A Rare Cause of Life-Threatening Hematemesis

Abstract

Question: A 46-year-old woman with renal cell carcinoma (RCC) in the left kidney underwent surgical intervention for complete nephrectomy 2 years ago. She had a 3-day history of melena and presented at the emergency room with acute vomiting containing fresh blood. Physical examination revealed pale conjunctivae and tachycardia without abdominal tenderness. Laboratory studies confirmed normocytic anemia (hemoglobin, 6.8 g/dL), thrombocytopenia (platelet count, 82,000/mm3), prerenal azotemia (blood urine nitrogen, 48 mg/dL; creatinine, 1.8 mg/dL), occult blood (4+) in stool samples, and normal liver function (aspartate aminotransferase, 24 U/L; alanine aminotransferase, 26 U/L). Panendoscopy (Figure A) revealed convoluted vessels protruding into the gastric fundus with a cluster-of-grapes-like appearance and multiple cherry-red spots on the overlying mucosa. Abdominal sonography (Figure B) showed a large, heterogeneous, hypoechoic lesion in the left renal fossa. Multidetector-row computed tomography (MDCT) scan (Figure C) was then performed. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Panendoscopy revealed an isolated gastric varices (GV) with stigmata of bleeding at the fundus of the stomach. MDCT scan disclosed the recurrent RCC (10 × 8 × 7 cm3) that compressed the SV (Figure C) resulting in left-sided portal hypertension (LSPH). The portal veins and superior mesenteric vein were patent and not encased. The diagnosis was recurrent RCC-related LSPH with GV bleeding. LSPH arising from isolated obstruction of the SV, such as thrombosis or stenosis often resulted from pancreatic pathology, is a rare clinical event that may lead to isolated GV bleeding. In patients with SV obstruction, splenic blood flows retrogradely through the short, posterior gastric and gastroepiploic veins resulting in the formation of GV. Isolated GV at the gastric fundus had been observed in only 1% of patients with portal hypertension and were more common in patients with LSPH.1Ryan B.M. Stockbrugger R.W. Ryan J.M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar Various malignant neoplasms other than pancreas, including colon cancer, gastric cancer, lymphoma, oat cell carcinoma, renal cancer, and retroperitoneal liposarcoma, have been rarely reported as the causes of SV obstruction.2Seyfettin K. Şahin Ç. Osman Y. et al.Left-sided portal hypertension.Dig Dis Sci. 2007; 52: 1141-1149Crossref PubMed Scopus (102) Google Scholar RCC leading to hematemesis because of bleeding from an isolated GV has been scarcely reported in literature.3Joya Seijo M.D. del Valle Loarte P. Marco Martinez J. et al.Sinistral portal hypertension with bleeding gastric varices as initial manifestation of renal cell carcinoma.An Med Interna. 2004; 21: 283-284PubMed Google Scholar However, recurrent RCC as the cause of isolated GV has not been reported yet. Further evaluations for LSPH need to be investigated in patients with GV bleeding who have a normal liver function and unexplained splenomegaly. Management of LSPH depends on the underlying cause. Splenectomy, splenic artery embolization, and stenting of the splenic vein are effectively therapeutic choices for patients of LSPH associated with GV.1Ryan B.M. Stockbrugger R.W. Ryan J.M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar Our patient underwent targeted therapy for the RCC, and the shrunken tumor mass observed on the follow-up MDCT scan was measured 7 × 5 × 4 cm3. The patient survived from this episode of life-threatening hematemesis and did not show any recurrence of GV bleeding at the 6-month follow-up.