An Unusual Case of Bleeding Gastric Varices Secondary to Metastatic Ovarian Adenocarcinoma
Kaur R, Salgia R, Seudeal C, and Scher E. An Unusual Case of Bleeding Gastric Varices Secondary to Metastatic Ovarian Adenocarcinoma. J Gen Intern Med 2019; 34(2):S479.
J Gen Intern Med
Learning Objective #1: Recognize the presence and different potential causes of gastric varices in a patient that does not have liver disease CASE: The patient is a 58-year-old Caucasian female with a history of metastatic ovarian cancer and no previous history of liver disease, who initially presented to the hospital with hematemesis, melanotic stools, lethargy and generalized weakness. She was found to have a hemoglobin of 5.7 g/dL, which dropped to 4.5 g/dL. Liver function tests at this time were within normal limits and testing for chronic liver disease was unrevealing. Abdominal ultrasound revealed patent hepatic vasculature and splenomegaly. An emergent esophagogastroduodenoscopy (EGD) was performed which showed isolated gastric varices located in the fundus (Sarin Classification, IGV1). MRI of the abdomen confirmed a hypovascular mass in the splenic hilum concerning for possible metastasis. Pathology confirmed metastatic ovarian cancer in the splenic hilum. After presentation at tumor board, the decision was made to perform splenic artery embolization (SAE) to decrease the inflow to the spleen with subsequent splenectomy. Proximal SAE and splenectomy was done without complication. The patient has continued her care with oncology for further treatment with Paclitaxol +/-Bevacizumab. Following the patient's splenectomy, she has reported no further episodes of hematemesis or melanotic stools. IMPACT/DISCUSSION: Left sided portal hypertension (LSPH) causing gastric variceal bleeding is fortunately an infrequent cause of upper gastrointestinal hemorrhage. To the best of our knowledge, there has been one published case of metastatic ovarian cancer resulting in gastric varices which occurred 21 years following ovarian carcinoma surgery and adjuvant chemotherapy. This case demonstrates progression of ovarian meta-static disease despite chemotherapy status post debunking in the peritoneum, causing significant hemorrhage with complete resolution of bleeding gastric varices by splenic artery embolization, followed by splenec-tomy. It highlights the need for ongoing awareness regarding the evaluation and management of IGV in patients who do not have underlying liver disease. Ultimately, the finding of IGV on endoscopy in a non-cirrhotic patient should prompt the investigation into other causative processes that could obstruct the splenic venous system. Conclusion: Portal hypertension generally develops in the setting of liver cirrhosis, and can result in subsequent esophageal and/or gastro-esophageal varices. LSPH, on the other hand, can arise in non-cirrhotic patients secondary to obstruction of the splenic vein, leading to isolated gastric varices. Given that most cases of LSPH remain asymptomatic, the incidence is likely < 5% of all portal hypertension cases. This is an uncommon case of metastatic ovarian adenocarcinoma to the splenic vein hilum causing outflow obstruction and resultant gastric variceal hemorrhage. This patient was ultimately treated with splenic artery embolization followed by splenectomy.