Gastrointestinal hemorrhage caused by the direct invasion of a hepatocellular carcinoma successfully treated with polyglycolic acid sheet shielding

A 76-year-old man with a history of alcoholic liver cirrhosis presented with a 4-day history of melena. He had been diagnosed 30 months previously with hepatocellular carcinoma (HCC), but chose to not receive further evaluation or treatment. Laboratory findings revealed severe anemia (hemoglobin 4.9 g/dL) and liver dysfunction. A computed tomography (CT) scan demonstrated an enlarged HCC mass (10-cm diameter) located in the left lobe of the liver, compressing the stomach ([Fig. 1]). Esophagogastroduodenoscopy (EGD) detected a submucosal tumor with central ulceration in the lesser curvature of the stomach ([Fig. 2]).

Fig. 1 Computed tomography scan of the abdomen showing a markedly enlarged hepatocellular carcinoma in the left lobe (arrowhead), approximately 10 cm in diameter, which was compressing the stomach (arrows).

Fig. 2 Endoscopic views showing: a a submucosal tumor with central ulceration in the lesser curvature of the stomach; b, c infiltrating irregular reddish-white tumor with partial necrosis, showing intermittent blood oozing.

The patient was diagnosed with upper gastrointestinal (GI) hemorrhage caused by direct HCC invasion and angioembolization was performed to promote hemostasis. However, a follow-up CT scan revealed that the perigastric portion of the HCC remained viable and the possibility of recurrent bleeding remained a concern. In response, a polyglycolic acid (PGA) sheet (Neoveil; Gunze Co., Kyoto, Japan) and fibrin glue were endoscopically applied to the ulcerous lesion ([Video 1]), implementing a method used in previous studies [1] [2]. An EGD 2 days after the procedure showed that the PGA sheet remained intact.

Video 1 Endoscopic shielding of a hemorrhagic gastric ulcer due to invasive hepatocellular carcinoma using polyglycolic acid (PGA) sheet and fibrin glue.

The patient opted to be discharged and received palliative medical care at home. He had no subsequent recurrence of melena prior to his death from hepatic failure 14 days after the procedure.

HCC with direct invasion into the stomach is very rare and the prognosis is ominous owing to poor hepatic reserve and continuous bleeding from the lesion [3]. Moreover, a nonsurgical treatment, such as angioembolization, does not always achieve complete hemostasis [4]. Application of PGA sheets has been used to prevent perforation, stricture, or bleeding after endoscopic submucosal dissection (ESD) [1] [2] and has effectively repaired GI fistulas and perforated post-ESD ulcers [5]. Therefore, the endoscopic application of PGA shielding for patients with HCC and direct GI invasion may be considered as the conservative treatment of choice.

Endoscopy_UCTN_Code_TTT_1AO_2AD

• References

• 1 Takimoto K, Toyonaga T, Matsuyama K. Endoscopic tissue shielding to prevent delayed perforation associated with endoscopic submucosal dissection for duodenal neoplasms. Endoscopy 2012; 44: E414-E415
• 2 Ono S, Tsuji Y, Fujishiro M. et al. An effective technique for delivery of polyglycolic acid sheet after endoscopic submucosal dissection of the esophagus: the clip and pull method. Endoscopy 2014; 46: E44-E45
• 3 Chen LT, Chen CY, Jan CM. et al. Gastrointestinal tract involvement in hepatocellular carcinoma: clinical, radiological and endoscopic studies. Endoscopy 1990; 22: 118-123
• 4 Fujii K, Nagino M, Kamiya J. et al. Complete resection of hepatocellular carcinoma with direct invasion to the stomach remnant. J Hepatobiliary Pancreat Surg 2004; 11: 441-444
• 5 Ono H, Takizawa K, Kakushima N. et al. Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer. Endoscopy 2015; 47: E18-E19