General Medicine Registrar at Auckland City Hospital
A Case Of Massive Upper Gastrointestinal Bleeding From Metastatic Melanoma
CASE: 62 year old male brought into resus by ambulance to Auckland hospital emergency department with ongoing haematemesis. The patient's background included a Clark level 5 acral lentiginous melanoma which was resected a year ago and was currently being investigated for metastatic spread after developing abdominal pain and malaise a month ago. The major haemorrhage protocol was activated and the patient required 10 units of red blood cells. Recent gastroscopy showed a necrotic, malignant gastric ulcer which required immediate consultation between gastroenterology, interventional radiology, anaesthetics, intensive care, medical oncology, general surgery and general medicine regarding treatment options. He proceeded for Digital Subtraction Angiography for pseudoaneurysm embolisation as there was active bleeding from the gastric artery into the ulcer. This was successfully occluded with multiple tornado coils. Once he was stabilised and the bleeding settled, he was commenced on pembrolizumab.
DISCUSSION: New Zealand has one of the highest reported rates of melanoma in the world. A large number of these become invasive or metastatic. Metastatic disease in the gastrointestinal tract is commonly from melanoma. Patients with metastatic melanoma to the gastrointestinal tract have an overall poor prognosis and median survival time for melanoma patients presenting with gastrointestinal invasion is less than one year. Melanoma is a relatively rare cause of upper gastrointestinal bleeding, accounting for less than 3% of all severe cases of bleeding¹.
CONCLUSION: -Melanoma is one of the most common malignancies to metastasise to the gastrointestinal tract². -Gastrointestinal bleeding is a possible complication although uncommon, bleeding may be catastrophic. -Invasion of the gastrointestinal tract is a poor prognosticator. -If bleeding occurs, endoscopy may not be the answer although gastroenterology should still be consulted early.
REFERENCES: (1) Buckshaw et al. The American Journal of Gastroenterology: October 2019;Volume 114:Issue-pS1685-S1686 (2) Falk et al. Case Reports: 2018;bcr-2018-225869