Dipen Patel, MD, MBA, Kanana Aburayyan, MD, Sami Ghazaleh, MD, Azizullah Beran, MD, Christian Nehme, MD, Jordan Burlen, MD, Thomas Sodeman, MD, Ali Nawras, MD, FACG; University of Toledo Medical Center, Toledo, OH
Introduction: Pancreatic neuroendocrine tumors (NET) are rare tumors with potential for malignant transformation. They are divided into two categories based on if they produce hormones. Functional tumors account for 25% of NETs and are characterized by active secretion of hormones like insulin and glucagon. Non-functional tumors account for 75% of NETs. Common presentations of non-functional tumors include abdominal pain, weight loss, anorexia, and nausea. These symptoms are usually related to local tumor invasion and liver metastasis. In this case we present a patient with melena who was found to have a duodenal ulcer from eroding mass that led to the diagnosis of advanced stage NET.
Methods: The patient is a 69-year-old male with a past medical history significant coronary artery disease, and antiphospholipid syndrome on warfarin who presented with abdominal pain and melena of 1-day duration. Vital signs were stable and physical examination was remarkable for lower abdominal tenderness. Lab workup was significant for hemoglobin of 8.3 mg/dl, INR of 3.4 and aPTT of 38 seconds. CT angiogram of the abdomen and pelvis showed a lobulated mass in the region of the duodenum and pancreas measuring 6.6 x 5.0 x 4.2 cm with lesions in the liver concerning for metastatic disease (Figure 1). Supportive care was provided, and IV pantoprazole infusion was started. EGD showed LA Grade B esophagitis and one non-bleeding duodenal ulcer with heaped edges (Figure 2). Patient also underwent endoscopic ultrasound with fine needle aspiration of the pancreatic mass which also showed grade 1 well differentiated neuroendocrine tumor (Figure 3). Patient was treated conservatively, his melena resolved gradually, and his hemoglobin stabilized. Soon after discharge, patient was started on octreotide acetate for cancer treatment. Discussion: Non-functional neuroendocrine tumors are usually asymptomatic and are discovered incidentally on imaging done to evaluate unrelated conditions. When symptomatic, symptoms include abdominal pain, weight loss, anorexia, nausea, obstructive jaundice and palpable mass. Mean tumor size is small, however, up to 73% of cases are metastatic at time of diagnosis. In our case, the tumor was relatively large and invaded into the duodenum. The resulting duodenal ulcer caused melena that led to this diagnosis. No previous cases of pancreatic NET presenting with melena were identified on our careful literature review.
Figure 1: CT angiogram abdomen and pelvis showed lobulated mass in the region of the duodenum and pancreas with lesions in the liver concerning for metastatic disease.
Figure 2: EGD of duodenal bulb ulcer
Figurer 3: EUS of pancreatic neuroendocrine tumor
Disclosures: Dipen Patel indicated no relevant financial relationships. Kanana Aburayyan indicated no relevant financial relationships. Sami Ghazaleh indicated no relevant financial relationships. Azizullah Beran indicated no relevant financial relationships. Christian Nehme indicated no relevant financial relationships. Jordan Burlen indicated no relevant financial relationships. Thomas Sodeman indicated no relevant financial relationships. Ali Nawras indicated no relevant financial relationships.