Isolated Gastric Varices: A Rare Presentation of Pancreatic Cancer

Abstract

Pancreatic cancer remains a disease with high morbidity and mortality. Due to vague symptoms at presentation, the disease is often diagnosed at late stages, with a 5-year survival rate of only 8%. Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas, 15-20% occur in the body of the pancreas, and 5-10% occur in the tail. This case describes a new diagnosis of a pancreatic tail mass presenting as obscure overt gastrointestinal bleeding in the context of portal hypertension. A 60-year-old male presented with recurrent melena associated with fatigue and dyspnea. His symptoms started two months prior to presentation, at which time he underwent upper endoscopy, colonoscopy, tagged-RBC scan, and capsule endoscopy, all of which were negative. Upon hospital presentation, he underwent a repeat upper endoscopy. He was found to have isolated gastric varices that bled during the procedure. Abdominal CT scan with portal venous phase contrast revealed a nodular and heterogenous appearance of the liver parenchyma, splenomegaly, and a recanalized umbilical vein suggestive of portal hypertension. There was a 3.4 cm area of hypo-enhancement of the midpole of the spleen with some mildly enlarged retroperitoneal lymph nodes, suggestive of a mass lesion. He underwent urgent transjugular intrahepatic portosystemic shunt (TIPS) placement, with successful reduction of the hepatic venous pressure gradient from 15 to 2 mmHg, with occlusion of the distal portion of the splenic vein near the splenic hilum. Thereafter, he underwent laparoscopic distal pancreatectomy and splenectomy. The pathology revealed invasive, undifferentiated carcinoma of the pancreas with local lymph node involvement. He subsequently commenced adjuvant chemotherapy. Pancreatic body and tail cancer may cause left sided portal hypertension, with isolated gastric varices, splenomegaly, and hypersplenism. Other patients may have established portal hypertension, but the finding of isolated gastric varices should raise suspicion for left-sided portal hypertension. Endoscopists evaluating obscure gastrointestinal bleeding must maintain a high index of suspicion for less common causes of bleeding. When isolated gastric varices are detected, abdominal cross-sectional imaging should be considered to evaluate for splenic vein thrombosis and/or a pancreatic or splenic mass leading to left-sided portal hypertension.