Small Bowel Metastasis of Hepatocellular Carcinoma Detected by Capsule Endoscopy
A 60-year-old man with liver cirrhosis type B was treated with sorafenib chemotherapy for HCC (stage IVb) at Hiroshima University Hospital. He had been admitted for melena and anemia since October 2011. There was no obvious source of bleeding by both upper and lower gastrointestinal endoscopy. Therefore, CE was performed in November 2011. Physical findings were normal. Laboratory examination indicated a white blood cell count of 3,850/μl, a red blood cell count of 325 × 104/μl and a platelet count of 11.0 × 104/μl. The hemoglobin concentration was 9.2 g/dl. Liver function examination revealed the following levels: aspartate aminotransferase 61 IU/l (normal 2–39 IU/l), alanine aminotransferase 57 IU/l (normal 2–39 IU/l), total protein 7.7 g/dl (normal 6.5–8.1 g/dl), serum albumin 3.1 g/dl (normal 3.8–5.2 g/dl), alkaline phosphatase 722 IU/l (normal 96–310 IU/l), leucine aminopeptidase 177 IU/l (normal 45–71 IU/l), γ-glutamyl transpeptidase 138 IU/l, cholinesterase 0.10 IU/l (normal 0.6–1.2 IU/l), and total bilirubin 1.4 mg/dl (normal 0.1–0.4 mg/dl). With respect to renal function, the blood urea nitrogen level was 43.6 mg/dl and the creatinine level 2.54 mg/dl. The results for tumor markers were negative for carbohydrate antigen 19-9 and carcinoembryonic antigen; however, the levels of alpha fetoprotein and protein indicated by vitamin K absence (PIVKA II) were high at 86.5 ng/ml (normal ≤5 ng/ml) and 45,302 ng/ml (normal ≤10 ng/ml), respectively. The Child-Pugh score was 6 points (grade B).\nA computed tomography (CT) scan showed that the HCC consisted of a tumor in the liver (fig. ), a portal vein tumor thrombus (VP2) (fig. ) and multiple lung metastases (fig. ). CE showed a polypoid lesion with bleeding in the ileum, but there were no other findings in the small bowel (fig. ). DBE was performed after CE. The lesion was determined to be a pedunculated polyp in the ileum (fig. ). Histological examination of biopsy specimens showed tumor cells resembling HCC on hematoxylin and eosin stain (fig. ). Immunohistochemical examination showed tumor cells positive for hepatocyte antigen (fig. ) and glypican-3 antigen (fig. ).\nThe tumor was diagnosed as a small bowel metastasis of moderately differentiated HCC. We decided to perform prophylactic endoscopic mucosal resection (EMR) to control the continuous bleeding after receiving informed consent from the patient and his family. During EMR, the non-lifting sign was positive after glycerol injection (fig. ) however, we then tried to resect the tumor (fig. ). Histological examination of the resected specimen showed tumor cells resembling HCC on hematoxylin and eosin stain (fig. ). The patient had no melena or anemia and was well after EMR (hemoglobin increased from 9.2 to 11.5 g/dl) without transfusion. However, he died of liver failure 2 months later.