An Uncommon Cause of Major Lower Gastrointestinal Bleeding Abigail Kopecky, MD1 and Randall E Lee, MD, FACP2,1

1Department of Internal Medicine, University of California, Davis, Sacramento, CA 2Gastroenterology Section, Sacramento VA Medical Center, Mather, CA

CLINICAL COURSE

He had no recurrent bleeding. CT chest, abdomen,

and pelvis showed mixed density lesions in the

pelvis and L-spine, but no liver masses.

Chromogranin A was 8 nmol/L (0-5). Surgical

resection confirmed a 2-cm stage T2N0Mx primary

neuroendocrine tumor in the terminal ileum.

Octreotide scan showed no evidence of

metastases.

INITIAL PRESENTATION

HISTORY OF PRESENT ILLNESS:

A 61y.o. man with heavy alcohol use, on aspirin

for atrial fibrillation, presented to the ER with two

days of maroon stools streaked with bright red

blood. Associated postural presyncope. No

nausea, vomiting or abdominal pain.

PAST MEDICALHISTORY:

Two years ago, a routine screening colonoscopy

to the cecum noted hemorrhoids, diverticulosis,

and a 2-cm rectal neuroendocrine tumor,

completely excised on repeat endoscopy. No

follow up since then.

MEDICATIONS:

aspirin, metoprolol, hydrochlorothiazide, lisinopril

FAMILY HISTORY:

No GI or other malignancy.

PHYSICAL EXAM

● Obese male, no distress, hypotensive (BP

88/56, improved to 123/78 after 1L IV NS), HR 71

● Oropharynx was clear

● Abdomen was obese, soft, non-tender

● Maroon guaiac-positive stool on rectal exam

INVESTIGATIVE STUDIES

LABS: CBC showed hemoglobin of 10 g/dL, which was

a drop of 4 g/dL from baseline. Platelet count, INR, and

LFTs were within normal limits.

EGD and colonoscopy with ileoscopy within 24 hours

of admission determined the source of the bleeding

was a round, friable, vascular mass in the ileum, less

than 10 cm from the ileocecal valve.

INTRODUCTION

Major lower gastrointestinal bleeding usually is

due to colonic diverticulosis or angioectasia. This

case describes an uncommon cause of significant

bleeding from the small intestine.

DISCUSSION

● Neuroendocrine tumors most commonly occur in

the GI tract, and the most common GI location is

the ileum. Most small bowel NETs initially are

asymptomatic or have vague symptoms and

usually are an incidental endoscopic finding; a

major lower GI bleed is a rare presentation.

● The "carcinoid syndrome" of chronic diarrhea and

flushing was not seen in this case, and is present

only in a minority of cases. It classically is seen

when carcinoid tumors arising from the midgut

have metastasized to the liver, with secretion of

serotonin and other vasoactive substances directly

into systemic circulation.

● While routine screening colonoscopy often does

not examine the ileum, this case illustrates the

critical importance of ileoscopy during colonoscopy

for an initial GI bleed evaluation.

REFERENCES

American Joint Committee on Cancer (AJCC) Staging Manual, 7th Ed, Edge SB, Byrd DR,

Compton CC, et all (Eds), Springer New York 2010.

Goldfinger SE and JR Strosberg, et al. Clinical characteristics of carcinoid tumors. In:

UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA 2012.

Kulke MH, Mayer RJ. Carcinoid tumors. New England Journal of Medicine 1999; 340:858.

Oberg K. Carcinoid Tumors: Current Concepts in Diagnosis and Treatment. The Oncologist

1998; 3:339-345.

Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterology Clinics of

North America 2005; 34:643.

Ileal mass pre- and post-biopsy.

PATHOLOGY

Endoscopic biopsy of the mass showed a well-

differentiated neuroendocrine tumor (NET).

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