S2603 A Case Series: Pseudocirrhosis Presenting as Acute Upper Gastrointestinal Bleeding After FOLFOX Therapy

Abstract

INTRODUCTION: Pseudocirrhosis refers to morphologic changes seen on imaging in patients with metastatic disease to the liver. We present two cases of upper gastrointestinal bleed in patients with pseudocirrhosis due to metastatic gastrointestinal adenocarcinomas. CASE DESCRIPTION/METHODS: Case 1 A 31 year old female with metastatic adenocarcinoma to the liver, likely cholangiocarcinoma, presented with abdominal pain and vomiting. She completed a course of FOLFOX and was on ivosidenib. She was admitted with concern for sepsis and developed emesis. Imaging revealed progressive metastatic disease with pseudocirrhosis. Placement of a nasogastric tube returned bright red blood and a three point drop in hemoglobin to 4.5 g/dL. Emergent EGD revealed large esophageal varices with a “white nipple sign.” A pediatric bite block precluded banding. The varices were sclerosed with sodium tetradecyl sulfate without complication. Due to poor prognosis she was discharged to hospice. Case 2 A 44 year old male with metastatic colon cancer to the liver, on FOLFOX and panitumumab, presented with hematemesis and melena. He was tachycardiac, tender to abdominal palpation and rectal exam was positive for melena. Laboratory data revealed a hemoglobin of 7.6 g/dL, three points below his baseline. Imaging showed an increased number and size of hepatic lesions and pseudocirrhosis with sequelae of portal venous hypertension. EGD revealed large esophageal varices with red wales. Seven bands were deployed without complication. He was placed on hospice due to lack of chemotherapy options. DISCUSSION: Pseudocirrhosis describes morphologic changes in the liver that mimic cirrhosis, such as diffuse hepatic nodularity, capsular retraction and caudate lobe enlargement, in patients without histopathologic changes of cirrhosis. The diagnosis is made radiologically and is seen in patients with metastatic malignancy to the liver. It is thought that infiltrating tumors lead to fibrosis. Chemotherapy causes decreased tumor burden and scarring leads to capsular retraction. Chemotherapy can induce ischemic injury leading to nodular regenerative hyperplasia. Qayyum et al, report only 9% of patients with pseudocirrhosis have signs of portal hypertension. These patients rarely develop severe manifestations of portal hypertension such as a variceal bleed. Pseudocirrhosis is commonly associated with metastatic breast cancer. Pseudocirrhosis is rarely seen with gastrointestinal malignancy and only two cases were associated with FOLFOX, as in our patients.Image 1.: Case 1's EGD revealed large esophageal varices with a “white nipple sign.”Image 2.: Case 2's EGD revealed large esophageal varices with red wales.Image 3.: CT Image of Case 2 with ascites in the right paracolic gutter and perigastric ascites, splenomegaly, scalloping of the liver margins and metastases. Medial to the spleen is a visible splenorenal shunt.