A Rare Case of Gastric Variceal Hemorrhage Secondary to Infiltrative B-Cell Lymphoma

Abstract

Portal hypertension commonly arises in the setting of advanced liver cirrhosis and is the consequence of increased resistance within the portal vasculature. Less commonly, left-sided noncirrhotic portal hypertension can develop in a patient secondary to isolated obstruction of the splenic vein. We present a rare case of left-sided portal hypertension and isolated gastric varices in a patient with large B-cell lymphoma, who was treated with splenic artery embolization. The patient is a 73-year-old male with no previous history of liver disease, who presented with coffee ground emesis and melena. On admission to hospital, he was found to have a hemoglobin level of 3.4 g/l. Emergent esophagogastroduodenoscopy showed isolated bleeding gastric varices (IGV1 by Sarin classification) in the fundus and cardia with subsequent argon plasma coagulation injection. He was transferred to our tertiary center where work-up revealed normal liver function tests, and abdominal ultrasound showed patent hepatic/portal vasculature without cirrhosis. MRI demonstrated a large heterogeneously enhancing mass in the pancreatic tail, with invasion into the spleen and associated splenic vein thrombosis. Surgery consultation was obtained, but urgent splenectomy was not recommended. The patient instead underwent splenic artery embolization to prevent future bleeding from his known gastric varices. Pathology from a CT-guided biopsy was consistent with diffuse large B-cell lymphoma. PET imaging showed uptake in the splenic hilum/pancreatic tail region with no additional metastatic involvement. He was evaluated by the Hematology Department to initiate R-CHOP chemotherapy. During his outpatient follow-up, he reported no further episodes of melena or hematemesis. To the best of our knowledge, there have only been two published case reports of large B-cell lymphoma causing upper gastrointestinal bleeding from isolated gastric varices. These cases were treated with splenectomy or chemotherapy alone. Thus far, splenectomy has been the standard treatment approach for splenic vein thrombosis with clinical complication, such as gastric variceal bleeding. We present a case of successful treatment of bleeding isolated gastric varices using a less invasive and less morbid approach through splenic artery embolization. This case highlights the need for an increased awareness of the diverse etiologies of left-sided portal hypertension and isolated gastric varices, as well as the consideration of minimally invasive management strategies.

Left-sided portal hypertension caused by peripancreatic lymph node tuberculosis misdiagnosed as pancreatic cancer: a case report and literature review

“…Whether asymptomatic patients require treatment remains controversial, but it is necessary to intervene to prevent active bleeding. In addition to addressing bleeding, it is often necessary to treat the primary disease [16,17,19,57,58]. Based on the patient's clinical condition, there are several methods that can be used to relieve isolated gastric bleeding.…”

“…Based on the patient’s clinical condition, there are several methods that can be used to relieve isolated gastric bleeding. To reduce venous blood reflux, splenectomy remains the preferred treatment for patients with gastric bleeding due to LSPH, and splenic artery embolization can be used as a supplementary measure in patients in whom splenectomy is deemed unsuitable [ 13 , 16 , 17 , 19 , 57 – 59 ]. Moreover, while endoscopic therapy is highly advantageous for the treatment of acute massive gastric bleeding, rebleeding is unavoidable [ 60 – 63 ].…”

“…Most patients with LSPH are asymptomatic, and only a few patients exhibit isolated gastric varices, ruptures, and fatal bleeding caused by splenic vein obstruction resulting from thrombosis, mechanical compression, tumor invasion, and metastasis [7][8][9][10][11][12][13][14]. It is difficult to diagnose LSPH [15], and bleeding from LSPH is frequently fatal [8,13,[16][17][18][19]. Diseases resulting in LSPH often need to be distinguished from pancreatic cancer, therefore it is necessary for due attention to be paid to the diagnosis and treatment of LSPH [20][21][22].…”

A Rare Presentation of Non-Hodgkin’s Lymphoma Presenting With Bleeding Esophageal Varices Secondary to a Malignant Portal Vein Tumor Thrombosis

“…A localized malignancy causing PVTT can appear as a heterogeneous mass on Doppler ultrasound invading the portal vein, while CT can be used to assess the extent of vascular involvement. It is important to recognize that in the event of NHL-associated tumor thrombosis, esophageal varices can form as the result of a PVTT, while gastric varices can be the result of a splenic vein thrombosis [12]. Regardless, treatment of a PVTT is crucial: a thrombus extension into the superior mesenteric vein can result in intestinal ischemia with potential perforation, and a chronic tumor thrombus burden can result in portal hypertension with portosystemic shunts and bleeding varices, as seen in our case [1].…”

Isolated Gastric Fundal Varices Caused by Diffuse Large B-Cell Lymphoma

“…To our knowledge, we have only found 5 case reports published in peer-reviewed journals of lymphoma causing UGIB through IGV. 4,[10][11][12][13] Our patient was managed conservatively with a nonselective b-blocker, vasoactive agent, and proton pump inhibitor. The decision to manage our patient conservatively was multidisciplinary in nature, with active communication between the medical oncology, gastroenterology, and internal medicine teams.…”