Left-sided portal hypertension revisited

Abstract

Background: Splenic vein obstruction can lead to left-sided portal hypertension, which is a rare segmental portal hypertension condition, often caused by inflammatory or neoplastic disease of the pancreas. Today, adequate study by cross-sectional imaging, e.g., ultrasound and computed tomography, allows the identification of particular features of the venous collateral pathways that favor the development of gastroesophageal varices. Methods: A retrospective study of 15 cases of left-sided portal hypertension secondary to complete thrombosis of the splenic vein was performed, with special attention to the morphodynamic conditions predicting the development of gastroesophageal varices. Results: In patients with left-sided portal hypertension, gastroesophageal varices were greatly favored by two conditions: collateral pathways directed to the gastric fundus and hypertension in the left gastric vein. This last condition typically occurs when the left gastric vein inflows into an already obstructed splenic trunk, or in the case of concomitant portal hypertension. On the contrary, patients with left-sided portal hypertension and collaterals connected with the left renal or adrenal veins have minor risk of gastroesophageal varices. Conclusions: In every case of left-sided portal hypertension, upper digestive endoscopy and close follow-up are recommended. Besides, computed tomography can demonstrate particular conditions directly favoring gastroesophageal varices, and aid in selection of the appropriate therapeutic decisions.