P3301 - Multifaceted Diagnostic Approach for Unexplained Anemia in a Post Liver Transplant Patient With Metastatic Adenocarcinoma and Roux-en-Y Gastric Bypass

Yash R. Shah, MD¹, Carensa Cezar, MD², Sumant Inamdar, MD², Mauricio Garcia Saenz De Sicilia, MD², Matthew Deneke, MD², Mary K. Rude, MD^2
1Trinity Health Oakland / Wayne State University School of Medicine, Pontiac, MI; ²University of Arkansas for Medical Sciences, Little Rock, AR

Introduction: The incidence of small bowel adenocarcinoma (SBA) is 2.24 per 100,000 in the United states. The common presenting symptoms are vague non-specific abdominal pain, nausea and vomiting. Some patients are diagnosed due to bleeding or symptoms of obstruction.80% of JA are diagnosed at stage III or IV due to vague presentation and poorly defined diagnostic modalities. We present the first ever reported case of metastatic jejunal adenocarcinoma in a patient with a history of liver transplant and Roux-en-Y gastric bypass surgery (RYGB).

Case Description/Methods: A 62-year-old woman with a history of RYGB (1993), liver cirrhosis and chronic kidney disease stage IV requiring liver-kidney transplant with gastrostomy tube placement in remnant pouch for severe malnutrition was admitted to the hospital for evaluation of multiple ring enhancing lesions on the liver on follow up magnetic resonance cholangiopancreatography post transplant. Endoscopic retrograde cholangiopancreatography (ERCP) was unremarkable and biopsy was not obtained during endoscopic ultrasound due to poor visualization of the hepatic lobes. The IR guided liver biopsy was inconclusive due to limited sample.



The patient’s hemoglobin was 5.3 g/dL and she was also complaining of dark stools. Labs were significant for elevated creatinine (2mg/dL), elevated ALP (416IU/L), elevated GGT (120IU/L), elevated CA-19-9 (133.7 U/mL). Eventually a 5 cm partially obstructing mass with active bleeding was noted in the jejunum after extensive imaging and procedures (Table 1 and Figure 1). The biopsy results showed invasive moderately differentiated adenocarcinoma. She was not deemed a candidate for chemotherapy or surgical excision due to metastasis of the tumor and altered anatomy due to prior RYGB. She was discharged with outpatient palliative care follow-up.

Discussion: Jejunal adenocarcinoma usually presents around the age of 60 years. In patients with liver transplant, malignancies related deaths is one of the most common causes in patients surviving at least 1 year post-transplant. The estimate of De novo malignancies in post transplant patients is estimated between 3.1-14.4% with a mortality rate of 0.6-8%. Current guidelines do not recommend specific malignancy screening in patients with bariatric surgery, however PET-CT prior to transplant or endoscopic evaluation of the remnant pouch could be a consideration in targeted populations to definitively rule out preexisting malignancies prior to liver transplantation.



Disclosures:


Yash R. Shah, MD¹, Carensa Cezar, MD², Sumant Inamdar, MD², Mauricio Garcia Saenz De Sicilia, MD², Matthew Deneke, MD², Mary K. Rude, MD². P3301 - Multifaceted Diagnostic Approach for Unexplained Anemia in a Post Liver Transplant Patient With Metastatic Adenocarcinoma and Roux-en-Y Gastric Bypass, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.