A 31-year-old Korean male patient was transferred to our hospital from a local hospital because of persistent melena of undetermined origin. Four months ago, the patient visited the hospital with complaints of chest tightness and productive cough. An X-ray film of the chest at that time showed a patch infiltration in the right lower lung field. Studies of the sputum for acid fast bacilli were negative but anti-tuberculosis medications were started under the impression of pulmonary tuberculosis. Three months later, he was admitted to the same hospital because of melena and underwent extensive work-ups including gastroscopic examination, barium studies of the colon and small bowels, and a gastric mucosa scan for Meckel's diverticulum, but no bleeding focus was found. During the stay in that hospital, the melena improved spontaneously and he was discharged. He did fairly well until 10 days prior to this admission when recurrent melena developed. Additional studies including 99mTC-sulfur colloid scintigraphy were carried out, but no bleeding focus was found.
On admission, the patient appeared pale and acutely ill. The blood pressure was 130/70 mm/Hg, pulse rate 120/min, respiratory rate 20/min, and the temperature 36.5 C. The heart sound was normal without murmur. Breathing sound was decreased at the right lower lung field. No lymphadenopathy was found in the neck or axilla. No palpable abdominal mass was felt. Rectal examination revealed internal hemorrhoid and hematochezia.
The hemoglobin was 4.6 g/dl and the hematocrit was 14%. The white blood cell count was 6300/mm3 and the platelet 203,000/mm3. The urea nitrogen was 22.4 mg/dl, the creatinine 1.5 mg/dl, the protein 2.5 g/dl (the albumin 1.3 g/dl and the globulin 1.2 g/dl), the bilirubin 0.4 mg/dl, the alkaline phosphatase 53 IU, the aspartate aminotransferase (AST) 10 IU, and the alanine aminotransferase (ALT) 10 IU. The serum sodium was 127 mEq/L and the potassium 4.1 mEq/L. Chest X-ray film revealed an ill defined dense infiltrate with air bronchogram in the right lower lung field (Fig. 1). Mesenteric arteriography was performed but could not find any bleeding focus. Because of severe hematochezia, the flexible sigmoidoscopy was not available. The hemorrhoid with massive bleeding was found by anoscopy. An emergency hemorrhoidectomy was carried out on the second hospital day. However, a large amount of hematochezia persisted even after the operation and signs of serious disseminated intravascular coagulopathy (DIC) follwed. On the 10th hospital day while the DIC improved, the patient complained of abdominal distension and pain. Ascites was suspected.
An abdominal paracentesis revealed intraabdominal bleeding. An emergency exploratory laparotomy was perfomed. On operation, multiple polypoid masses of various sizes were palpated intraluminally in the jejunum from 10 cm below the Treitz ligament to the 120 cm distally. A large perforation of the jejunum (8 cm in diameter) probably caused by necrosis of the bowel wall was found on the antemesenteric border of the jejunum 20-25 cm below the Treitz ligament. Multiple mass lesions including hematomes were also found in the mesenteric root of the small intestine. Small bowel resection and end-to-end anastomosis were performed. On section, 36 polypoid masses were scattered grossly along the full length of the resected jejunum. The largest mass was 5.0x8.0x4.0 cm in size and composed of brownish homogeneous materials. Similar materials were filled in the mesenteric arteries and veins (Fig. 2).
Mlicroscopically, numerous hemosiderin pigments were scattered throughout the fields. The cells in the polypoid mass lesion were consistent with large round cells of undetermined origin. Each cell had a round nucleus containing prominent nucleoli. The cytoplasm was homogenous and clear (Fig. 3). The immunohistochemical study for S-100 protein was negative. Electron microscopically, obvious desmosomes were identified as convincing evidence of carcinoma (Fig. 4). Bronchoscopic examination, which was done on the 10th postoperative day, revealed an obstructing round mass at the entrance of the right main bronchus (Fig. 5). Histologically, this lesion was diagnosed as large cell carcinoma of the lung (Fig. 6).
On the 27th postoperative day, massive amounts of hematemesis and hematochezia developed again. The patient died on the 31st postoperative day due to hypovolemic shock.