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Upper gastrointestinal bleeding is often seen in patients admitted to intensive care units. Ulcers are the most common cause of these haemorrhages, but other factors such as oesopageal varices or malignancy may also be sources [1]. We report a 36-year-old male patient (BMI \ 30 kg/m) admitted to hospital because of a first session of haematemesis and recurrent dyspnoea only days before. Patient’s history revealed only 15 years of nicotine abuse and an undefined infection episode 17 years ago. On admission, clinical examination, vital parameters, chest X-ray and ECG findings were unremarkable. Initial laboratory tests revealed no pathologic coagulation tests, but impaired hemoglobin levels (12.3 g/dl). An oesophagoscopy was performed and revealed varices grade 3 [2]. Nine consecutive ligatures were placed. Furthermore, since there was no history or ultrasonic findings of liver disease, a thoracic CT scan was performed, revealing a large retrocardial mass (12 9 12 9 6 cm, Fig. 1) between the main bronchi displacing the oesophagus. An endosonography excluded an infiltration of the oesophagus, and a pathological specimen taken by video-assisted thoracoscopy showed a vascularised tumor without malignancy. Meanwhile, an emergency oesophagoscopy was indicated due to another session of haematemesis with need for mass transfusion. In the following days, an anterolateral rightsided thoracotomy with tumor resection followed. The arterial delivery was provided by a number of bronchial arteries of both main bronchi. The cause of the paraoesophageal plexus varices was more likely the tumorous venous drainage than the compression by the tumour itself (Fig. 2). Histological examination and further immunohistochemical differentiation of the resected mass revealed an ectopic accessory spleen confirmed by a second, independent pathologist. A deep venous thrombosis occurred preoperatively promoted by lack of anticoagulation despite immobilization. Because postoperatively the thrombosis reached the pelvic vessels, a venous thrombectomy was also performed. The postoperative oesophagoscopy showed varices decreased to grade 2, and anticoagulation with coumadin was started.

Acute gastrointestinal bleeding due to oesophageal varices: an unusual case of a thoracic spleen