Alcoholic Pancreatitis-induced Extrahepatic Portal Venous System Thrombosis (EPVST): A Pair of Illustrative Cases

Abstract

Introduction: Vascular complications of recurrent acute or chronic alcoholic pancreatitis are well-known, including extrahepatic portal venous system thrombosis (EPVST), which occurs at a rate of approximately 13% in this population. The splenic vein is the most commonly affected site in these vascular complications, with the portal and superior mesenteric veins being less common. Prognosis of patients with EPVST depends on early diagnosis and prompt treatment with anticoagulation. Here, we present two cases of patients presenting with EPVST, one in the portal vein and one in the splenic vein, illustrating the manifestations and the course of these important clinical entities. Case 1: A 48-year-old, alcoholic, HIV-positive male presented with epigastric pain, severe epigastric tenderness, and nausea. He had a history of admissions for acute alcoholic pancreatitis. Initial blood work showed evidence of hemoconcentration with elevated amylase and lipase levels suggestive of acute pancreatitis. Abdominal CT scan showed pancreatic inflammation with portal vein thrombosis (Figure 1). The patient was started on therapeutic anticoagulation and treated with aggressive fluid hydration with pain management. The patient improved symptomatically and repeat CT scan 8 weeks later showed resolution of portal vein thrombosis.FigureCase 2: A 37-year-old alcoholic male with multiple past admissions for recurrent pancreatitis presented with epigastric pain, mild epigastric tenderness, nausea, and vomiting for 2 days. Initial labs showed minimal elevations in pancreatic enzyme levels. Abdominal CT scan revealed pancreatic inflammation and calcification with splenic and right common iliac vein thrombosis (Figure 2). Therapeutic anticoagulation was started with significant improvement in the patient's clinical condition. Conclusion: Despite being a well-known complication of recurrent acute or chronic alcoholic pancreatitis, the exact mechanism(s) causing venous thrombosis in this patient population is unclear. Venous stasis, spasm, and mass effects from inflamed pancreas are three of the possible causes. Prompt treatment with therapeutic anticoagulation is essential to prevent complications such as chronic portal vein thrombosis, portal venous hypertension, mesenteric ischemia, and infarction. The optimal duration of anticoagulation remains unknown and warrants further study.