2039 Invasive "Intracholecystic Papillary-Tubular Neoplasm" (ICPN) Presenting as Hemobilia in a Jehovah's Witness Patient

• DOI: 10.14309/01.ajg.0000597688.08666.f2
• Publication Date: 2019-10-08T16:16:29Z
• Authors: Divya G. Iyer; Pradeep K. Siddappa; Amreet K. Aujla; Michael A. Selden
• Keywords: Melena

INTRODUCTION: Hemobilia is a rare cause of upper gastrointestinal bleeding, which requires high index suspicion for diagnosis. In various case series, hemobilia due to neoplastic disease the hepatobiliary system ranges from 6% - 15%. ICPNs are neoplasms gallbladder that usually detected incidentally. This Jehovah’s Witness patient with severe symptomatic anemia secondary invasive ICPN. CASE DESCRIPTION/METHODS: 71-year-old 4 month history anemia, suspected be multiple small intestine angioectasias seen on prior enteroscopies, presented 3 day fatigue, dyspnea exertion, and melena. Patient’s hemoglobin/hematocrit at presentation was 6.4/23.4. She underwent gastroduodenoscopy showed blood in second part duodenum prompted side viewing duodenoscopy examination oozing ampulla (Figure 1). Abdominal MRI markedly distended polypoid appearing wall thickness 2). Patient received iron infusions improve hemoglobin hematocrit. then open cholecystectomy, intraoperatively surgeons did not appreciate any mass lesion gallbladder. Surgical pathology found mucinous adenocarcinoma (1.0 cm) arising large (14.5 ICPN high-grade dysplasia (Figures 3a,b). The tumor invaded muscularis propria had negative cystic duct margins carcinoma or dysplasia. Two lymph nodes were positive malignancy. It staged as III-b pT1b, pN1, pMx. After discussion board, she recommended have surveillance imaging months because her comorbidities precluded chemotherapy. DISCUSSION: To best our knowledge this only reported presenting hemobilia. Residual changes 6.4% patients GB carcinomas. presence acted red herring patient. fortuitous timing endoscopy visualize bleeding clinched diagnosis made it difficult identify eventually confirmed surgical pathology. should always differential GI bleed actively investigated when no obvious lesions noted gastric intestinal mucosa.