Acute Gastrointestinal Hemorrhage, Sequela of Pancreatic Neuroendocrine Tumor

Purpose: Pancreatic neuroendocrine tumors (PNET) account for fewer than 5% of pancreatic malignancies. Portal hypertension in the setting of malignancy results from vascular occlusion by tumor invasion, hypercoagulability, or extrinsic compression. This case describes the approach to therapy for an acute upper gastrointestinal (GI) hemorrhage in a patient with both portal and splenic vein thrombosis secondary to a PNET.

Materials and Methods: The patient is a 64-year-old woman with history of PNET with metastasis to the liver, splenic and portal vein thrombosis, and gastroesophageal varices, who presented with coffee ground emesis and melena. Initial labs noted a hemoglobin/hematocrit (Hgb/HCT) of 9.5/28. EGD showed grade II esophageal varices with no stigmata of recent bleeding, and three esophageal varices were banded. Computed tomography of the abdomen and pelvis showed a heterogeneously enhancing 11.8-cm left hepatic lobe mass, flattened inferior vena cava, thrombosed portal and splenic veins, and esophageal, gastrohepatic, and splenorenal varices. Repeat labs noted a decreased Hgb/HCT of 8.5/24.2, warranting consultation of interventional radiology.

Results: Venography noted large gastric varices draining into the left renal vein. Balloon-occluded retrograde transvenous obliteration (BRTO) could not be safely performed because the balloon occlusion catheter would not pass into the junction of the varices and left renal vein. Multiple platinum coils were placed in the gastric varix to temporize the bleeding. Angiogram noted large varices draining from the splenic hilum into the left upper quadrant. Upper and middle pole branches of the splenic artery were embolized with Embozene microspheres (500-µm size), and partial stasis was achieved. No significant filling of varices was seen, and forward blood flow into the spleen was preserved. Hgb and HCT stabilized, and the patient was discharged home.

Conclusions: Unlike esophageal varices, bleeding from gastric varices is more severe with a mortality rate of approximately 45%. Per the American Association for the Study of Liver Diseases, endoscopic variceal band ligation or obturation with cyanoacrylate is first-line therapy. If endoscopic therapy fails, transjugular intrahepatic portosystemic shunt (TIPS) or BRTO is the next best step. For our patient, TIPS was contraindicated because of portal vein thrombosis, and BRTO was unsuccessful. In cases such as this, temporization with coils and/or partial splenic arterial embolization are alternative therapies for the management of acute upper GI hemorrhage caused by gastric varices.