Massive Esophageal Variceal Bleeding as the Initial Presentation of Peripancreatic Tuberculoma with Portal Hypertension

Intra-abdominal tuberculoma is a rare manifestation of extrapulmonary tuberculosis (TB). It is even rarer for this condition to present with massive esophageal variceal bleeding. There are a few reports of portal hypertension associated with tuberculosis. A 52-year-old man with a history of chronic hepatitis B and a 1-year history of pulmonary TB was seen with complaints of hematemesis and bloody stools. He was thrombocytopenic, and abdominal computed tomography (CT) revealed a peripancreatic mass with vascular encasement and splenomegaly. CT-guided biopsy identified the tumor as a tuberculoma. During treatment for TB with an antituberculous regimen, massive esophageal varices bleeding occurred and endoscopic variceal band ligation was performed. Recurrent bleeding subsequently necessitated an exploratory laparotomy. This unusual presentation of an intra-abdominal tuberculoma with vessel encasement with portal hypertension and splenomegaly required CT-guided biopsy for a definitive diagnosis. Surgical intervention may be required for a patient who has esophageal varices resulting from portal hypertension after standard therapy for TB. Periportal tuberculoma should be included in the differential diagnosis of pancreatic head tumor with periportal vessel encasement and portal hypertension, especially for patients without evidence of cirrhosis or with a history of pulmonary TB. © 2009 Buddhist Compassion Relief Tzu Chi Foundation.