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September 9, 2019

Image challenge: An unusual cause of esophageal varices

What caused a 55-year-old patient with no nausea, vomiting, hematemesis, melena or abdominal pain, to present with a sudden onset of retrosternal chest pain? 

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Gastroenterology clinical image challenge: A 55-year-old man with a past medical history significant for obesity, hypertension, obstructive sleep apnea, and pacemaker placement for syncope and bradycardia at the age of 14 presented to our emergency department with complaints of sudden onset of 8/10 intensity, nonradiating, retrosternal chest pain of burning character that was not related to exertion or food intake. He had no nausea, vomiting, hematemesis, melena or abdominal pain. Pertinent findings on physical examination were a pacemaker in the right upper chest, no jugular venous distention and an enlarged palpable liver. His blood work was significant for hemoglobin of 11.2 g/dL with an unknown baseline. Liver chemistries revealed a total bilirubin of 0.4 mg/dL, aspartate aminotransferase 21 U/L, alanine aminotransferase 24 U/L, and alkaline phosphatase of 90 U/L.


The pain partially resolved after a dose of pantoprazole. Computed tomography angiography of the chest was negative for pulmonary embolism, but did reveal extensive venous collaterals in the thorax and upper abdomen with hepatomegaly. There was nonopacification of the proximal portion of the superior vena cava, which contained leads from a right-sided chest wall pacer.


The patient was admitted for a esophagogastroduodenoscopy that demonstrated nonbleeding varices throughout the esophagus; the varices being larger in the proximal part of the esophagus than the distal (Figure). This finding prompted a serological workup for possible cirrhosis which was negative. A liver biopsy was performed revealing mild focal bridging fibrosis with no definitive evidence of cirrhosis. There was mild dilatation of portal vein branches and central veins. There were large and small droplet steatosis involving less than 10 percent of hepatocytes.


What is the cause of patient’s esophageal varices?


To find out the diagnosis, read the full case in Gastroenterology.


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