Clinical presentation

A 50-year-old man with known metastatic pancreatic somatostatinoma was admitted with a 1-day history of haematemesis, melaena and haematochezia. Following an initial diagnosis 14 years earlier, he underwent distal pancreatectomy and splenectomy, followed by lateral hepatectomy a year later for residual hepatic disease, as well as biliary stenting for malignant obstructive jaundice. He was subsequently started on sunitinib, and his disease had remained stable before this presentation. At admission, he was haemodynamically stable, with haemoglobin concentration of 6.2 g/dl and platelet count of 126×10⁹/l. Other blood tests were unremarkable. Oesophagogastroduodenoscopy revealed a large amount of blood in the stomach, portal hypertensive gastropathy and multiple gastric and duodenal varices, but no active bleeding from these or the biliary stent. …