A rare cause of gastrointestinal haemorrhage: gastric invasion by hepatocellular carcinoma
A 76-years-old lady with background history of cryptogenic Child's B liver cirrhosis presented with intermittent epigastric pain of 2 weeks duration associated with abdominal distension and nausea. On examination, vital signs were stable but marked pallor was noted in her conjunctiva. Physical examination was remarkable for abdominal distension with mild splenomegaly and ascites. Rectal examination revealed brown stools.\nLaboratory investigations revealed anaemia with haemoglobin of 6.8 g/dl. Liver function tests were unremarkable with the exception of low albumin of 33 g/l and mildly elevated aspartate transaminase of 46 U/l. Coagulation profile was mildly deranged with a prothrombin time of 11.3 s and a normal partial thromboplastin time. She was admitted under the gastroenterology service with the preliminary diagnosis of dyspepsia with anaemia for investigation. Two pints of packed cells were transfused.\nDuring the second day of admission, the patient passed out large amounts of melena and had an episode of haematemesis. She also developed tacchycardia with heart rate increasing to 110–120 b.p.m. Repeat blood investigations showed that haemoglobin had fallen from 6.8 to 5.3 g/dl despite blood transfusion. An emergency oesophagogastroduodenoscopy was performed. Findings were that of grade 1 oesophageal varices with no features of variceal bleed. There was a large clot in the fundus and cardia of the stomach. After attempted removal of the blood clots with flushing, the patient developed torrential bleeding necessitating intubation for airway protection. The bleeding eventually ceased spontaneously and the source of bleeding was identified to be originating from a large ulcer crater in the greater curve with an overlying clot (Fig. ). Endoscopic ultrasound was performed which showed a 10 cm mass lesion abutting the stomach wall and extending into the peritoneal cavity (Fig. ). The preliminary impression was that of a bleeding GI stromal tumour and care was transferred to the surgical team for consideration of surgical intervention.\nA computed tomography scan was performed which showed multifocal HCC with a large exophytic lesion invading into the greater curvature of the stomach (Figs. and ). Peritoneal metastases and ascites were present. The patient underwent an angioembolization of the hepatic tumour on the same evening. Angiography identified a replaced left hepatic artery as the dominant vessel supplying the lesion of concern in the left lateral hepatic segment (Fig. a). Gelfoam embolization was performed with no residual tumour enhancement thereafter (Fig. b).\nThe patient's bleeding ceased after intervention and her haemoglobin levels stabilized. Alpha-foetoprotein level was elevated at >60 500 μg/l. She was eventually discharged and will be reviewed by the medical oncologists for consideration of palliative chemotherapy.