A 66-year-old female with pancreatic carcinoma and multiple | Figure 1

A 66-year-old female with pancreatic carcinoma

A 66-year-old female with pancreatic carcinoma and multiple admissions for hematochezia and melena over the past 8 months presents with melena. Prior endoscopic workup has revealed gastric varices treated by cyanoacrylate and internal hemorrhoids. Upon admission, abdominal CT demonstrates main portal and splenic vein narrowing as well as gastrosplenic varices.

  1. What is the most common etiology for sinistral portal hypertension (SPH)?
  2. What are the possible treatment options for GI bleeding secondary to SPH?

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  1. What are the treatment options for bleeding rectal varices?
    Endoscopic therapies (injection sclerotherapy, band ligation, cyanoacrylate injection), endovascular therapies (TIPS, partial splenic embolization, balloon-occluded retrograde transvenous obliteration), and surgical management (direct suture ligation).
  2. What this patient’s conditions may be a contraindication for some of these procedures?
    Hepatic encephalopathy is a relative contraindication to TIPS. Pancytopenia is a contraindication for partial splenic embolization due to the risk of infection/splenic abscess formation.


A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.
He had a history of hypertension, long-term smoking, and a sedentary lifestyle.
On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.


A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets.
Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.


A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.