A 35 years old male patient presented with a one-month history of abdominal discomfort. Upon evaluation, he has a mildly pale conjunctiva. Abdominal examination revealed an enlarged spleen measuring 6 cm from the left lower costal margin along the line of growth. Serological and hematological investigations were all in the normal range except for raised bilirubin (TB -1.9 mg/dl, DB-0.4 mg/dl).
On ultrasound examination, the liver was normal-sized with normal homogenous echotexture. Spleen was enlarged (20.3cm) with periportal collaterals. The endoscopic evaluation revealed grade III EV with a red color sign and white nipple sign.
Prophylactic Esophageal Variceal Ligation (EVL) was done; the patient was admitted for close follow-up. Upon discharge, he was started on propranolol and linked to a hematology clinic. He was found to have JAK 2 mutation and was started on anticoagulation (warfarin).
He was admitted once for upper gastrointestinal bleeding (UGIB) 5 months after the commencement of warfarin, for which emergency EVL was done. The patient was discharged upon improvement. On his last follow-up, the patient was relatively well and his vitals are all in the normal range.