Gastrointestinal: An unusual cause of lower gastrointestinal bleed: Ileal carcinoid tumor

A 39-year-old male patient presented with hematochezia and melena of 7-day duration. He denied any history of hematemesis, fever, abdominal pain, or jaundice. He also denied any prior history of similar episodes. At initial presentation, his blood pressure was 122/86 mmHg with heart rate of 100 per minute, and physical exam was unremarkable. Laboratory investigation showed hemoglobin of 10.0 g/dL, total leukocyte count of 7.3 × 109/L, and platelet count of 350 × 109/L. Liver function test and kidney function test were within normal limits. Upper gastrointestinal endoscopy did not reveal any bleeding source. Colonoscopy showed a large polypoidal mass in the ileum protruding through the ileocecal valve (Fig. 1). Computed tomography of the abdomen showed a single polypoidal lesion in the terminal ileum without any significant lymphadenopathy or distant metastasis (Fig. 2). Histopathological examination of the lesion turns out to be carcinoid tumor (Fig. 3). Serum chromogranin A level was raised (180 ng/mL; normal <30 ng/mL). He underwent right hemicolectomy, and postoperative period was uneventful. Histopathological examination of resected specimen also confirmed diagnosis of carcinoid tumor with mitotic index of <2% and Ki-67 of <3%. Carcinoid tumors are slow-growing neuroendocrine tumors arising from the enterochromaffin cells present in the gastrointestinal system. Ileum is the most common site for small intestinal carcinoid tumors and most of the tumors developing within 60 cm from ileocecal valve. Because of their indolent growth, most small intestinal carcinoid tumors are asymptomatic and found incidentally. In symptomatic patients, abdominal pain and intestinal obstruction are the most common initial symptoms. Gastrointestinal bleeding is a rare manifestation of ileal carcinoid tumors. Surgical resection of the primary tumor is the treatment of choice.