Emergent Management of Gastric Variceal Bleed in the Setting of Acute Pancreatitis-Related Sinistral Hypertension With Partial Splenic Embolization: A Series of Two Cases

Clinical Analysis of Sinistral Portal Hypertension

Background

Sinistral portal hypertension (SPH) is the only type of portal hypertension that is entirely curable. However, it can easily cause varicose veins in the esophagus and/or stomach, as well as upper gastrointestinal hemorrhage. This study aimed to investigate the clinical characteristics and treatments of sinistral portal hypertension.

Methods

All patients with pancreatic disease were included in this retrospective cohort study at the Affiliated Hospital of Southwest Medical University (Luzhou, China) from September 2019 to September 2021. The required information including the patient's demographics, serum laboratory indicators, imaging and endoscopy examinations, and clinical features were gathered and evaluated. The results were expressed as numbers and percentages.

Results

Out of the 830 patients with pancreatic diseases, 61 (7.3%) developed SPH. The most common cause of SPH was acute pancreatitis (80.3%), followed by chronic pancreatitis (11.5%). The splenic vein was the most frequently affected vein in patients (45/61, 73.8%). The findings of the contrast-enhanced computed tomography (CECT) indicated that 51 cases (83.6%) had gastric fundal-body varices, and three cases had combined gastric and esophageal varices. In the perigastric collateral channel formation, gastroepiploic varices (43/61, 70.5%) most frequently occurred in patients with SPH. Splenomegaly was a prevalent manifestation in SPH patients (45.9%). Five cases had gastrointestinal variceal hemorrhage.

Conclusion

SPH was associated with the patency of the splenic vein and the formation of distinctive perigastric collateral veins. Surgery and/or endoscopic treatment were recommended, particularly for patients who have experienced a significant amount of gastrointestinal bleeding and have failed conservative treatment.

Endovascular management of sinistral portal hypertension-related variceal hemorrhage: a multicenter retrospective study

PURPOSE

This study aimed to assess the safety and efficacy of endovascular managements, including splenic vein recanalization (SVR), partial splenic embolization (PSE), and percutaneous transsplenic gastric varices embolization combined with PSE (PSE+GVE), for management of SPH-related variceal hemorrhage (VH).

METHODS

A total of 61 patients with SPH-related VH from three hospitals were enrolled and classified into three groups: the SVR group (Group 1, n=24), the PSE+GVE group (Group 2, n=17), and the PSE group (Group 3, n=20). Baseline characteristics and clinical outcomes were compared among the groups.

RESULTS

The technical success rates for transhepatic and transsplenic SVR were 27.8% and 34.6%, respectively. No major complications were observed during any of the procedures. The median follow-up period was 53.2 months. The 2-year GI rebleeding rates for Group 1, 2, and 3 were 0%, 5.9%, and 35%, respectively. Groups 1 and 2 have a lower GI rebleeding rate (p = 0.002, p = 0.048, respectively) and better results of the degree of GV (p = 0.003, p = 0.044, respectively) compared to Group 3. No significant differences were found in 2-year GI rebleeding rates and the degree of GV between Group 1 and 2 (p = 0.415, p = 0.352, respectively).

CONCLUSION

SVR, PSE+GVE, and PSE seem safe and effective for management of SPH-related VH. SVR appears to be the superior treatment option. Transsplenic access may further increase the SVR success rate. PSE+GVE seems to have comparable outcomes in GV control and GI rebleeding rates compared to SVR, while superior to PSE.

Sinistral Portal Hypertension Due to a Pancreatic Pseudocyst: A Rare Cause of Upper Gastrointestinal Bleeding

Sinistral portal hypertension (SPH), also known as segmental portal hypertension, is a complication of pancreatic disorders and an extremely rare cause of upper gastrointestinal (GI) bleeding. SPH is observed in patients without cirrhosis and arises from splenic vein thrombosis. Unmitigated backflow of blood may cause gastric venous congestion and ultimately GI hemorrhage. Herein, we report a rare case of massive hematemesis due to SPH in a male patient with a history of chronic pancreatitis and pancreatic pseudocyst. Our patient was successfully treated with endoscopic necrosectomy followed by open splenectomy, distal pancreatectomy, and partial gastric resection.

A narrative review of acute pancreatitis-induced splanchnic vein thrombosis: from pathogenesis to clinical management

Acute pancreatitis-induced splanchnic vein thrombosis (APISVT) is an important sequela complication of acute pancreatitis, which may cause poor prognosis, such as severe gastrointestinal hemorrhage, bowel ischemic necrosis and liver failure. However, its mechanism remains uncertain, and there is not a general consensus on the management. In this study, we reviewed the latest academic publications in APISVT, and discussed its pathogenesis, clinical presentation, adverse outcome and treatment, especially focused on the role of anticoagulant therapy. It was indicated that anticoagulation therapy can significantly elevate thrombus recanalization and reduce the incidence of complications and mortality with no increase of bleeding. Actually, as most of these studies were retrospective analyses and prospective studies included small samples, the conclusion remains controversial. Thus, well-designed randomized controlled trials are urged to verify the effectiveness and safety of anticoagulation therapy for APISVT.