S2906 Medical Management of Variceal Bleeding Associated With Portal Hypertension Secondary to Significant Metastatic Burden in the Liver: Strategies for Reducing Rebleeding Events

Abstract

Introduction: Portal hypertension (pHTN) is a cirrhosis complication that can uncommonly develop in patients with high liver metastatic tumor burden, especially those undergoing oxaliplatin chemotherapy. Symptomatic pHTN, such as gastrointestinal variceal bleeding, can complicate oncological management. Transjugular intrahepatic portosystemic shunt (TIPS) may not be a safe option, but medical therapy strategies are lacking. Case Description/Methods: A 70-year-old male with a history of colorectal carcinoma metastatic to the liver, status-post ileocolectomy and end-ileostomy with mucus fistula, and treated with oxaliplatin-bevacizumab based therapy, presented twice in one week to the emergency department with acute anemia and bleeding from his mucus fistula and then his ostomy. Abdominal CT at presentation was notable for progressed metastatic tumor burden in the liver and splenomegaly, raising concern for developing pHTN. Vascular abdominal ultrasound showed umbilical vein recanalization. EGD revealed small esophageal varices and moderate portal hypertensive gastropathy, but ileoscopy did not show a bleeding source. Venography studies showed peri-fistular and stomal varices, which were successfully treated with transcutaneous sclerotherapy, and subsequent direct portal pressure of 16mmHg. Given high rebleeding risk, the patient required long-term therapies for pHTN management. His malignancy burden and hypercoagulable risk precluded him from TIPS. Medical management was recommended, patient started on carvedilol 12.5 mg twice daily and atorvastatin was increased to 80mg daily; he was discharged without further bleeding to date. Discussion: This case illustrates a difficult case of pHTN that can be can be associated with both metastatic liver burden but also fibrosis associated with oxaliplatin therapy. Bevacizumab is an additional cause for increased bleeding risk and poor wound healing. Oncologic regimens may also need to be altered given the new pHTN occurrence. While data support the use of beta blockers and statins in pHTN and variceal bleeding management, much of this evidence comes from cirrhosis literature. Further investigation into pharmacologic management of portal hypertension in patients with significant metastatic burden in the liver. Interestingly, the downregulation of VEGF synthesis by high-dose statins may assist with anti-angiogenesis effect of bevacizumab and may be of interest for future clinical research.Figure 1.: Figure 1a - CT imaging showing metastatic burden to the liver; figure 1b -- venography showing peristomal varices.Table 1.: Pertinent lab values at various points of disease course from diagnosis of metastatic cancer onward.