J Lipid Atheroscler.  2014 Dec;3(2):111-115. 10.12997/jla.2014.3.2.111.

Idiopathic Splenic Vein Thrombosis Presenting as Splenic Infarction and Consequent Gastric Variceal Bleeding

• Lee YB
• Kim SM
• Heo JS
• Seok H
• Shin IS
• Eun YH
• Kim DK

• KMID: 1773890
• DOI: http://doi.org/10.12997/jla.2014.3.2.111

Abstract

Left-sided portal hypertension and consequent gastric varices can occur in patients with isolated splenic vein thrombosis. It is a rare but clinically significant and curable cause of gastrointestinal hemorrhage. Our patient, a 20-year-old woman, with left flank pain was diagnosed with having idiopathic splenic vein thrombosis with resultant splenic infarction. Thorough workups for the possible etiologies of splenic vein thrombosis were all negative. After six months of anticoagulation, follow-up computed tomography revealed formation of gastric varices; one month following the discovery, she developed gastrointestinal bleeding. Splenectomy was performed, resulting in the resolution of gastric varices.

Keyword

Splenic vein thrombosis; Left-sided portal hypertension; Gastric varices; Splenic infarction

MeSH Terms

Esophageal and Gastric Varices*
Female
Flank Pain
Follow-Up Studies
Gastrointestinal Hemorrhage
Hemorrhage
Humans
Hypertension, Portal
Splenectomy
Splenic Infarction*
Splenic Vein*
Thrombosis*
Young Adult

Figure

• 

  Fig. 1 Contrast-enhanced CT of the abdomen showing splenic vein thrombosis and splenic infarction. (A) Transverse CT image during the portal-venous phase revealed a wedge-shaped low-density lesion (white arrowhead) on superomedial aspect of the spleen, which is considered to be splenic infarction, (B) Image from the same CT scan also demonstrated splenic vein thrombosis (arrow) at the splenic hilum portion.

• 

  Fig. 2 Follow-up CT images showing venous collaterals and gastric varices. (A) Transverse CT image during the portal-venous phase revealed venous collaterals (arrow) around the splenic hilum, (B) Image from the same CT scan also demonstrated a conglomerate of gastric varices (arrow), (C) Follow-up CT scan taken 5 months after splenectomy showed resolution of gastric varices.

• 

  Fig. 3 Gastrofiberscopic findings. (A) Gastric varices with bleeding induced by the gag reflex were demonstrated by endoscopy, (B) Two weeks after splenectomy, gastrofiberscope showed complete resolution of gastric varices.

Reference

1. Köklü S, Köksal A, Yolcu OF, Bayram G, Sakaoğullari Z, Arda K, et al. Isolated splenic vein thrombosis: an unusual cause and review of the literature. Can J Gastroenterol. 2004; 18:173–174.

2. Köklü S, Yüksel O, Arhan M, Coban S, Başar O, Yolcu OF, et al. Report of 24 left-sided portal hypertension cases: a single-center prospective cohort study. Dig Dis Sci. 2005; 50:976–982.

3. Muhletaler C, Gerlock AJ Jr, Goncharenko V, Avant GR, Flexner JM. Gastric varices secondary to splenic vein occlusion: radiographic diagnosis and clinical significance. Radiology. 1979; 132:593–598.

4. Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Suga T. Gastric varices with splenic vein occlusion treated by splenic arterial embolization. J Gastroenterol. 2000; 35:290–295.

5. Sutton JP, Yarborough DY, Richards JT. Isolated splenic vein occlusion. Review of literature and report of an additional case. Arch Surg. 1970; 100:623–626.

6. Sakorafas GH, Sarr MG, Farley DR, Farnell MB. The significance of sinistral portal hypertension complicating chronic pancreatitis. Am J Surg. 2000; 179:129–133.

7. Köklü S, Coban S, Yüksel O, Arhan M. Left-sided portal hypertension. Dig Dis Sci. 2007; 52:1141–1149.

8. Goldberg S, Katz S, Naidich J, Waye J. Isolated gastric varices due to spontaneous splenic vein thrombosis. Am J Gastroenterol. 1984; 79:304–307.

9. Little AG, Moossa AR. Gastrointestinal hemorrhage from left-sided portal hypertension. An unappreciated complication of pancreatitis. Am J Surg. 1981; 141:153–158.

10. Agarwal AK, Raj Kumar K, Agarwal S, Singh S. Significance of splenic vein thrombosis in chronic pancreatitis. Am J Surg. 2008; 196:149–154.

11. Butler JR, Eckert GJ, Zyromski NJ, Leonardi MJ, Lillemoe KD, Howard TJ. Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and metaanalysis of its incidence and rate of gastrointestinal bleeding. HPB (Oxford). 2011; 13:839–845.

12. Cohen DL. Electronic clinical challenges and images in GI. Image 1: gastric variceal hemorrhage owing to splenic vein thrombosis in a patient with idiopathic retroperitoneal fibrosis. Gastroenterology. 2008; 135:e1–e2.

13. Makowiec F, Riediger H, Emmrich J, Kröger J, Hopt UT, Adam U. Prophylactic splenectomy for splenic vein thrombosis in patients undergoing resection for chronic pancreatitis. Zentralbl Chir. 2004; 129:191–195.

14. Zadrozny D. Left-side portal hypertension as a clinical problem. Wiad Lek. 1999; 52:494–499.

15. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med. 2001; 345:1683–1688.

16. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005; 43:167–176.

17. Confer BD, Hanouneh I, Gomes M, Alraies MC. Q: is anticoagulation appropriate for all patients with portal vein thrombosis. Cleve Clin J Med. 2013; 80:611–613.