What’s Your Diagnosis?
A sinister cause of hematemesis
Published previously in Gastroenterology (2015;148:e5-6)
By Kati Glockenberg, M.D., Ethan M. Weinberg, M.D., and David W. Wan, M.D.
A52-year-old man with myelofibrosis presented to the emergency department with hematemesis. Earlier that day, he had experienced cough, rhinor- rhea, and pharyngitis. On the evening of admission, he vomited blood, prompting him to seek medical attention. He denied fevers, chills, chest pain, ab-
dominal pain, melena, hematochezia, prior history of upper
gastrointestinal bleeding, nonsteroidal anti-inflammatory
drug ingestion, or alcohol abuse. He was afebrile and hemo-
dynamically stable. Physical examination was significant for
splenomegaly and brown, guaiac-positive stool. His abdomen
was nontender and nondistended without overt evidence of
hepatomegaly. Pertinent laboratory results were as follows:
blood urea nitrogen, 34 mg/dL; International Normalized
Ratio, 1.3; white blood cell count 4. 6 × 103/microL; plate-
lets, 194 × 103/microL; and hemoglobin, 12. 5 g/dL, which
decreased to 9. 6 g/dL on repeat 6 hours later. On presenta-
tion, he was given an intravenous bolus of esomeprazole 80
mg and initiated on an intravenous esomeprazole drip at 8
mg/h. An urgent upper endoscopy revealed isolated gastric
varices with recent evidence of bleeding (Figure A, yellow
arrow). He was given a bolus of intravenous octreotide 50
microg followed by an intravenous octreotide drip at 50 mi-
crog/h and ceftriaxone 1 g/d. The patient was transferred to
the intensive care unit for further monitoring. n
What was the cause of this patient’s gastric varices and
what is the next appropriate step?
Dr. Glockenberg, Dr. Weinberg, and Dr. Wan are at New
York-Presbyterian Hospital in the Department of Medicine; Dr.
Weinberg and Dr. Wan are in the Division of Gastroenterology
and Hepatology; Dr. Wan is also with Weill Cornell Medical
College, New York, N. Y.
See The Answer on page 27