acute upper gastrointestinal ( ugi ) bleeding is a common problem in our clinical practice and is often due to peptic ulcer diseases accounting for about 60% of cases . approximately 70% of newly diagnosed tccs are superficial tumors , of which 5070% will recur after endoscopic transurethral resection and 1020% will progress to invasive disease . local invasion through direct extension of the tumor is the most common mechanism of spread . however , 5% of patients with well or moderately differentiated superficial carcinomas and 20% of patients with high - grade superficial disease manifest vascular or lymphatic spread . the most common sites of clinically diagnosed metastasis are pelvic lymph nodes , lung , bone , and liver [ 5 , 6 ] . although oral and intestinal metastases of tcc have been previously reported [ 5 , 6 , 7 , 8 , 9 ] , we present here a rare case of massive ugi bleeding secondary to duodenal and oropharyngeal metastases of tcc of the urinary bladder . initial laboratory results revealed an elevated inr ( 1.9 ) , anemia ( hemoglobin = 70 g / l , baseline of 150 g / l ) . his significant past medical history included stage iiib tcc of the urinary bladder previously treated with partial cystectomy with lymph node dissection and adjuvant chemotherapy ( gemcitabine and carboplatin ) 2 years previously , complicated by pulmonary embolism treated with long - term coumadin , and a subsequent local recurrence in the right iliac region treated with radiation 1 year before . an initial endoscopy showed a large bleeding mass at the second stage of the duodenum . visualization of the lesion was difficult due to bleeding , and the patient was transferred to the intensive care unit for resuscitation and reversal of anti - coagulation . he responded to fluid administration , intravenous proton pump inhibitor and transfusion and remained hemodynamically stable . a repeat endoscopy was performed 4 days later . a large tumor occupying 40% of the circumference and 7 cm in length in the second stage of the duodenum without active bleeding was clearly seen and multiple biopsies were taken . the biopsies showed a poorly differentiated malignant neoplasm consistent with metastasis from urothelial carcinoma , which was essentially identical to the previous surgical specimen obtained from the urinary bladder . the patient was discharged home 2 weeks later with a follow - up appointment with his oncologist . two weeks later , the patient returned to the hospital complaining of a painful swelling of the floor of his mouth . while in hospital he received a course of palliative radiation therapy for the control of bleeding . he progressively deteriorated in cardiopulmonary and neurological function and expired with cardiopulmonary arrest one month later after establishing an agreement on comfort care only . two large independent autopsy case series showed that intestinal metastasis could be found in as many as 13% of patients with tcc [ 5 , 6 ] . girotra and jani have recently reported a case of occult ugi bleeding secondary to duodenal metastasis of tcc of the urinary bladder . in contrast to their case , our patient had a significant hemorrhage requiring blood transfusion , likely secondary to concurrent anti - coagulation therapy . moreover , our patient had massive oropharyngeal bleeding from his metastatic disease requiring blood transfusion and palliative radiation therapy . metastasis of renal cell carcinoma and testicular neoplasms is a commonly reported cause for ugi bleeding secondary to urological malignancies in the literature [ 13 , 14 ] . to our knowledge , these rare hemorrhagic duodenal metastases lead us to consider metastatic disease as an important differential diagnosis of bleeding duodenal masses , especially in patients with a history of urological malignancies .
acute upper gastrointestinal ( ugi ) bleeding is a common problem in our clinical practice and is often due to peptic ulcer diseases . 
 occasionally , malignancy may be implicated in these situations . here 
 we report a rare case of ugi bleeding secondary to metastatic transitional cell carcinoma ( tcc ) of the urinary bladder . a 62-year - old man with a history of stage iiib tcc of the urinary bladder presented with hematemesis . 
 endoscopy showed a large tumor in the second stage of the duodenum that occupied 40% of the duodenal circumference , over 7 cm in length . 
 biopsies revealed a poorly differentiated malignant neoplasm consistent with metastasis from urothelial carcinoma that was identical to the previous surgical specimen of the urinary bladder . 
 he was treated with supportive therapy and intravenous proton pump inhibitor and was discharged home 2 weeks later . 
 two weeks after discharge , the patient returned to the hospital with a painful swelling of the floor of his mouth . 
 biopsy again showed the same cancer type . 
 he had unremitting bleeding from his mouth requiring multiple transfusions and a course of palliative radiation therapy . 
 he progressively deteriorated in his cardiopulmonary and neurological functions and expired with cardiopulmonary arrest one month later .