A 52-year-old man originally from West Africa presented with two episodes of hematemesis over one day and with intermittent diffuse abdominal pain and fatigue over one week. He is a known HIV/AIDS patient with poor compliance along with a history of chronic Hepatitis B cirrhosis and moderate-sized varices, H. pylori with non-compliance with treatment, and Kaposi sarcoma, diagnosed via biopsy of a non-healing foot lesion during a prior admission. Physical exam was notable for bilateral cervical lymphadenopathy and left inguinal lymphadenopathy. He had multiple 1-2 cm cutaneous nodular lesions on the bilateral knees and the left hand as well as hemorrhagic lesions and plaques on the soft palate. He was mildly and diffusely tender to palpation of the abdomen but without hepatosplenomegaly. Laboratory studies revealed a hemoglobin of 6.6, hematocrit of 21, and a CD4 count of 165. He was transfused with packed red blood cells and initiated on octreotide and pantoprazole as continuous infusions. Esophagogastroduodenoscopy (EGD) revealed Grade 3 esophageal varices without stigmata of recent bleeding but also extensive ulcerated and nodular lesions in the esophagus, stomach, and extending through to the third part of the duodenum consistent in appearance with Kaposi sarcoma. The patient was treated with liposomal Doxorubicin and had no recurrence of bleeding during the hospitalization. He was discharged home to complete chemotherapy and to initiate antiretroviral therapy as an outpatient.
Discussion:
Kaposi sarcoma is a vascular tumor that is typically associated in the United States with the immunosuppressed state of HIV infection or chronic immunosuppressive therapy. It frequently appears as a violaceous to erythematous cutaneous lesion but also can affect mucous membranes and, less commonly, viscera, even in the absence of associated cutaneous disease. One in five patients with gastrointestinal Kaposi sarcoma are asymptomatic, and symptoms, when present, include nausea, vomiting, abdominal pain, protein-losing enteropathy, and gastrointestinal bleeding of variable acuity, ranging from mild iron deficiency anemia to hematemesis and hematochezia. When seen during EGD, the lesions can be maculopapular, nodular, or polypoid.
Upper gastrointestinal bleeding secondary to Kaposi sarcoma as presented in this case is managed with endoscopy and supportive care, as there is no standardized treatment for acute management of bleeding secondary to these lesions. Biopsies are pursued with caution as these lesions commonly bleed on contact. Kaposi Sarcoma involving the mucous membranes and/or viscera is treated with HAART along with systemic chemotherapy using liposomal doxorubicin. Unfortunately, it is reported that 1/3 of patients will fail this treatment, and those successfully treated follow a 13% relapse rate per year.
Conclusions:
In summary, upper gastrointestinal bleeding is a common problem encountered by the internist in the inpatient setting, most frequently caused by peptic ulcer disease. Hemorrhages can less commonly be associated with neoplasms such as Kaposi sarcoma, with few cases reported. However, these alternate etiologies should be considered in the differential in the setting of known immunosuppression.