S2120 Isolated Gastric Variceal Hemorrhage Secondary to Idiopathic Sinistral Portal Hypertension

Abstract

INTRODUCTION: Sinistral portal hypertension (SPH), also known as left-sided portal hypertension or segmental portal hypertension, is a rare cause of upper gastrointestinal bleeding (UGIB). SPH differs from other forms of portal hypertension in that the liver function is preserved and a patent portal vein is present. We describe a case of gastric variceal hemorrhage due to idiopathic SPH successfully managed by splenic artery embolization (SAE). CASE DESCRIPTION/METHODS: A 53-year-old man who underwent explore laparotomy 10 days ago due to multiple self-inflicted stab wound reported melena. His hemoglobin dropped from 10 g/dL to 7 g/dL. Repeat explore laparotomy and Computed tomography angiogram (CTA) did not find the etiology for the bleeding. Esophagogastroduodenoscopy (EGD) was performed and showed large slowly oozing isolated gastric varices (IGV-1) in the fundus. He went for an emergent angiogram that revealed patent portal and splenic veins with multiple large gastric varices. His portal pressures were normal with a 4 mmHg hepatic venous pressure gradient. A splenic artery embolization was successfully performed. Extensive review of his history and imaging ruled out pancreatitis, malignancy, cirrhosis or instrumentation of related vasculature. He had no further melena and his hemoglobin remained stable since the procedure. Repeat CTA and EGD confirmed decreased in caliber of the gastric varices. DISCUSSION: SPH is a localized form of portal hypertension and is an important cause of potentially life threatening UGIB.1 Most commonly, it is secondary to pancreatitis, malignancy, splenic vein thrombosis and retroperitoneal fibrosis.2 Our patient was unique as there were gastric varices without an identifiable cause. SAE is an effective treatment method, theoretically akin to splenectomy, blocking the direct arterial inflow to the spleen and thereby reducing the outflow venous pressure.