P0090 - A Case of Metastatic Bladder Cancer to the Pancreas Causing Gastric Outlet Obstruction

Matthew Tjahja, MD, MS¹, Jonathan C. Ramirez, MD¹, Steven Smith, MD², Namisha Thapa, DO², Nikhil Seth, MD^1
1Baylor Scott & White Health, Temple, TX; ²Baylor Scott & White, Temple, TX

Introduction: Bladder cancer commonly metastasizes to the lungs, lymph nodes, liver, and bones. Metastasis to the pancreas is rare, but a few case reports exist describing this event where a biliary stent is placed for palliation. We describe a case involving gastric outlet obstruction (GOO) where EUS-guided biliary access was unsuccessful, requiring IR-guided biliary stent placement followed by endoscopic duodenal stent placement.

Case Description/Methods: An 81-year-old male with a history of prostate cancer and high-grade urothelial bladder cancer with abdominal lymph node metastasis on chemotherapy presented with nausea, vomiting, and weakness. He had previously undergone TURBT followed by radical cystoprostatectomy and ileal conduit creation. Initial vital signs were within normal limits. Labs were notable for ALT 360 U/L, AST 197 U/L, ALP 828 U/L, T bili 5.2 mg/dL, lipase 173 U/L, and WBC 22.9K/mm3. CT scan revealed a 4cm pancreatic head mass with possible invasion of the fourth portion of the duodenum, distended gallbladder and slightly increased common bile duct and intrahepatic biliary dilation.

Duodenal biopsies and EUS-FNA of the pancreatic mass were consistent with poorly differentiated carcinoma suggestive of metastasis from the patient's urothelial primary. Significant extrinsic duodenal sweep compression prevented the ability to perform ERCP-guided biliary stent placement. EUS-guided biliary access through the dilated left intrahepatic duct with antegrade guidewire passage was attempted, but unsuccessful due to the biliary obstruction caused by the GOO. The patient underwent IR-guided placement of fully covered metal biliary stents. Liver function tests improved and patient was discharged with plans for duodenal stent placement to manage his GOO.

He returned two days later with continuing weakness. He underwent EGD with placement of a 22mm x 9mm uncovered enteral duodenal stent. He ultimately was able to tolerate a full liquid diet and opted to pursue comfort care.

Discussion: Pancreatic metastasis of urothelial bladder cancer is rare. In our case, GOO prevented successful ERCP and EUS-guided biliary access and required IR-guided biliary stent placement followed by endoscopic placement of a duodenal stent. This case highlights this unique finding of bladder cancer metastasizing to the pancreas causing obstructive jaundice. It also showcases the multidisciplinary teamwork necessary for the management of these patients.


Figure: Image A: Attempted EUS-guided biliary access with obstruction. Image B: Extrinsic Duodenal Compression. Image C: Visualization of transpapillary metal stent placed by IR. Image D: Visualization of duodenal stent extending past the pylorus.


Disclosures:
Matthew Tjahja indicated no relevant financial relationships.
Jonathan Ramirez indicated no relevant financial relationships.
Steven Smith indicated no relevant financial relationships.
Namisha Thapa indicated no relevant financial relationships.
Nikhil Seth indicated no relevant financial relationships.


Matthew Tjahja, MD, MS¹, Jonathan C. Ramirez, MD¹, Steven Smith, MD², Namisha Thapa, DO², Nikhil Seth, MD¹. P0090 - A Case of Metastatic Bladder Cancer to the Pancreas Causing Gastric Outlet Obstruction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.