A 55-year-old woman with a history of liver hydatid disease who underwent surgery in 2009 with portal hypertension secondary to portal cavernomatosis as a complication of surgery, without associated liver cirrhosis.
She had grade III-IV esophageal varices without previous admissions for gastrointestinal bleeding.
The patient came to the emergency department with acute episode of meningitis and depositions of 15 days of evolution.
Urgent gastroscopy showed 4 large varicose cords from the middle third of the esophagus extending into the active subglottic region with red signs on the wall but without evidence of bleeding.
Nine ligation bands were placed without immediate complications.
No potentially bleeding lesions or remnants of the esophagus were observed.
Subsequently, she presented multiple episodes of melena, with secondary anaemia and need for transfusion of a total of 22 episodes of melena.
Two endoscopic attempts were made to control bleeding without targeting bleeding of previous bands or other gastrointestinal level.
A computed tomography (CT) scan showed esophageal varices secondary to chronic thrombosis of the face-to-face axis, active stenosis and ascites without identifying bleeding.
Magnetic resonance imaging (MRI) showed hepatic hydatidosis already described in previous studies, cavernomatosis associated with portal thrombosis and splenic enlargement.
Selected findings include performing an abdominal arteriography of the celiac trunk and superior mesenteric artery that did not identify active bleeding points or vascular malformations.
Due to the absence of findings, it was decided to perform enteroscopy in which a conglomerate of submucosal varices with radial echo was observed in the first duodenal knee.
Acetalate (cyanoacrylate) glue was placed in the duodenal varices without immediate complications.
After 48 hours of recurrence of the bleeding the patient presented with a high volume embolization that caused bronchoaspiration and secondary cardiorespiratory arrest despite the resuscitation maneuvers performed
