S4636 Pseudocirrhosis Unmasked: A Rare Case of Malignancy-Driven Esophageal Variceal Bleeding in a Non-Cirrhotic Patient

Introduction: Esophageal variceal bleeding is typically linked to cirrhotic portal hypertension. However, rare non-cirrhotic causes can produce similar hemodynamic consequences. Pseudocirrhosis, a radiologic mimic of cirrhosis often caused by metastatic cancer, is an underrecognized etiology that may lead to life-threatening upper gastrointestinal (GI) bleeding. We present a striking case of variceal hemorrhage in a non-cirrhotic patient, ultimately attributed to colorectal cancer metastases. Case Description/Methods: A 57-year-old man with a history of hepatitis C (now RNA-negative) and alcohol use disorder (abstinent for 11 months) presented with acute hematemesis and melena. He endorsed chronic nonsteroidal anti-inflammatory drug use for back pain. On admission, he was tachycardic (heart rate 110–130s) with normocytic anemia (Hb 7.1), WBC 13.7, platelets 275, INR 1.37, and elevated liver enzymes (AST 211, ALT 87, ALP 543). Total bilirubin was 2.3, and albumin 2.8. He was started on octreotide, pantoprazole, and ceftriaxone for suspected variceal or ulcer bleeding. Emergent esophagogastroduodensoscopy revealed large esophageal varices with red wale signs, successfully managed with band ligation. Subsequent computed tomography and MRI showed innumerable hepatic masses with the largest measuring 14.8 cm, trace ascites, mild intrahepatic biliary ductal dilation, and signs of pseudocirrhosis with possible portal vein thrombosis. Paracentesis was consistent with portal hypertension, and spontaneous bacterial peritonitis was ruled out. Carcinoembryonic antigen was markedly elevated (>2000), prompting colonoscopy, which revealed an obstructing sigmoid adenocarcinoma. A Port-A-Cath was placed for outpatient chemotherapy initiation. Discussion: This case highlights an uncommon but critical cause of variceal bleeding: portal hypertension secondary to hepatic metastases, not cirrhosis. Pseudocirrhosis from tumor infiltration distorted liver architecture, likely obstructing portal flow and precipitating variceal formation. Although classically seen in breast cancer, pseudocirrhosis may arise from GI malignancies and mimic decompensated cirrhosis on imaging. Clinicians should maintain a broad differential in patients with variceal bleeding but no classic cirrhotic history. Elevated tumor markers and early cross-sectional imaging can uncover an oncologic etiology. Prompt recognition enables both hemostatic intervention and timely cancer-directed care. This case reinforces the importance of recognizing malignancy-driven portal hypertension as a potential cause of variceal hemorrhage in non-cirrhotic patients.