A 65-year-old woman was diagnosed with hepatocellular carcinoma (HCC) in February 20XX−1. Following three cycles of transarterial chemoembolization (TACE) for recurrent HCC, combination therapy with atezolizumab and bevacizumab (Atezo+Beva) was initiated in February Y, 20XX. Eight days after treatment initiation (Y+8), the patient developed a fever and generalized malaise. By day 14 (Y+14), her symptoms worsened, prompting a visit to her primary physician, where a fever of 39°C was recorded. However, no hypoxemia was observed, and she was sent home. The following day (Y+15), she developed dyspnea and hypoxemia (SpO₂ in the 80% range), and chest computed tomography (CT) revealed a hilar central alveolar infiltration. She was subsequently admitted to her previous hospital. Comprehensive evaluation led to a diagnosis of congestive heart failure associated with thyrotoxicosis. According to the IMbrave150 study, thyroid dysfunction occurs in 13.4% of patients receiving Atezo+Beva therapy;however, cases classified as Common Terminology Criteria for Adverse Events Grade 3 or higher, requiring hospitalization, are extremely rare, with an incidence of only 0.3%.

We report the case of an 81-year-old woman with a history of primary biliary cholangitis who had been hospitalized multiple times for hepatic encephalopathy. She presented with fresh bloody stools, and contrast-enhanced abdominal computed tomography (CT) revealed a dilated inferior mesenteric vein and varices protruding into the rectal lumen. A colonoscopy confirmed the presence of rectal varices (Rb), leading to a diagnosis of rectal variceal bleeding as the source of the hematochezia. Given her history of recurrent hepatic encephalopathy, percutaneous embolization was performed via a direct approach to the superior rectal vein to occlude the rectal varices and their feeding vessels. A follow-up colonoscopy performed 2 days after embolization showed that the rectal varices had decreased in size and had changed in color from red to blue. Contrast-enhanced CT conducted 5 days post-treatment demonstrated the disappearance of contrast enhancement in the rectal varices and thrombus formation leading to cessation of blood flow in the inferior mesenteric vein. The patient was subsequently discharged without further episodes of rectal variceal bleeding or recurrence of hepatic encephalopathy.