Esophageal Varices Masquerading as a GE Junction AVM

Abstract

Esophageal variceal hemorrhage occurs at a yearly rate of 5-15% and although bleeding from esophageal varices ceases spontaneously in up to 40% of patients, it is associated with a mortality of at least 20% at 6 weeks. Endoscopic intervention with variceal ligation is the mainstay of treatment, with varices usually well visualized and ligated. We report a unique case of a patient with cirrhosis, who presented to a tertiary care center ICU with severe acidemia and respiratory distress from underlying gastrointestinal hemorrhage from esophageal varices mimicking a bleeding AVM on initial endoscopy. A 53 year old male with a history of cirrhosis from hep C presented to the ER with abdominal pain, weakness and dyspnea. On arrival he was afebrile, BP of 102/85, HR of 141 and saturating 98% on room air. His intial CBC showed a Hb/Hct of 9.6/33.1, WBC count of 29.3, platelet count of 151. BMP showed a BUN of 36, creatinine of 1.2, HCO3 of 8, AG of 25 and lactic acid of 18.3. Infectious workup was negative. Liver profile showed slightly elevated AST of 67 but was otherwise normal. Coagulation profile showed a PT of 17.6, PTT of 36 and INR of 1.6. The patient was intubated for pending respiratory failure and was immediately noted to have frank blood drain through his OG tube. He had progressively worsening hypotension requiring initiation of vasopressor support with 3 agents and repeat bloodwork a few hours later showed a Hb/Hct of 4.7/15.9. The patient was started on massive transfusion protocol, along with octreotide, PPI and bicarbonate infusions. He underwent emergent endoscopy which revealed a bleeding arterial vessel (image 1) which was sclerosed and clipped(image 2). However, due to persistent bleeding and hypotension, a repeat endoscopy 8 hours later, after having received multiple blood products, revealed large actively bleeding varices (image 3) that were banded. The patient had persistent acidemia despite CRRT and had continued bleeding while being too unstable for TIPS.He was eventually transitioned to comfort measures only and passed away. This case highlights a challenging yet insightful scenario. In patients with known cirrhosis, presenting with brisk upper GI bleed with severe volume depletion, esophageal varices might only become prominent with adequate volume resuscitation. It is important to keep a high clinical suspicion and treat aggressively with the view to proceed for urgent TIPS early on in the course in case of refractory bleeding.3011_A Figure 1. First Endoscopy- Bleeding vessel at GE junciton3011_B Figure 2. Hemostatic clips applied to bleeding vessel3011_C Figure 3. Re-look endoscopy- Large actively bleeding Varices