Massive Esophagogastric Variceal Bleeding from Chronic Portal Vein Thrombosis in a Non-Cirrhotic Young Man: A Resource-Limited Endoscopic Management Dilemma.
Tahajud O & Ahmed O • International medical case reports journal • 2026
This case report illustrates the management dilemma of massive esophagogastric variceal bleeding from chronic portal vein thrombosis with cavernous transformation in a non-cirrhotic young man, highlighting the challenges of acute variceal hemorrhage management in resource-limited settings where definitive gastric-variceal therapy is unavailable.
Key Findings
Background
A 31-year-old non-cirrhotic man presented with massive variceal hemorrhage and severe anemia secondary to chronic portal vein thrombosis.
Presenting hemoglobin was 3.5 g/dL, indicating severe hemorrhagic anemia
Clinical presentation included massive hematemesis, melena, loss of consciousness, and hemorrhagic shock
Imaging confirmed chronic portal vein thrombosis with cavernous transformation, collateral vessels, splenomegaly, and ascites
Hepatic morphology was preserved with no radiologic features of cirrhosis, supporting noncirrhotic portal hypertension as the underlying etiology
Results
Upper gastrointestinal endoscopy identified advanced esophageal varices and a recently bleeding gastric varix requiring complex therapeutic prioritization.
Endoscopy revealed four large esophageal variceal columns with red color signs and evidence of recent bleeding
A large fundal gastroesophageal varix type 2 (GOV2) with evidence of recent bleeding was also identified
The recently bleeding GOV2 was considered the immediate therapeutic priority over the esophageal varices
Immediate esophageal band ligation was deferred because definitive gastric-variceal therapy was unavailable locally
Results
Initial stabilization was achieved using a multimodal medical approach during the undifferentiated upper gastrointestinal bleeding phase.
Treatment included crystalloid resuscitation, packed red blood cell transfusion, octreotide infusion, proton pump inhibitor therapy, and antibiotics
This regimen was initiated prior to definitive endoscopic diagnosis
The patient was discharged on hospital day 5 without early rebleeding
Discussion
Resource-limited settings create a management dilemma when concurrent esophageal and gastric varices are present and definitive gastric-variceal therapy is unavailable locally.
Definitive gastric-variceal therapy was not available at the treating facility
Staged esophageal variceal ligation was planned after referral for definitive gastric-variceal treatment
Urgent referral for definitive gastric-variceal therapy was arranged as an alternative to local management
The case illustrates that performing esophageal band ligation without addressing the bleeding GOV2 first was considered inappropriate given available resources
Results
Chronic portal vein thrombosis with cavernous transformation can produce clinically significant noncirrhotic portal hypertension with life-threatening esophagogastric varices in young patients.
The patient was 31 years old, illustrating that this condition can affect young adults
Contrast-enhanced CT confirmed cavernous transformation of the portal vein alongside collateral vessels, splenomegaly, and ascites
Preserved hepatic morphology on imaging distinguished this from cirrhotic portal hypertension
The case demonstrates that noncirrhotic portal hypertension from portal vein thrombosis can present with advanced variceal disease comparable in severity to cirrhotic etiologies
Conclusions
The case underscores the importance of prompt resuscitation, vasoactive therapy, antibiotics, careful endoscopic risk assessment, and timely referral in acute variceal hemorrhage management.
Antibiotics were included as part of the initial management protocol during the acute bleeding phase
Careful endoscopic risk assessment was cited as critical to decision-making when definitive therapy is unavailable
Timely referral was identified as a key management step when local resources are insufficient for definitive variceal treatment
The authors frame these elements as core principles applicable to resource-limited settings
What This Means
This research describes the case of a 31-year-old man who arrived at a hospital in critical condition due to massive bleeding from abnormally enlarged veins (varices) in his esophagus and stomach. These varices developed because a blood clot had blocked his portal vein — the major vein carrying blood to the liver — causing a dangerous buildup of blood pressure in the surrounding vessels. Importantly, his liver itself appeared healthy, meaning this was not caused by cirrhosis, which is the more commonly recognized cause of this type of bleeding. His blood count was extremely low (hemoglobin of 3.5 g/dL, far below normal), and he had lost consciousness from blood loss before reaching the hospital.
The medical team stabilized him with blood transfusions, intravenous fluids, a medication called octreotide to reduce blood pressure in the portal system, acid-suppressing drugs, and antibiotics. A camera examination of his upper digestive tract (endoscopy) found both large esophageal varices and a recently bleeding gastric (stomach) varix — a particularly dangerous type that is harder to treat. The hospital did not have the equipment or resources to treat the gastric varix definitively on-site, which created a difficult decision: treating only the esophageal varices without addressing the more immediately dangerous gastric varix could have been harmful. The team therefore deferred the esophageal treatment and urgently transferred the patient for specialized gastric varix care, with plans to treat the esophageal varices afterward. The patient was discharged after five days without further bleeding.
This research suggests that when patients present with both esophageal and gastric varices bleeding simultaneously, clinicians must carefully prioritize which lesion poses the greatest immediate risk and make treatment decisions based on what resources are actually available. In settings where advanced treatments like tissue glue injection or specialized radiological procedures for gastric varices are not accessible, prompt stabilization with medications combined with urgent referral to a higher-level facility may be the safest approach. The case also highlights that life-threatening variceal bleeding is not limited to patients with cirrhosis — young people with portal vein thrombosis can develop equally severe disease and require the same urgent, coordinated care.
Tahajud O, Ahmed O. (2026). Massive Esophagogastric Variceal Bleeding from Chronic Portal Vein Thrombosis in a Non-Cirrhotic Young Man: A Resource-Limited Endoscopic Management Dilemma.. International medical case reports journal. https://doi.org/10.2147/IMCRJ.S640530