title: Seeding of the percutaneous endoscopic gastrostomy tract from esophageal squamous cell cancer presenting as an acutely bleeding malignant gastric ulcer: a novel clinicoendoscopic presentation.
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 x 7 x 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.
authors.affiliation: Division of Gastroenterology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA. mscappell@yahoo.com
authors.forename: Mitchell S
authors.initials: MS
authors.lastname: Cappell
authors.forename: Adedamola
authors.initials: A
authors.lastname: Lufadeju
authors.forename: Ajit
authors.initials: A
authors.lastname: Challa
authors.forename: Philip O
authors.initials: PO
authors.lastname: Katz
mesh_terms: D034861:Abdominal Wall / Q000473:pathology; D016145:Endoscopy, Digestive System; D017707:Erythrocyte Transfusion; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D005774:Gastrostomy / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008551:Melena / Q000209:etiology / Q000628:therapy; D008875:Middle Aged; D009366:Neoplasm Seeding; D018307:Neoplasms, Squamous Cell / Q000473:pathology / Q000601:surgery*; D013276:Stomach Ulcer / Q000150:complications / Q000209:etiology* / Q000473:pathology*; D014057:Tomography, X-Ray Computed