Original Article

Seeding of the Percutaneous Endoscopic Gastrostomy Tract from Esophageal Squamous Cell Cancer Presenting as an Acutely Bleeding Malignant Gastric Ulcer: A Novel Clinicoendoscopic Presentation

Authors: Mitchell S. Cappell, MD, PhD, Adedamola Lufadeju, MD, Ajit Challa, MD, Philip O. Katz, MD

Abstract

Background: While the clinical presentation of cutaneous stomal metastases after percutaneous endoscopic gastrostomy (PEG) placed for pharyngoesophageal malignancy is well described, the clinicoendoscopic findings with gastric stomal metastases is insufficiently characterized. A novel clinicoendoscopic presentation is reported of significant gastrointestinal bleeding caused by an ulcerated gastric stomal metastasis.


Methods: A male patient was admitted for melena with a growing abdominal wall mass at a former PEG stoma. A PEG had been inserted 8 months earlier for esophageal obstruction from squamous cell cancer. Abdominal computed tomography revealed an 8 × 7 × 6 cm mass extending from the skin to the gastric wall. Esophagogastroduodenoscopy revealed an ulcerated gastric mass. Pathologic examination revealed squamous cell carcinoma in both the gastric ulcer margin and the cutaneous mass. The patient was transfused 2 units of packed erythrocytes.


Results: Review of all 44 identified stomal metastases after PEG revealed only 15 cases of pathologically proven gastric involvement, including only five illustrated endoscopic reports. Previously reported clinical manifestations of malignant gastric stomal involvement include an asymptomatic gastric mass, an asymptomatic gastric ulcer, a gastric ulcerated mass with chronic anemia, or gastric perforation from gastric involvement.


Conclusions: The current novel report of significant upper gastrointestinal bleeding from a malignant gastric ulcer at the PEG insertion site, that required blood transfusions, extends the clinicoendoscopic spectrum of peristomal metastases after PEG. Peristomal ulcers occurring in this circumstance should be biopsied at an initial or follow-up EGD, despite the recent gastrointestinal bleeding, to exclude malignancy.


Key Points


* Although cutaneous peristomal seed metastasis (at the PEG exit site) after PEG performed for pharyngoesophageal malignancy is well recognized, gastric peristomal seed metastasis (at the PEG entrance site) has been infrequently reported, with only 15 cases of pathologically proven gastric involvement.


* Review of the previously reported cases of gastric stomal metastases revealed that patients may present with an ulcerated gastric mass associated with profound anemia, either with or without fecal occult blood.


* A 59-year-old male presented with acute upper gastrointestinal bleeding, requiring transfusion of 2 units of packed erythrocytes, due to a malignant peristomal ulcerated gastric mass (at the PEG entrance site) from seed metastases 8 months after undergoing PEG for esophageal squamous cell carcinoma.


* The current novel report of significant acute upper gastrointestinal bleeding from a malignant peristomal ulcer, that required blood transfusions, extends the clinicoendoscopic spectrum of persitomal metastases after PEG.


* The currently described endoscopic appearance of an ulcerated gastric mass provides the pathophysiologic basis for the clinically observed upper gastrointestinal bleeding.

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