A251 ISOLATED GASTRIC VARICES DISGUISING AS RECURRENT UPPER GASTROINTESTINAL BLEED IN A CIRRHOTIC PATIENT

Abstract

Background: Isolated gastric varices (IGV) represent an uncommon condition in cirrhotic patients. We describe a case of IGV disguising as recurrent upper gastrointestinal bleed (UGIB) in a cirrhotic patient. Aims: Describe a case of IGV presenting as recurrent UGIB. Methods: Case report Results: Case: A 57 year-old man presented with an upper gastrointestinal bleed. This patient is known for cirrhosis, hypertension, diabetes mellitus, obstructive sleep apnea and obesity. He left against medical advice, reconsulting with rebleeding (hemoglobin (Hb) of 42g/L), and altered mental status requiring intubation. IV crystalloid and blood transfusion were given along with ceftriaxone, pantoprazole and somatostatin. An initial upper endoscopy (EGD) showed a large 5x6cm non-mobile clot in the fundus with no evidence of varices. A second look EGD showed no new findings and no varices were noted. A CT angiography (CTA) was negative apart from hepatosplenomegaly. The next day, hematochezia recurred with drop in Hb to 62 g/L. A third EGD noted brisk blood flow from the cardia/fundus with no clear source. A repeat CTA was normal. An endoscopic ultrasound (EUS) showed isolated gastric varices (IGV). A transjugular intrahepatic portosystemic shunt (TIPS) with embolization was performed. Post TIPS, the patient did not rebleed. Discussion: The patient described above was bleeding from an isolated gastric varices (IGV1 as per Sarin et al. classification). 20% of patients with portal hypertension develop gastric varices, in whom only 8% are IGV1.1 Multiple studies have demonstrated the superiority of EUS compared to EGD in the detection rate of gastric varices. It is likely due to a poorer sensitivity of EGD in the detection of small gastric varices as well as misdiagnosing them as thickened gastric folds.2,3 It is important to identify accurately the source of bleeding as gastric varices are typically associated with more severe bleeding episodes than esophageal varices, as well as a higher risk for rebleeding and a high mortality. Fundal varices have significantly higher bleeding incidence (78% for IGV1).1 Our patient's acute variceal bleed was treated with TIPS. Placement of TIPS has been shown to be very effective at controlling the episode of active bleeding, achieving a hemostatic rate as high as 90-100%, with a moderate risk of rebleeding (16-41%).3 However, as per Baveno VI recommendations, TIPS is second line therapy and is indicated when endoscopy guided cyanoacrylate injection fails. Conclusions: Hence, EUS plays an important role in diagnosis as well as in the management of isolated gastric varices. (Figure Presented).