Refractory Gastric Antral Vascular Ectasia as a Sentinel for "Burned-Out" Metabolic Dysfunction-Associated Steatotic Liver Disease and Rapid Hepatocellular Carcinoma Progression in a Post-transcatheter Aortic Valve Implantation Dialysis Patient

Gastric antral vascular ectasia (GAVE) is challenging to manage in multimorbid patients, where etiology varies between cirrhosis, autoimmune disease, or chronic kidney disease (CKD). We report a 76-year-old man with transcatheter aortic valve implantation (TAVI), hemodialysis, and past alcohol abuse presenting with refractory GAVE. Baseline imaging in 2021 showed metabolic dysfunction-associated steatotic liver disease (MetALD) with advanced fibrosis and severe steatosis (S3). Two years later (April 2023), during acute bleeding, despite six sessions of endoscopic ablation, hemostasis was elusive. At this stage, elastography showed deceptive radiological evidence of complete steatosis regression (S0) with stable fibrosis. This "pseudo-normalization", likely driven by fibrosis replacing fat and tumor-induced lipid mobilization, masked the underlying pathology. Eight months post-bleeding (December 2023), clinical deterioration revealed decompensated cirrhosis and a massive 6.7 cm hepatocellular carcinoma (HCC). Diagnostic obscurity caused by steatosis resolution in "burned-out" MetALD can be fatal. In this patient, the refractory nature of the GAVE, rather than its mere presence, served as a crucial sentinel sign for occult malignancy and advancing portal hypertension. The patient was referred for palliative care and remains under supportive management.