Cheikh Talal El Imad, MD
Staten Island, New York
Mira Alsheikh, MD1, Cheikh Talal El Imad, MD2, Sherif Andrawes, MD1, Simcha Weissman, DO3, Liliane Deeb, MD2, Khalil Kamar, MBBCh1
1Staten Island University Hospital, Staten Island, NY; 2Staten Island University Hospital, Northwell Health, Staten Island, NY; 3Hackensack University - Palisades Medical Center, Teaneck, NJ
Introduction: Small bowel (SB) primary melanomas (PM) are extremely rare; around 30 cases are reported to date. Diagnosis is challenging due to difficult endoscopic access and dealing with its complications such as bleeding is even more difficult. We describe in this report a case of jejunal primary melanoma presenting with lower gastrointestinal (GI) bleeding controlled with Hemospray.
Case Description/Methods: A 70-year-old man with coronary artery disease on aspirin presented with symptomatic anemia. He endorsed recurrent melena associated with weight loss. Vital signs were stable. Physical exam remarkable for melena on rectal exam. Computed tomography scan of the abdomen revealed a jejunal mass. The patient underwent a push enteroscopy, which showed a large ulcerated necrotic mass in the mid-jejunum that was actively bleeding. The entire mass was oozing from multiple foci with a large surface area. It was invading the jejunal wall with larger vessels exposed. Hemospray was used to achieve hemostasis. Pathology revealed malignant melanoma; a thorough skin and eye exam was negative for PM. The patient denied any history of excision of pigmented skin lesions. The final diagnosis was primary melanoma of the jejunum.
Discussion: Malignant melanomas are mostly cutaneous. Only 3-4% originate in mucosal membranes as primaries. The diagnosis is challenging due to nonspecific manifestations and difficult pathologic access. Radiological studies are the first diagnostic approach. Balloon enteroscopy allows histopathological diagnosis and management of complications such as bleeding. In our case, the jejunal tumor was ulcerated with an extensive surface area and multiple foci of actively bleeding vessels. Due to the abundant lymphovascular supply of the intestinal mucosa, SB melanoma is a highly vascularized tumor. Hemospray was the preferred initial modality in this particular scenario and was successfully used for hemostasis. It is an inorganic powder that provides hemostasis by acting as mechanical tamponade and increasing the local concentration of clotting factors. It is easy to use with an excellent safety profile, does not require precise targeting, and is efficacious in large surfaces. Mucosal tissues do not absorb it; thus, it has no risk of systemic toxicity. It is FDA approved for hemostasis of non-variceal GI bleeding. It is contraindicated in varices and fistulas. It was also used in cancer-related bleeding with promising results. It can be applied repeatedly as a bridge to other definitive modalities.
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Citation: Mira Alsheikh, MD; Cheikh Talal El Imad, MD; Sherif Andrawes, MD; Simcha Weissman, DO; Liliane Deeb, MD; Khalil Kamar, MBBCh. P0822 - EMERGING USE OF HEMOSPRAY IN LOWER GASTROINTESTINAL BLEEDING: PRIMARY MUCOSAL MELANOMA OF THE JEJUNUM. Program No. P0822. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.