title: Diagnosis of small-bowel metastasis of hepatocellular carcinoma by double-balloon enteroscopy.
abstract: BACKGROUND
  Hepatocellular carcinoma (HCC) is a major cause of cancer-related deaths around the world. Nearly half of patients with HCC display metastatic disease at the time of initial diagnosis, frequently involving the liver, bone, brain, lungs, and adrenal glands, but gastrointestinal involvement is rare. Melena occurring secondary to a metastatic tumor from HCC is particularly rare. Herein, we present a case of melena secondary to metastatic HCC after chemoradiation to lung and brain metastases from HCC, diagnosed preoperatively by double-balloon enteroscopy. To the best of our knowledge, this represents the first such case to be reported.
  
  
  METHODS
  60-Year-old man had been diagnosed with hepatitis B virus-associated hepatocellular carcinoma (HCC). He was readmitted for investigation of general fatigue and iron-deficiency anemia. Esophagogastroduodenoscopy, total colonoscopy, and CT failed to identify any cause for gastrointestinal bleeding. Double-balloon enteroscopy, however, revealed small bowel metastasis from HCC preoperatively. After 5 days of conservative management, segmental small bowel resection and end-to-end anastomosis were performed. The histological appearances were considered typical for moderately differentiated HCC. DISSCUSSION: Endoscopic findings of gastrointestinal metastasis from HCC vary, such as raised and centrally ulcerated lesions, polypoid tumors, or submucosal tumors. Immunohistochemical findings are thus key to differentiating HCC from adenocarcinoma in the diagnosis of GIT metastasis. Some patients with gastrointestinal bleeding remain undiagnosed even after upper endoscopy and total colonoscopy, and most such patients will display bleeding sites in the small bowel. Video capsule endoscopy and DBE have been introduced recently for the evaluation of the small bowel. DBE, which was developed by Yamamoto et al.,(5) allowed us to obtain biopsy specimens, circumventing one limitation of capsule endoscopy. In this case, DBE contributed significantly to diagnosis and treatment.
  
  
  CONCLUSIONS
  DBE thus seems to represent a valuable method, particularly in the preoperative setting, due to the possibility of precisely identifying the tumor site and achieving preoperative diagnosis.
authors.affiliation: Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
authors.forename: Masaki
authors.initials: M
authors.lastname: Kunizaki
authors.forename: Shigekazu
authors.initials: S
authors.lastname: Hidaka
authors.forename: Hajime
authors.initials: H
authors.lastname: Isomoto
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Takeshita
authors.forename: Atsushi
authors.initials: A
authors.lastname: Nanashima
authors.forename: Terumitu
authors.initials: T
authors.lastname: Sawai
authors.forename: Toru
authors.initials: T
authors.lastname: Yasutake
authors.forename: Takeshi
authors.initials: T
authors.lastname: Nagayasu