Endoscopic treatment of duodenal bleeding caused by direct hepatocellular carcinoma invasion with an ethanol injection.

Abstract

We report a case of a man who developed duodenal bleeding caused by direct hepatocellular carcinoma (HCC) invasion, which was successfully treated with endoscopic ethanol injection. A 57-year-old man with known HCC was admitted for melena and exertional dyspnea. He had been diagnosed with inoperable HCC a year ago. Urgent esophagogastroduodenoscopy (EGD) showed two widely eroded mucosal lesions with irregularly shaped luminal protruding hard mass on the duodenal bulb. Argon plasma coagulation and Epinephrine injection failed to control bleeding. We injected ethanol via endoscopy to control bleeding two times with 14 cc and 15 cc separately without complication. Follow-up EGD catched a large ulcer with necrotic and sclerotic base but no bleeding evidence was present. He was discharged and he did relatively well during the following periods. In conclusion, Endoscopic ethanol injection can be used as a significantly effective and safe therapeutic tool in gastrointestinal tract bleeding caused by HCC invasion.

Full text

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case report
Gut and Liver, Vol. 6, No. 1, January 2012, pp. 122-125
Endoscopic Treatment of Duodenal Bleeding Caused by Direct
Hepatocellular Carcinoma Invasion with an Ethanol Injection
Jin Nam Kim*, Hong Sik Lee†, Seung Young Kim†, Jung Han Kim†, Sung Woo Jung†, Ja Seol Koo†, Hyung Joon Yim†, Sang
Woo Lee†, Jae Hyun Choi†, Chang Duck Kim†, and Ho Sang Ryu†
*Division of Gastroenterology, Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, †Department of
Internal Medicine and Digestive Disease and Nutrition, Korea University College of Medicine, Seoul, Korea
We report a case of a man who developed duodenal bleed-
ing caused by direct hepatocellular carcinoma (HCC) inva-
sion, which was successfully treated with endoscopic ethanol
injection. A 57-year-old man with known HCC was admitted
for melena and exertional dyspnea. He had been diagnosed
with inoperable HCC a year ago. Urgent esophagogastroduo-
denoscopy (EGD) showed two widely eroded mucosal lesions
with irregularly shaped luminal protruding hard mass on the
duodenal bulb. Argon plasma coagulation and Epinephrine
injection failed to control bleeding. We injected ethanol via
endoscopy to control bleeding two times with 14 cc and 15
cc separately without complication. Follow-up EGD catched
a large ulcer with necrotic and sclerotic base but no bleed-
ing evidence was present. He was discharged and he did
relatively well during the following periods. In conclusion,
Endoscopic ethanol injection can be used as a signifi cantly
effective and safe therapeutic tool in gastrointestinal tract
bleeding caused by HCC invasion. (Gut Liver 2012;6:122-
125)
Key Words: Endoscopic treatment; Ethanol injection; Duode-
nal bleeding; Hepatocellular carcinoma
INTRODUCTION
Gastrointestinal (GI) tract bleeding in patients with hepatocel-
lular carcinoma (HCC) is a common malady. The causes of GI
tract bleeding in patients with HCC include varixes, peptic ul-
cers, gastropathy, Mallory-Weiss syndrome and tumor involve-
ment of the GI tract.1 Bleeding from the GI tract by direct tumor
invasion is very unusual and it has a very poor prognosis.2-4
Treatments that include surgery, transcatheter arterial chemo-
Correspondence to: Hong Sik Lee
Department of Internal Medicine and Digestive Disease and Nutrition, Korea University College of Medicine, 126-1 Anam-dong 5-ga, Seongbuk-gu,
Seoul 135-705, Korea
Tel: +82-2-920-5312, Fax: +82-2-953-1943, E-mail: hslee60@korea.ac.kr
Received on June 1, 2010. Revised on August 10, 2010. Accepted on September 10, 2010.
pISSN 1976-2283 eISSN 2005-1212 http://dx.doi.org/10.5009/gnl.2012.6.1.122
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
embolization (TACE) and local injection often fail to stop the
bleeding. Here we report on a case of a patient who developed
duodenal bleeding that was caused by direct HCC invasion and
this was successfully treated with endoscopic ethanol injection.
CASE REPORT
A 57-year-old man with known HCC was admitted for me-
lena and exertional dyspnea that he’d experienced for the previ-
ous 3 days. He did not drink alcohol and the serologic markers
for hepatitis B surface antigen and anti-hepatitis C virus were
negative. He had been diagnosed with inoperable HCC one year
previously and he had undergone TACE on a monthly basis.
However, the HCC was not properly controlled and portal vein
thrombosis developed (Fig. 1A and C). At the time of the diag-
nosis of HCC, esophagogastroduodenoscopy (EGD) showed only
a duodenal ulcer scar on the bulb without varixes. On admis-
sion, his blood pressure was 99/54 mm Hg (normal, 120/80 mm
Hg) and his pulse rate was 94/min (normal, 60 to 100/min). The
physical examination showed paled conjunctiva and one palm-
breadth of hepatomegaly below the costal margin. The labora-
tory tests were as follows: hemoglobin, 5.5 g/dL (normal, 12.6
to 17.4 g/dL), hematocrit, 16.8% (normal, 39% to 50%), white
blood cell count, 5,150/μL (normal, 4,500 to 11,000/μL), platelet
count, 104,000/μL (normal, 150,000 to 400,000/μL), serum pro-
tein, 6.1 g/dL (normal, 6.0 to 8.2 g/dL), albumin, 3.6 g/dL (normal,
3.2 to 5.4 g/dL), aspartate transaminase, 116 IU/L (normal, 0 to
50 IU/L), alanine transaminase, 133 IU/L (normal, 0 to 45 IU/
L), and total bilirubin, 0.39 mg/dL (normal, 0.0 to 1.6 mg/dL).
Urgent EGD showed two widely eroded mucosal lesions with an
hard, irregularly shaped mass on and protruding into the lumen
of the duodenal bulb (Fig. 2A). Under the impression of direct

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Kim JN, et al: Endoscopic Ethanol Injection for Invasive Hepatocellular Carcinoma 123
Fig. 1. (A, B) A bulky hepatocellu-
lar carcinoma mass compresses the
duodenum. (C, D) A tumor necrosis
approximately 4 cm in diameter at
the ethanol injection site (arrow).
Fig. 2. (A) A luminal protruding
hepatocellular carcinoma mass on
the duodenal bulb. (B) The regrowth
of the mass with oozing on the duo-
denal bulb. (C) Endoscopic ethanol
injection at the base of the mass. (D)
Follow-up esophagogastroduodenos-
copy shows the necrosis of the mass
on the duodenal bulb.

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124 Gut and Liver, Vol. 6, No. 1, January 2012
invasion of HCC into the duodenum, we performed snaring pol-
ypectomy for argon plasma coagulation (APC) and histological
confirmation. The histologic findings showed duodenal inva-
sion of HCC (Fig. 3). His vital signs and hemoglobin level were
improved after APC and blood transfusion. However, 15 days
later, he again complained about melena and dyspnea. EGD
revealed re-growth of the duodenal mass with oozing (Fig. 2B).
We injected ethanol (95%) via endoscopy to control the cancer
bleeding two times with doses of 14 and 15 cc, respectively (Fig.
2C). Fourteen days later, follow-up EGD noticed a large ulcer
with a necrotic and sclerotic base, but there was no evidence of
bleeding (Fig. 2D). Follow-up abdominal computed tomography
showed tumor necrosis in segment 4, which is where the etha-
nol had been injected (Fig. 1B and D). He was discharged and
was doing relatively well during the following period. Sadly, the
HCC progressed and he died of rebleeding and hepatic failure 3
months later.
DISCUSSION
HCC is one of the most common malignancies in the world
and it is showing an increasing incidence in industrialized
countries. Extrahepatic metastasis of HCC occurs in 30% to
75% of the patients via three routes: direct invasion and the
hematogenous and lymphogenous routes.5 The most common
metastatic site is the lung, followed by regional lymph nodes,
bones, heart and adrenal glands.6 GI tract involvement is rare,
and this is seen in only 0.5% to 2% of the cases.5,7 The most
commonly involved site of the GI tract is the duodenum, fol-
lowed by the stomach, colon, and jejunum.7,8 Patients with
HCC and GI tract involvement were generally in an advanced
stage of disease. A bulky tumor burden and persistent occult or
frank GI tract bleeding are the main clinical manifestations of
GI tract involvement of HCC.5 Tumor invasion of the GI tract
should be considered in the HCC patients with GI tract bleeding,
and particularly in the cases without esophageal varices. Treat-
ments that include surgery, TACE and local injection have been
carried out, but attempts to control this bleeding commonly
fail. Therefore, these patients have a dismal prognosis. None of
these patients have survived longer than 3 months except for
two reported cases of HCC invading the duodenum; external
beam radiotherapy was performed in one case9 and TACE was
performed in another3 to control the bleeding. Surgery may
offer significantly prolonged survival, yet most patients with
HCC have liver cirrhosis and a poor liver function, and so these
patients are not good candidates for resection. TACE may be an
efficient treatment for GI tract bleeding. Traditionally, it is used
for GI tract bleeding when endoscopic hemostasis is unsuccess-
ful. In this case, the patient had undergone TACE on a monthly
basis, but his HCC was not properly controlled and portal vein
thrombosis then developed. Therefore, TACE might not have
controlled the bleeding. We controlled the bleeding via endo-
scopic ethanol injection. Percutaneous ethanol injection (PEI)
was the first percutaneous treatment used in clinical practice
and it is recommended as the standard ablation treatment for
early stage nonsurgical HCC.10 This technique involves a needle
being introduced into the tumor and slow injection of absolute
or 95% ethanol into the lesion. The ethanol induces tumor de-
struction by drawing water out of the tumor cells and denatur-
ing the structure of the cellular proteins, and so it can achieve a
higher rate of complete tumor response for small HCCs.11,12 The
most common side effect of PEI is leakage of ethanol onto the
surface of the liver and into the abdominal cavity, causing pain
and fever. In the case of our patient, we injected ethanol into
the tumor mass via endoscopy to control his GI tract bleeding
from direct HCC invasion. The bleeding was successfully con-
trolled without side effects. Endoscopic ethanol injection is very
simple to perform and it can be performed during EGD.
As far as we know, this is the first case report that endoscopic
ethanol injection successfully controlled GI tract bleeding from
direct HCC invasion. In conclusion, endoscopic ethanol injection
might be used as an effective and safe therapeutic tool for duo-
denal bleeding caused by HCC invasion. Yet further studies are
necessary to clarify the effectiveness and safety of endoscopic
ethanol injection in the setting of invasive HCC.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was
reported.
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