Massive Gastric Variceal Hemorrhage Due to Splenic Vein Thrombosis: A Rare Initial Presentation of Asymptomatic Metastatic Pancreatic Adenocarcinoma

Abstract

Isolated sinistral portal hypertension (SPH) is extremely rare, representing less than 5% of all portal hypertension cases [1]. Rare cases of gastric varices can cases occur due to non-cirrhotic splenic venous thrombosis causing SPH. Here, we present massive gastric variceal bleeding from splenic vein thrombosis as the initial presentation of pancreatic adenocarcinoma. A 71-year old man presented to the emergency department with acute onset massive hematemesis and epigastric pain. He had tenderness in the epigastric and left upper quadrant without peritoneal signs. Hemoglobin was decreased at 8.3 g/d from baseline 12. Total bilirubin and liver function tests were within normal limits. Contrast enhanced CT showed splenic vein thrombosis (Figure 1A), gastric varices (Figure 1B) with active hemorrhage noted, and a 5 cm mass in the pancreatic tail (Figure 1C). No changes of cirrhosis were noted in the liver. The patient underwent successful splenic artery embolization (Figure 2). Diagnosis of metastatic pancreatic adenocarcinoma was confirmed with peritoneal biopsy. Gastric variceal bleeding as the initial presentation of pancreatic adenocarcinoma is incredibly unusual. Splenic vein thrombosis causes SPH and formation of collateral pathways to shunt blood around the occluded splenic vein, increasing pressure within the submucosal veins of the gastric fundus forming varices. Splenic vein thrombosis arising from pancreatic cancer carcinoma represents a rare occurrence. One study showed only 49% of 209 patients were correctly diagnosed with SPH after the first episode of bleeding with a median delay of 11 months[2]. Splenectomy is the standard treatment for splenic vein thrombosis, with splenic artery embolization reserved for patients who are poor surgical candidates with metastatic disease. Massive gastricvariceal hemorrhage due to non-cirrhotic portal hypertension from splenic vein thrombosis as the initial presentation of pancreatic adenocarcinoma is a rare occurrence. Recognizing rare causes of gastric varices such as SPH due to splenic vein thrombosis is important for early diagnosis of possible pancreatic adenocarcinoma.1357.tif Figure 1: Figures for Case Report