Chapter 49

PATIENT STORY

A 55-year-old man with a history of chronic alcoholism and recurrent bouts of pancreatitis presented with new onset of hematemesis and hematochezia. He complained of an acute exacerbation of his usual chronic left-sided abdominal pain. Vital signs showed tachycardia with a heart rate of 115 bpm and a blood pressure of 95/62 mm Hg. Physical examination was remarkable for epigastric and left upper quadrant tenderness without stigmata of cirrhosis. Laboratory work was significant for hemoglobin of 7.5 g/dL, a hematocrit of 22.2%, an amylase of 397 IU/L, and a lipase of 264 U/L. Hepatic function panel was within normal limits. After initial resuscitation, upper endoscopy was undertaken, showing actively bleeding gastric varices, but no evidence of esophageal varices. Hemostasis was obtained endoscopically. Subsequent computed tomography (CT) imaging demonstrated an atrophic calcified pancreas with occlusion of the splenic vein, splenomegaly, and multiple perigastric collaterals. No tumor was seen in the pancreas, and there was no evidence of cirrhosis. The patient subsequently underwent a laparoscopic splenectomy prior to discharge. Figures 49-1,49-2,49-3 show representative imaging of a patient with splenic vein thrombosis (SVT).

FIGURE 49-1

Coronal computed tomography (CT) imaging of a patient with splenic vein thrombosis (SVT). The point of thrombosis near an area of pancreatic inflammation is noted with the white arrow.

FIGURE 49-2

Axial computed tomography (CT) imaging of a patient with splenic vein thrombosis (SVT). Cross-sectional imaging of patients with SVT can reveal splenomegaly as well as multiple enlarged perisplenic collateral vessels. Collaterals are noted with the white arrow.

FIGURE 49-3

Endoscopic imaging of isolated gastric varices in a patient with splenic vein thrombosis (SVT). The varices are noted with black arrows.

HISTORY AND EPIDEMIOLOGY

• SVT was first recognized over 80 years ago as a cause of gastro-intestinal (GI) bleeding.1

• The exact incidence of SVT is unknown as the majority of patients are asymptomatic. It is also unknown how many patients with isolated SVT later go on to develop gastric varices.

• Between 45% and 72% of patients initially present with gastric variceal bleeding, with most of them requiring splenectomy.2

• SVT complicates pancreatitis or pancreatic pseudocysts in 7% to 20% of patients.3,4

• Patients with incidentally discovered gastric varices may have a lower risk of bleeding. The risk of variceal hemorrhage is 5% for patients with CT-identified varices compared to 18% for endoscopically identified varices. Of those, only 4% develop variceal hemorrhage and/or require splenectomy.5

• Partial occlusion of the splenic vein is considerably more common than complete occlusion, with 54% to 89% of patients with SVT demonstrating only partial occlusion.6,7

• The reported frequency has ...

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