It is never too late: a deceitful gastric ulcer
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- Caroselli, C., Tomezzoli, A., Caroselli, C. et al. Intern Emerg Med (2009) 4: 409. doi:10.1007/s11739-009-0278-8
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Prof. Bruno: A 94-year-old woman was referred to our Emergency Department (ED) with a history of nausea, fatigue, sudden-onset epigastric pain and extreme discomfort. Before 1 h to the ED visit, she had syncope and three vomiting episodes. Before 5 years, she experienced a gastric haemorrhage.
On admission, she showed hemodynamic shock with a blood pressure of 70/40 mmHg, she had a weak pulse, spoke slowly, and she was vague and slurred in her speech patterns. The 12-lead ECG showed a sinus tachycardia at 120 beats per minute. She was breathing rapidly at 27 breaths per minute and the non-invasive oxygen saturation (SpO2) showed 85% while she was breathing room air. Her body temperature was 36.3°C. The finger-stick glucose was normal 105 mg%.
Physical examination disclosed that the skin was cold with pallor. The lung fields were clear on auscultation; the abdomen was soft, but painful and tender. There were no hepatomegaly, no pulsating masses, or bruit was detectable. A rectal examination revealed no masses and no occult blood. The peripheral pulses were normal and symmetrical. She was treated with colloids, saline fluids and dopamine intravenously and as soon as possible, blood transfusions were begun.
The results of routine laboratory findings, including ammoniemia, platelet count, liver function and clotting system (prothrombin, thromboplastin and clottable fibrinogen) were within normal ranges except for anaemia: her haemoglobin concentration was 7.9 g per decilitre and the haematocrit 22.6% with a mean corpuscular volume of 87.9 μm3. Serological markers for hepatitis B and C were negative.
Her clinical condition stabilized following the blood transfusion and after oxygen administration. The cardiac output rose, and her blood pressure was 105/50 mmHg with a pulse rate of 89 beats per minute, respiratory rate 15 breaths/min and SpO2 95% after the administration of oxygen by mask (4 L min−1). Therefore, it was possible to do an oesophagogastroscopy.
Although 5 years before, she had a gastric haemorrhage, actually neither oesophageal varices nor peptic ulcer were observed during oesophagogastroscopy.
The ultrasonogram concomitantly with the finding of no liver cirrhosis revealed a large mass involving the liver, free effusion in the abdomen, and an abdominal aortic aneurysm of 4 cm without signs of rupture.
In light of these findings, she immediately underwent transcatheter intraarterial embolization (TAE) performed by intraarterial injection that successfully controlled life-threatening bleeding. Later, surgical hepatic resection was necessary for an attempted cure. The diagnosis of ruptured hepatocellular carcinoma (HCC) was confirmed by intraoperative and microscopic findings.
Even if the patient was not so young (!), she left hospital after 2 weeks in good health.
Dr. Tomezzoli, Dr. Longo: The diagnosis in this case rests on considering two different elements on this patient’s presentation: anaemia and shock. The patient in her past clinical history experienced a gastric haemorrhage, but this diagnosis was excluded by an esophagogastroduodenoscopy. In fact, the procedure permitted the exclusion of the presence of oesophageal varices or peptic ulcer. Further, we could also exclude gastrointestinal bleeding in hereditary haemorrhagic telangiectasia because this disease usually becomes evident in the fourth or fifth decade of life .
Even though an abdominal ultrasonographic study showed the presence of an abdominal aortic aneurysm and a free effusion in the abdomen, we could exclude signs of aortic rupture.
Prof. Bruno: In our clinical case, the first problem was to stabilize clinical parameters, and to resolve the shock condition. On admission, anaemia and shock suggested a preliminary diagnosis of upper gastrointestinal bleeding, and the patient required transfusions. Oesophagogastroduodenoscopy disclosed no lesions to explain the bleeding.
Dr. Costantino Caroselli, Dr. Longo: Following the intervention, we assisted in the resolution of the anaemia and gradually improving patient’s clinical condition. Although prognosis of these patients still remains to be poor, considering the high malignancy of hepatocarcinoma, in our case, the patient’s condition was quite good after hospital discharge. In fact, a total body computed tomography (CT) 3 months later disclosed no neoplasm recurrence, and the α-fetoprotein level was normal.
This case illustrates that TAE can stabilize the patient and yield a good outcome, even in the elderly patient.
Dr. Costantino Caroselli, Prof. Cynthia Caroselli: Hepatocellular carcinoma (HCC) is a well-described primary malignancy of the liver.
Moreover, the pathogenesis of HCC has been reported to be multifactorial. HCC is a frequent complication of liver cirrhosis, viral hepatitis infection and other chronic liver diseases  and they can regarded as the main effective causes. Recently, an interesting study investigated possible immunohistochemical markers in the diagnostics of HCC named thioredoxin superfamily of proteins , but the prognosis of HCC after its discovery still remains poor. In particular, the occurrence of spontaneous rupture of HCC is a serious and catastrophic complication of this tumour, and can be deadly, but the reasons for this complication still remain unclear. Several factors may contribute to the rupture of liver metastases, including tumour necrosis, increased intraabdominal palpation, coughing and tumour location . It is suggested that rupture is usually preceded by the rapid expansion of the tumour secondary to bleeding from within its substance . Large tumour size, male sex and exophytic growth of tumour may be predisposing factors for rupture . A previous study demonstrates a significant correlation existing between tumour diameter and bleeding time, and in addition, it is suggested that prolonged bleeding may be categorised as a new clinical manifestation in patient with HCC .
In our patient, the initial symptoms and the past history suggested a gastric ulcer, but it was excluded after oesophagogastroscopy. The initial diagnosis of HCC was made with an ultrasonogram.
Abdominal CT-axial scan pointed out a large tumour bleeding into peritoneum.
In our case, we could exclude most common risk factors of HCC: alcohol abuse, hepatitis B (HBV) or C (HCV) virus infection, liver cirrhosis and primary biliary cirrhosis. Moreover, we could exclude other rare causes such as haemochromatosis, use of androgenic steroids, primary sclerosing cholangitis, antitrypsin deficiency and porphyria cutanea tarda.
Therefore, in our patient it was not possible to establish the aetiology of HCC and the cause of bleeding. She had a life-threatening condition that TAE was effective in permitting bleeding to be controlled, and to salvage the patient from the severe haemorrhagic shock.
The treatment of HCC is dependent on many factors, especially on tumour size and staging. Patients with acceptable liver function should undergo surgery because it is the most effective procedure. The prognosis of ruptured HCC treated with second-stage hepatectomy is considered to be comparable with that of non-ruptured HCC .
Emergency TAE is the most effective and less-invasive treatment for haemostasis. Although TAE remains the best method to employ for haemostasis, it still has limitations. The rupture of HCC at an early phase in the development of liver fibrosis is a good indication for elective surgical treatment, and should be distinguished from rupture in the terminal phase of liver cirrhosis, which should be treated conservatively .
Therefore, it is advisable to aggressively resuscitate the patient in the ED, so that effective therapy can be started.
The authors wish to thank Dr. Eliana Viola for careful English revision of the manuscript.
Conflict of interest statement
The authors declare that they have no conflict of interest related to the publication of this manuscript.