Case report Esophageal carcinoma in a patient with bleeding esophageal varices P. H. M. Tung, S. Law, K. M. Chu, C. L. Liu, J. Wong Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SUMMARY. More than 20 cases of esophageal carcinoma have been reported to develop after endoscopic injection sclerotherapy (EIS), and this technique is implicated in the pathogenesis of esophageal cancer. We report a case of esophageal carcinoma presenting as a super®cial ulcer in a patient with esophageal varices with no prior EIS. Whether the development of esophageal carcinoma in patients with previous EIS is coincidental or consequential is controversial. Such carcinoma might have already existed before EIS in some reported cases. A causal relationship between EIS and esophageal carcinoma cannot be established without further clari®cation by a well-designed study. INTRODUCTION In spite of the extensive availability of ®beroptic upper endoscopy in the past two decades, early detection of esophageal carcinoma is rare. Cancer of the esophagus is associated with alcohol consump- tion. 1 The same risk factor is also associated with alcoholic cirrhosis and esophageal varices. 1 Toluidine blue staining has been reported to be helpful in the early detection of esophageal cancer in this high-risk group. 2 Development of carcinoma of the esophagus as a late consequence of endoscopic injection sclerothera- py (EIS) for esophageal varices has been reported. 3±12 Detection of super®cial esophageal carcinoma, how- ever, in a patient without EIS for esophageal varices seems to be relatively rare. 13,14 Early esophageal carcinoma is not infrequently missed in patients with an ulcer developing among extensive esophageal varices. Although rare, carcinoma of the esophagus should be considered in a patient with coexisting esophageal ulcer and varices even if there is no history of EIS. We report a case of esophageal carcinoma pre- senting as a super®cial ulcer in a patient with esophageal varices. The ulcer was initially thought to be related to the pressure eect of a Sengstaken tube. Progression of the ulcer size on follow-up led to the diagnosis of esophageal carcinoma by endoscopic biopsy. CASE REPORT A 63-year-old man was admitted to the Department of Surgery of the University of Hong Kong Medical Center at Queen Mary Hospital twice in 1996 and 1997 with head injury as a result of alcohol intoxi- cation. He had a history of alcoholic cirrhosis and Helicobacter pylori-related chronic gastritis managed by a gastroenterologist since 1996. In June 1997, he was admitted again because of gastrointestinal bleed- ing with a hemoglobin level of 6.3 gdl. Endoscopy revealed two columns of grade II esophageal varices without evidence of recent hemorrhage and a chronic duodenal ulcer (Fig. 1). He was treated with ome- prazole, but subsequently defaulted and returned to mainland China, where he developed another episode of hematemesis in February 1998. A Sengstaken tube was inserted and he was transferred back to Hong Kong. On admission, he had a depressed conscious level compatible with hepatic encephalopathy. Upper endoscopy showed two columns of grade II esopha- geal varices that were not bleeding, and an esopha- geal ulcer just proximal to the cardioesophageal junction (Fig. 2). The ulcer was thought to be the result of pressure necrosis from traction of the Sengstaken tube. He later regained consciousness Address correspondence to: Professor J. Wong, Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong. Tel: (+852) 2855 4774; Fax: (+852) 2817 6904; E-mail: hmtung@hkucc.hku.hk 329 Diseases of the Esophagus (1999) 12, 329±333 Ó 1999 ISDE/Blackwell Science Asia