Duodenal varices are an uncommon, life-threatening cause of acute gastrointestinal (GI) bleeding commonly caused by portal hypertension. Though generally regarded as a complication of advanced cirrhosis and portal hypertension, often overlooked is that in about 2.7% of cases, it can be the first presenting symptom of advanced hepatocellular carcinoma (HCC). We report a case of an isolated, duodenal variceal bleeding as the first clinical manifestation of HCC, complicated by portal venous thrombosis. Diagnosis of HCC was established by a markedly elevated α-fetoprotein, hepatitis B surface and core antibody positivity and consistent radiological findings. Although not the first choice, variceal bleeding was successfully arrested with endoclips. The patient thereafter declined further evaluation and unsurprisingly died within a few weeks from a massive GI bleed. An initial bleed from a duodenal varix often confers a poor prognosis. Patients with HCC who present with variceal bleeding reportedly have a median survival of 71 days.
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