Massive Esophagogastric Variceal Bleeding from Chronic Portal Vein Thrombosis in a Non-Cirrhotic Young Man: A Resource-Limited Endoscopic Management Dilemma.

Abstract

Introduction: Variceal upper gastrointestinal bleeding is a life-threatening manifestation of portal hypertension. Chronic portal vein thrombosis can cause clinically significant noncirrhotic portal hypertension with esophagogastric varices, and management is particularly challenging in resource-limited settings when definitive endoscopic or radiologic therapy is unavailable.

Case presentation: A 31-year-old man presented with massive hematemesis, melena, loss of consciousness, and hemorrhagic shock. Hemoglobin was 3.5 g/dL. He was stabilized with crystalloid resuscitation, packed red blood cell transfusion, octreotide infusion, proton pump inhibitor therapy during the initial undifferentiated upper gastrointestinal bleeding phase, and antibiotics. Upper gastrointestinal endoscopy showed four large esophageal variceal columns with red color signs and evidence of recent bleeding, together with a large fundal gastroesophageal varix type 2 (GOV2) with evidence of recent bleeding. Because the recently bleeding GOV2 was considered the immediate therapeutic priority and definitive gastric-variceal therapy was unavailable locally, immediate esophageal band ligation was deferred. Urgent referral for definitive gastric-variceal therapy was arranged, with staged esophageal variceal ligation planned thereafter. Contrast-enhanced computed tomography showed chronic portal vein thrombosis with cavernous transformation, collateral vessels, splenomegaly, and ascites, with preserved hepatic morphology and no radiologic features of cirrhosis, supporting noncirrhotic portal hypertension. He was discharged on hospital day 5 without early rebleeding.

Conclusion: This case highlights the management dilemma posed by recently bleeding GOV2 gastric varices with advanced esophageal varices in chronic portal vein thrombosis. It illustrates the challenges of managing acute variceal hemorrhage in resource-limited settings and highlights the importance of prompt resuscitation, vasoactive therapy, antibiotics, careful endoscopic risk assessment, and timely referral when definitive gastric-variceal treatment is not locally available.