A 53-year-old woman was admitted to the emergency department with melena over the preceding 12 h. The patient reported previous symptoms of bloating and early satiety for about 6 months, but no past history of gastrointestinal or liver diseases was known. The physical examination evidenced a deformity in the abdominal wall, secondary to a large palpable stony mass in the epigastrium, and hepatomegaly. No other signs of liver disease were apparent and the hemodynamic parameters were normal. The

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... nitial laboratory study disclosed anemia (hemoglobin 9.5 g/dL), and a slight elevation of alkaline phosphatase (185 U/L) and gamma-glutamyltransferase (40 U/L). An emergent upper gastrointestinal endoscopy was performed, showing an active spurting bleed from a subcardial gastroesophageal varix, successfully controlled with endoscopic band ligation. In order to clarify the nature of the abdominal mass and the etiology of the portal hypertension, the patient underwent an abdominal computed tomography (CT) scan, which revealed a large hypervascular pancreatic tumor (Fig. 1) , contiguous to the left hepatic lobe, stomach and Figure 1 Primary tumor and liver metastasis are clearly visible on the computed tomographic image: a hypervascular and heterogeneous mass with 15 × 10 cm in size, adjacent to the left hepatic lobe; multiple hepatic metastatic nodules, the larger located in the left lobe, with 12 cm in diameter. spleen, as well as multiple hepatic nodules with similar characteristics. It also showed splenic vein thrombosis and exuberant collateral blood vessels around the tumor (Fig. 2) . The radiological findings were suggestive of a pancreatic neuroendocrine tumor with liver metastasis, a diagnosis subsequently confirmed by the histological and immunohistochemical studies. The investigation was