case_images: PMC10741814_01
case_images: (A) Endoscopic view of the middle third of the esophagus shows grade 3 esophageal varices. (B) The gastroesophageal junction with view of the proximal stomach and distal esophagus shows high-grade varices. (C) Distal esophagus shows high-grade esophageal varices with red signs and an approximated lower esophageal sphincter. (D) Endoscopic view of the body of the stomach shows old blood and features of recent bleed from the varices. (E) View of the stomach through an endoscopic band ligator. (F) View of the fundus of the stomach and clotted blood. (G) Duodenal cap has features of duodenopathy. (H) Descending duodenum shows congested mucosa.
case_images: toj-23-0049-figure1.jpg
case_images: PMC10741814_01_toj-23-0049-figure1.jpg
case_images: f1
case_images: After a brief and targeted examination revealing mild ascites, the patient underwent an emergency upper gastrointestinal endoscopy (Figure 1) that showed 3 columns of grade 3 lower esophageal varices with red signs and an ulcer oozing blood over the varix at the gastroesophageal junction.
case_images: Computed tomography scan of chest and abdomen shows a heterogeneously enhancing mass in the right adrenal area with areas of low density suggesting necrosis. The mass measures 15 x 12 x 17 cm, is inseparable from the upper pole of the right kidney, and adjoins the right lobe of the liver (images in the third and fourth rows). Images in the second row show a partially occlusive thrombus in the inferior vena cava with extension of the thrombus into the right atrium and partially into the right ventricle. Secondary collaterals are seen developing in the chest and abdomen.
case_images: toj-23-0049-figure2.jpg
case_images: PMC10741814_01_toj-23-0049-figure2.jpg
case_images: f2
case_images: CT scan of the abdomen and chest with contrast showed a large necrotic mass centered at the right adrenal medulla infiltrating the upper lobe of the right kidney and the right lobe of the liver, with a tumor thrombus extending into the hepatic IVC, the right atrium, and the right ventricle (Figure 2).
case_images: Echocardiology images show (A) the right atrium dilated with a mass measuring 85 x 50 mm, extending into the middle of the right ventricle through the tricuspid valve, and fully obstructing the valve. The tricuspid valve area is 0.75 cm2 by pressure half-time. (B) The left atrium is slightly dilated. The left ventricle and aortic root are normal size. Mitral valve leaflets show normal mobility with no prolapse or regurgitation.
case_images: toj-23-0049-figure3.jpg
case_images: PMC10741814_01_toj-23-0049-figure3.jpg
case_images: f3
case_images: (A) Histopathology demonstrates nests, packets, and sheets of polygonal cells with pleomorphic, hyperchromatic round to ovoid nuclei and intranuclear inclusions 1-2 mitosis per 30 hpf. (B) Tumor cells stained positive for chromogranin.
case_images: toj-23-0049-figure4.jpg
case_images: PMC10741814_01_toj-23-0049-figure4.jpg
case_images: f4
case_images: All tumor cells were positive for chromogranin (Figure 4).
case_images: (A) S100 was positive in rare cells. (B) Cytokeratin was negative in tumor cells.
case_images: toj-23-0049-figure5.jpg
case_images: PMC10741814_01_toj-23-0049-figure5.jpg
case_images: f5
case_images: S100 was positive in a few tumor cells and cytokeratin was negative in all tumor cells, confirming pheochromocytoma (Figure 5).