The Sinister Entity Subdued: Conservative Management for Left-Sided Portal Hypertension

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Sinistral portal hypertension is a rare cause of upper gastrointestinal (GI) bleeding. It arises from a pancreatic source that leads to compression of the pancreatic vein, increasing the pressure in the left portal venous system, and resulting in gastric varices. Treatment typically involves splenectomy to alleviate pressure in the left portal venous system. We present a rare case of bleeding isolated gastric varices due to sinistral portal hypertension that was managed conservatively without need for surgery. Case Description/Methods: A 39-year-old male presented with hematemesis, melena, and pallor. He had history of Alcohol use disorder, chronic pancreatitis complicated by pancreatic abscess. His hemoglobin on presentation was 3.3 g/dl (Table 1). Computed tomography (CT) imaging was negative for GI bleed but showed splenic vein occlusion with mild gastric wall varices and an embolus in the right lower lobe pulmonary artery. Bedside esophagogastroduodenoscopy (EGD) revealed normal esophagus and duodenum, blood residue in the stomach but no gastric or fundal varices. The patient was started on Octreotide and PPI. His hospital course was complicated by right leg deep vein thrombosis (DVT); However, anticoagulation was held till stabilization of hemoglobin. He was evaluated by Interventional Radiology (IR) and IVC filter was placed. The patient's hemoglobin continued to drop despite pRBCs transfusion, PPI, with slow improvement of melena. EGD was repeated, revealing type 1 Isolated Gastric Varices (IGV 1) with minimal oozing of blood. IR reported the patient was a poor candidate for BRTO. Surgery evaluated the patient, but given stable Hb, clinical stability on conservative management, and history of pancreatitis increasing risk of surgery, they deferred management to the outpatient setting with follow up in 1 month for elective splenectomy. The patient remained stable. pRBC transfusions were held despite Hgb < 7 given lack of symptoms and was deemed medically stable for discharge. He was then seen in clinic a month and 3 months later, denied any melena or hematemesis with stable hemoglobin and it was decided that there is no need for elective surgery. Discussion: Sinistral portal hypertension presents significant risk of severe upper GI bleeding, typically managed with splenectomy or splenic embolization. In this case, successful management was achieved through conservative treatment, emphasizing the need for individualized, tailored management approaches. (Figure Presented).

Volume

119

Issue

10

First Page

S2442

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