Pankaj Aggarwal, MD
San Antonio, Texas
Pankaj Aggarwal, MD1, Tamneet Singh, MD1, Souleymane Y. Diallo, DO1, Jacqueline Rampy, MD1, Adrianne K. Thompson, MD2, William Perry, MD2, Shail Govani, MD, MSc2
1University of Texas Health Science Center, San Antonio, TX; 2South Texas Veterans Health Care System, San Antonio, TX
Introduction: Renal cell carcinoma (RCC) is a type of kidney cancer that rarely metastasizes to the small bowel. There are only a few reported cases. We present a rare case of metastatic RCC to the small bowel 13 years after nephrectomy.
Case Description/Methods: A 70-year-old man with a history of RCC treated with nephrectomy 13 years prior presented to the hospital with melena and a hemoglobin of 10g/dL. Upper endoscopy was unrevealing. Colonoscopy showed diverticulosis and scant blood in the cecum. After discharge, a capsule endoscopy showed bright red blood starting in the mid to distal small bowel. The patient later underwent a repeat capsule endoscopy which did not identify any further bleeding or a source of blood loss. The patient subsequently underwent an anterograde enteroscopy to the mid-small bowel without identifying a source GI bleeding. With oral iron supplementation, his hemoglobin normalized and the patient had no further episodes of melena.
One year later, the patient presented to the hospital with abdominal pain and was found to have a distal small bowel obstruction and to be anemic with a hemoglobin level of 11g/dL. A non-contrast CT abdomen and pelvis did not identify a cause of obstruction. After conservative management, patient was referred for MR enterography which showed a 5cm enhancing mass in the terminal ileum (image 1). The mass was biopsied via ileocolonoscopy (image 2), which showed metastatic renal cell carcinoma, clear cell type. He subsequently underwent surgical metastasectomy (image 3). Surgical pathology confirmed metastatic RCC with no evidence of lymph node involvement.
Discussion: Metastatic RCC to the small bowel is rare and has mostly been described anecdotally thus far. Despite undergoing a presumably curative nephrectomy, this patient had a recurrence 13 years after surgery. Thus, this case adds to the growing body of literature to support late gastrointestinal metastasis from RCC as a potential cause of occult GI bleeding.
Additionally, this patient’s case is unique in that both capsule endoscopy and CT failed to identify the site of bleeding. Given the size of the mass, this case highlights the miss rate of capsule endoscopy. The poor distal small bowel prep likely reduced the ability to detect this distal small bowel lesion. Ultimately, the mass was identified via MR enterography. This case sheds light on an important issue regarding the utility and efficacy of capsule endoscopy compared to magnetic resonance imaging in the identification of small bowel neoplasms
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Citation: Pankaj Aggarwal, MD; Tamneet Singh, MD; Souleymane Y. Diallo, DO; Jacqueline Rampy, MD; Adrianne K. Thompson, MD; William Perry, MD; Shail Govani, MD, MSc. P1725 - YOU MAY SPREAD BUT CAN’T HIDE! A RARE CASE OF METASTATIC RENAL CELL CARCINOMA TO THE SMALL BOWEL AFTER NEPHRECTOMY. Program No. P1725. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.