Pancreatic adenocarcinoma is one of the leading cancer-related causes of death in the United States. Most patients experience symptoms once the disease is advanced, limiting treatment options.1 Common symptoms of pancreatic cancer include weight loss, abdominal pain, and jaundice; blood tests may show abnormalities related to mass effect on the biliary tree.2 Rarely, a tumor at the head of the pancreas can invade adjacent structures to cause a gastrointestinal bleed (GIB), and a smaller percentage of patients experience an upper gastrointestinal bleed (UGIB).3 In contrast, colorectal, stomach, and esophageal malignancies are considered common causes of bleeding; ranking as the first, second, and fourth- highest cause of gastrointestinal malignancy in the United States, respectively.4 There are limited publications regarding UGIB caused by pancreatic cancer, and of those available, the majority of patients were diagnosed with pancreatic cancer prior to the UGIB or presented with melena and hematochezia compared to hematemesis.567 We present a 78-year-old female whose massive hematemesis was the initial presentation of metastatic pancreatic adenocarcinoma.

A 78-year-old female with a history of atrial fibrillation on apixaban presented to our emergency department with multiple days of melena and an episode of syncope. She reported constant non-radiating epigastric pain for days, associated with nausea. She denied changes in weight or appetite, night sweats, and yellowing of her skin. In the emergency room, she had hematochezia and massive hematemesis, leading to hemorrhagic shock (blood pressure 72/53mmHg) and hypothermia (87°F). She was resuscitated with intravenous fluids, and a massive transfusion protocol was initiated. She received eight units of red blood cells, four units of fresh frozen plasma, and two units of platelets. Prior to transfusion, hemoglobin level was 7.6g/dl (baseline from 3 months prior was 12.4g/dl). She was intubated for airway protection and admitted to the medical intensive care unit for vasopressor support and urgent endoscopy .

A proton pump inhibitor infusion was started, and urgent upper endoscopy showed a 4 cm non-obstructing, deeply cratered duodenal ulcer with a large clot and diffuse oozing (Image 1). Hemostasis was achieved with the use of mineral powder that provides physical compression and promotes clotting. The lesion was not amenable to other forms of treatment given its size. She was subsequently extubated and transferred to the medical floor, where she had recurrence of melena. The patient’s melanotic stools self-resolved, but a continuously increasing alkaline phosphatase was noted, which prompted further workup (Figure 1).

A right upper quadrant ultrasound showed a hypoechoic lesion in the head of the pancreas measuring 3.1 cm, associated with dilation of the main pancreatic and common bile duct. The liver appearance was heterogeneous with focal hypodense lesions. Further blood work was remarkable for a carcinoembryonic antigen of 2139 ng/mL and cancer antigen 19-9 was, 11782 U/mL. A CT chest, abdomen, and pelvis with contrast showed a 3.4x2.5 cm pancreatic head mass invading the duodenum, occlusive thrombi of the main portal vein and superior mesenteric vein, multiple liver lesions, and a distended stomach concerning for partial gastric outlet obstruction (Image 2). The diagnosis of pancreatic adenocarcinoma was confirmed via biopsy.

Given her diminished functional status and poor prognosis, she was discharged home with hospice services. She passed comfortably at home 1 month after discharge.

The patient’s massive gastrointestinal bleed as the initial presentation of pancreatic cancer is rare. The presentation of pancreatic tumors is generally benign relative to other malignancies because, commonly, pancreatic malignancies have vague symptoms and do not lead to significant morbidity until they are advanced.8 For example, 92% of patients’ pancreatic malignancies present with weight loss, and 82% of patients present with painless jaundice due to obstruction of the common bile duct; symptoms that were not present in our patient.2 Furthermore, routine laboratory analysis is usually non-specific and would only be abnormal if the malignancy expands to obstruct the biliary tree. GIB is a rare complication of pancreatic cancer; it has been reported in patients with previously diagnosed malignancy.39 A retrospective study of 246 patients diagnosed with pancreatic cancer found that of the patients who experienced GIB (13%), the majority had melena or hematochezia (n= 18) and less commonly hematemesis (n=9).7 Bleeding, when present, is most commonly caused by gastroduodenal tumor invasion (56.4%), variceal bleeding (19.1%), or less commonly direct tumor hemorrhage into the pancreatic duct.310 Furthermore, hemorrhage is associated with a high risk of mortality, and cases with milder GIB still had a median overall survival time of 5.5 months less than those without GIB.710 A separate study showed that for patients whose bleeding was due to tumor invasion, median overall survival was 2.8 months less than if due to any other etiology.10 Based on the findings of these studies, we determined that our patient’s initial presentation of massive UGIB due to pancreatic cancer tumor invasion into the duodenum, complicated by hemorrhagic shock, is rare and associated with poor prognosis.7910

She passed 1 month after initial diagnosis, which is consistent with survival rates reported after all-cause GIB due to pancreatic cancer.10

Lastly, a retrospective single-center study of 41 patients with GIB due to pancreatic cancer showed that patients treated with hemostatic radiation therapy (HRT) had better rates of hemostasis (100%) when compared to endoscopic approach (70.6%). Not only did HRT lead to higher rates of initial hemostatic effect, but it also showed lower rates of recurrence (7.7%) compared to endoscopy (35.3%).10 This could represent an alternative option to achieve hemostasis in GIB due to pancreatic cancer; although limited in cases like our patient where the presence of pancreatic cancer was not known and her massive GIB required emergent treatment.

Upper gastrointestinal bleeding caused by pancreatic cancer tumor invasion is a rare but important complication associated with poor prognosis and high mortality.

Providers should have a high level of suspicion when evaluating GIB, and should consider pancreatic cancer as part of the differential diagnosis.