Scheduled biopsy, unexpected bleeding

A 74-year-old female patient, with chronic HBV infection, diabetes mellitus and a history of hysterectomy, known with a neglected cystic pancreatic lesion (mucinous cystadenoma), in whom the latest CT evaluation shows a pancreatic tumour with a cystic component, most likely a cystadenocarcinoma, is admitted for EUS-FNB to obtain a definitive diagnosis.

Clinical examination shows upper abdominal tenderness and splenomegaly.

Laboratory tests reveal hypochromic microcytic iron-deficiency anaemia, thrombocytopenia, an inflammatory syndrome and CA 19-9 > 1000 U/mL.

CT: cystic-solid pancreatic tumour invading the SMV, the preconfluent SV and the PV trunk; secondary portal hypertension; non-cirrhotic liver; ascites, peritoneal M1 under observation.

EUS: bleeding from a variceal channel, with interruption of the procedure.

EGD: large oesophageal varices with active bleeding; endoscopic band ligation (7 bands on 3 variceal columns), with bleeding control at the end of the procedure (Figures 1-5, Video 1).

Figure legends:
Photo 1 – Large oesophageal varices seen through the band-ligator cap.
Photo 2 – Active variceal bleeding, with the oesophageal lumen filled with blood.
Photo 3 – Oesophageal variceal columns and blood in the lumen during ligation.
Photo 4 – Variceal column suctioned into the cap before band release.
Photo 5 – Post-ligation appearance: varix strangulated by the band ("pseudopolyp").

• Mucinous cystadenoma has a known malignant potential; in this patient, lack of surveillance most likely allowed progression to cystadenocarcinoma, diagnosed only at an advanced stage, with vascular and peritoneal invasion.
• In this case, portal hypertension is exclusively prehepatic, caused by tumour invasion of the SMV, SV and PV, in a non-cirrhotic liver.
• Splenomegaly and thrombocytopenia may predict the presence of gastro-oesophageal collaterals, so an EGD before endoscopic ultrasound (EUS) may be justified.
• Haemostasis was achieved by immediate endoscopic band ligation, applied to all 3 variceal columns.
• Portal trunk invasion complicates TIPS as a rescue option, making variceal eradication by repeated ligation the only real protection against rebleeding.

• Mucinous cystadenoma requires rigorous periodic surveillance; neglecting it may lead to the diagnosis of an advanced cystadenocarcinoma.
• Tumour-related portal hypertension can turn a diagnostic procedure into a haemorrhagic emergency.
• Prompt endoscopic band ligation is life-saving, and variceal eradication is essential for secondary prophylaxis, as beta-blocker therapy is not effective in tumour-related portal hypertension.