We present the case of 88 year old lady who presented with long standing history of diarrhoea (18 months). She had been previously investigated under the gastroenterologists with various tests including upper GI endoscopy and colonoscopy. In view of deterioration of symptoms she was admitted under the geriatric team as she could no longer cope with the diarrhoea. On examination she looked well and had fullness in the right hypochondrial region. Blood tests showed abnormal liver function tests with bilirubin of 10, ALT of 73 and Alkaline Phosphatase of 655. Ultrasound Abdomen revealed hepatomegaly with iso-echoic lesions throughout both lobes representing metastasis. CT scan confirmed liver metastasis but did not reveal the primary. However on further questioning it was revealed that she had intermittent flushing and therefore a 24 h urinary 5 HIAA was done. It was hugely elevated (672, normal range<31) suggesting a diagnosis of Carcinoid syndrome. The Endocrinology team and Oncology teams were involved and further investigation with an Octreotide scan showed that the hepatic lesions were octreotide positive, but did not reveal any other uptake. Her symptoms have responded well to somatostatin analogue therapy.
The Carcinoid syndrome results from neuroendocrine tumours with the ability to produce serotonin and tachykinins which cause typical symptoms of diarrhoea, flushing, bronchospasm and right heart failure. Carcinoid tumours present at a mean age of 5060 years but has been reported in elderly patients before. In about two-third of cases, the carcinoid arises from the gastrointestinal tract. However the location of origin in the liver happens in approximately 1%.