endoscopy, 3 colonoscopies, CT enterography, Meckel scan, 2 capsule endoscopies, and a device-assisted enteroscopy (antegrade), without identifying the source of bleeding. Capsule endoscopy had suggested proximal small bowel bleeding, but no source of bleeding was identified in a subsequent anterograde enteroscopy.
He presented for a second opinion with ongoing melena and was admitted for further evaluation and stabilization. Hemoglobin at the time of admission was 7.4 g/dL. Repeat capsule endoscopy was performed. It showed an ulcerated mass in the mid-to-distal jejunum (Figure 1). A subsequent single balloon-assisted endoscopy was performed. The scope was advanced very deeply (150 cm beyond tattoo from previous enteroscopy), however, failed to reach the mass. A follow-up abdominal and pelvic CT without contrast showed wall thickening and an intraluminal mass in the mid-small bowel approximately 5.5 cm in length. He continued with ongoing melena and required transfusions (3 red blood cell units). The decision was made for an exploratory laparotomy. On opening the abdomen, numerous implants in the abdominal wall consistent in appearance with carcinomatosis were noted. The small bowel was run from ligament of Treitz to the cecum, and a single 8-cm mass was noted in the distal jejunum. This was resected and sent to pathology. Pathological evaluation revealed metastatic clear cell renal cell carcinoma with clean margins (Figure 2). The patient recovered uneventfully from the surgery. Before discharge, hemoglobin was stable at 9.6 g/dL. He was having no melena at the time of discharge or thereafter. No further transfusions were needed and hemoglobin increased to 10.8 g/dL about 1 month after his surgical intervention.
Our case represents an important example of clear cell renal cell carcinoma metastasizing to the bowel and causing persistent life-threatening gastrointestinal bleeding. It serves as a useful example of this infrequent but clinically relevant etiology of small bowel gastrointestinal bleeding. Included below is a summative table of previously published literature, describing small bowel metastases (excepting duodenal metastases) by renal cell carcinoma (Table 1). From the 10 previous cases of jejunal metastases described; 4/10 presented with intussusception, whereas the remainder presented with lower gastrointestinal bleeding. The average age of this small population was 59 years; average time to presentation postnephrectomy was 5.2 years; 4 were women and 6 were men.
This case also serves as an important reminder to consider a patient's full medical history, both while evaluating for causes of gastrointestinal bleeding and as a general principle of practice. Although endoscopy or interventional radiology interventions are often needed for the management of small bowel bleeding, in this case, surgical intervention was necessary for definitive treatment. As mentioned previously, CT enterography is recommended if concern for malignancy is present,2 and a repeat study might have sped the diagnosis and treatment of this patient. Although metastatic carcinoma is an established possible cause of small bowel gastrointestinal bleeding,12 it is uncommon that clear cell renal cell carcinoma should metastasize to the small bowel1 and may therefore be missed as a potential cause. Thus, it is important to consider metastatic cancer in the differential of unexplained gastrointestinal bleeding in a patient with personal history of cancer.
In general, the management of small bowel gastrointestinal bleeding can be an extremely difficult undertaking. As is demonstrated with this case, it is not uncommon that a patient is required to undergo multiple procedures and imaging studies and still not have a final diagnosis.13 In addition, even once a diagnosis is made or suspected, treating the causative disease can also be a limiting factor, frequently because of difficult-to-assess locations, as in our case.14 If an active source is identified, endoscopic or surgical intervention should be performed without delay. In a stable patient with no source identified after the above approaches, conservative management is recommended, including as-needed transfusions and blood draws. Repeating the above diagnostic methodologies can be attempted in patients with recurrent bleeding if it would guide or change clinical management.2
Author contributions: BM Mitchell wrote the manuscript. J. Lapinski edited the manuscript and provided the pathology images. A. Rubio-Tapia wrote the manuscript, provided the endoscopic images, and is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
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