A Rare Case of Gastric Variceal Hemorrhage Secondary to Infiltrative B-Cell Lymphoma: Presidential Poster

Abstract

Portal hypertension commonly arises in the setting of advanced liver cirrhosis, and is the consequence of increased resistance within the portal vasculature. Less commonly, left-sided non-cirrhotic portal hypertension can develop in a patient secondary to isolated obstruction of the splenic vein. We present a rare case of left-sided portal hypertension and isolated gastric varices in a patient with large B-cell lymphoma, who was treated with splenic artery embolization. The patient is a 73-year-old male with no previous history of liver disease, who presented with coffee ground emesis and melena. On admission to an outside hospital, he was found to have a hemoglobin of 3.4 g/L. EGD showed isolated bleeding gastric varices (IGV1 by Sarin classification) in the fundus and cardia with subsequent APC injection. He was transferred to our tertiary center where work up revealed normal liver function tests, and abdominal ultrasound showed patent hepatic/portal vasculature without cirrhosis. MRI demonstrated a large heterogeneously enhancing mass in the pancreatic tail, with invasion into the spleen and associated splenic vein thrombosis. Surgery consultation was obtained, but urgent splenectomy was not recommended. He instead underwent splenic artery embolization to prevent future bleeding from his known gastric varices. Pathology from a CT guided biopsy was consistent with diffuse large B-cell lymphoma. PET imaging showed uptake in the splenic hilum/pancreatic tail region with no additional metastatic involvement. He was evaluated by Hematology to initiate R-CHOP chemotherapy. During his outpatient follow-up, he reported no further episodes of melena or hematemesis. To the best of our knowledge, there have only been two published case reports of large B cell lymphoma causing upper GI bleeding from isolated gastric varices. These cases were treated with splenectomy or chemotherapy alone. Thus far, splenectomy has been the standard treatment approach for splenic vein thrombosis with clinical complication such as gastric variceal bleeding. We present a case of successful treatment of bleeding isolated gastric varices using a less invasive and less morbid approach through splenic artery embolization. This case highlights the need for increased awareness of the diverse etiologies of left-sided portal hypertension and isolated gastric varices, as well as the consideration of minimally invasive management strategies.Figure 1Figure 2Figure 3