Journal of Clinical Case Reports and Images

Journal of Clinical Case Reports and Images

Current Issue Volume No: 2 Issue No: 4

Case-report Article Open Access
  • Available online freely Peer Reviewed

  • Massive Hematemesis As Initial Presentation Of Advanced Pancreatic Adenocarcinoma

    1 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell 

    Abstract

    Pancreatic adenocarcinoma is one of the leading causes of cancer-related death in the United States. Rarely, a tumor at the head of the pancreas can invade adjacent structures to cause a gastrointestinal bleed (GIB). We present a 78-year-old female whose massive upper GIB was the initial presentation of metastatic pancreatic adenocarcinoma. Prior reports have documented GIB in patients with known pancreatic cancer, but in our case, the diagnosis was made after the bleed was controlled, making this presentation rare and associated with a poor prognosis.
    Author Contributions
    Received Sep 06, 2023     Accepted Sep 14, 2023     Published Sep 18, 2023

    Copyright© 2023 Farshadmand B.S. Jonathan, et al.
    License
    Creative Commons License   This work is licensed under a Creative Commons Attribution 4.0 International License. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Funding Interests:

    Citation:

    Farshadmand B.S. Jonathan, Rodriguez M.D. Neyshia, Kashfi M.D. Simon, Mehta M.D. Prachi et al. (2023) Massive Hematemesis As Initial Presentation Of Advanced Pancreatic Adenocarcinoma Journal of Clinical Case Reports and Images. - 2(4):19-23
    DOI 10.14302/issn.2641-5518.jcci-23-4743

    Introduction

    Introduction

    Pancreatic adenocarcinoma is one of the leading cancer-related causes of death in the United States. Most patients experience symptoms once the disease is advanced, limiting treatment options.1 Common symptoms of pancreatic cancer include weight loss, abdominal pain, and jaundice; blood tests may show abnormalities related to mass effect on the biliary tree.2 Rarely, a tumor at the head of the pancreas can invade adjacent structures to cause a gastrointestinal bleed (GIB), and a smaller percentage of patients experience an upper gastrointestinal bleed (UGIB).3 In contrast, colorectal, stomach, and esophageal malignancies are considered common causes of bleeding; ranking as the first, second, and fourth- highest cause of gastrointestinal malignancy in the United States, respectively.4 There are limited publications regarding UGIB caused by pancreatic cancer, and of those available, the majority of patients were diagnosed with pancreatic cancer prior to the UGIB or presented with melena and hematochezia compared to hematemesis.567 We present a 78-year-old female whose massive hematemesis was the initial presentation of metastatic pancreatic adenocarcinoma.

    Discussion

    Discussion

    The patient s massive gastrointestinal bleed as the initial presentation of pancreatic cancer is rare. The presentation of pancreatic tumors is generally benign relative to other malignancies because, commonly, pancreatic malignancies have vague symptoms and do not lead to significant morbidity until they are advanced.8 For example, 92% of patients pancreatic malignancies present with weight loss, and 82% of patients present with painless jaundice due to obstruction of the common bile duct; symptoms that were not present in our patient.2 Furthermore, routine laboratory analysis is usually non-specific and would only be abnormal if the malignancy expands to obstruct the biliary tree. GIB is a rare complication of pancreatic cancer; it has been reported in patients with previously diagnosed malignancy.39 A retrospective study of 246 patients diagnosed with pancreatic cancer found that of the patients who experienced GIB (13%), the majority had melena or hematochezia (n= 18) and less commonly hematemesis (n=9).7 Bleeding, when present, is most commonly caused by gastroduodenal tumor invasion (56.4%), variceal bleeding (19.1%), or less commonly direct tumor hemorrhage into the pancreatic duct.310 Furthermore, hemorrhage is associated with a high risk of mortality, and cases with milder GIB still had a median overall survival time of 5.5 months less than those without GIB.710 A separate study showed that for patients whose bleeding was due to tumor invasion, median overall survival was 2.8 months less than if due to any other etiology.10 Based on the findings of these studies, we determined that our patient s initial presentation of massive UGIB due to pancreatic cancer tumor invasion into the duodenum, complicated by hemorrhagic shock, is rare and associated with poor prognosis.7910

    She passed 1 month after initial diagnosis, which is consistent with survival rates reported after all-cause GIB due to pancreatic cancer.10

    Lastly, a retrospective single-center study of 41 patients with GIB due to pancreatic cancer showed that patients treated with hemostatic radiation therapy (HRT) had better rates of hemostasis (100%) when compared to endoscopic approach (70.6%). Not only did HRT lead to higher rates of initial hemostatic effect, but it also showed lower rates of recurrence (7.7%) compared to endoscopy (35.3%).10 This could represent an alternative option to achieve hemostasis in GIB due to pancreatic cancer; although limited in cases like our patient where the presence of pancreatic cancer was not known and her massive GIB required emergent treatment.

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