Segmental Portal Hypertension Research Articles

Segmental portal hypertension secondary to chronic pancreatitis

Segmental portal hypertension secondary to chronic pancreatitis

Hematemesis From Varices in a 14-year-old Without Hepatobiliary Disease: A "Wandering" Diagnosis.

Hematemesis From Varices in a 14-year-old Without Hepatobiliary Disease: A "Wandering" Diagnosis.

S2120 Isolated Gastric Variceal Hemorrhage Secondary to Idiopathic Sinistral Portal Hypertension

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.

A wandering SPLEEN

A 34-year-old woman was referred to us for splenomegaly. She reported several episodes of precedent acute abdominal pain in the left flank. A computed tomography (CT) was performed, showing an enlarged “wandering spleen” located in the left flank (Fig. 1A), as well as a splenic vein stenosis complicated by segmental portal hypertension (Fig. 1B). There was no abnormality in the enhancement of the spleen during the CT. The gastroscopy performed in hepato-gastroenterology did not reveal any endoscopic sign of portal hypertension.

Intraoperative Challenge for Vascular Reconstruction in Orthotopic Liver Transplantation Because of Extensive Portal Thrombosis and Intimal Dissection of the Hepatic Artery.

CASE REPORT The presence of the portal vein (PV) thrombosis in cirrhotic patients is not considered an absolute contraindication for liver transplantation, despite being technically challenging and associated with longer operative time and poor outcomes.1 We aim to present a patient with an extensive portal thrombosis who underwent a deceased donor liver transplantation. A 41-year-old man presented with a diagnosis of alcoholic cirrhosis (Model for End-Stage Liver Disease score = 28) and a history of multiple upper gastrointestinal bleeding and refractory ascites. Computed tomography revealed revascularized PV cavernous transformation with signs of left segmental portal hypertension in the splenic, gastric, and esophagic territories, without low-pressure signs in the superior mesenteric vein system (Figure 1). The patient underwent a successful nonanatomical liver transplantation with an implantation of the donor PV into the recipient's left gastric vein (LGV) in an end-to-side fashion. To increase the flow in the liver graft, a distal ligation of LGV was performed to avoid vascular steal phenomenon toward the esophagus or gastric territories (Figure 2). Intraoperatively, a complete intimal dissection of the recipient common hepatic artery was confirmed and thus, the donor hepatic artery flow was reconstructed using an iliac artery interposition graft from the infrarenal aorta (Figure 3). The postoperative outcome was uneventful, and the patient was discharged under anticoagulation therapy on the seventh postoperative day (Video 1; watch the video at https://links.lww.com/ACGCR/A20).Figure 1.: Computed tomography showing signs of segmental portal hypertension in the splenic, gastric, and esophagic areas due to portal vein cavernous transformation.Figure 2.: Nonanatomical reconstruction of the graft portal flow with an implantation of the donor PV into the recipient left gastric vein (distal ligation to increase PV flow). PV, portal vein.Figure 3.: The final aspect of the liver graft vascular reconstruction. The arterial anastomosis of the donor common hepatic artery and iliac artery interposition graft from the infrarenal aorta. PV reconstruction of the donor PV and the recipient left gastric vein. PV, portal vein.The presence of PV thrombosis is a complex scenario in patients on a waiting list for liver transplantation, and it is observed in 10% of preoperative imaging in cirrhotic patients.2 The cause of the occurrence of PV thrombosis is multifactorial, and it is probably related to the presence of extensive fibrosis of the hepatic parenchyma, a procoagulant state, and periportal lymphangitis. Other risk factors have been described including male sex, alcoholic liver disease, previous splenectomy, and the coexistence of a hepatocellular carcinoma. Unfortunately, the presence of PV thrombosis has been associated with poor patient survival after a liver transplantation.3,4 Despite being a challenging situation, it does not represent a contraindication for liver transplantation.1 There are several options to manage portal reconstruction including anatomical reconstruction with portal-portal anastomosis after portal thrombectomy or nonanatomical reconstruction including the implantation of the donor PV in the recipient superior mesenteric vein, LGV, vena cava with or without the use of interposition iliac vein grafts.5 From the surgical point of view, PV flow reconstruction in this setting represents a technical challenge and usually increases operative time, bleeding risk, graft failure rate, and finally, the risk of postoperative PV rethrombosis.6 In our case, it was performed for a nonanatomic PV reconstruction using the recipient LGV with an end-to-lateral anastomosis and distal ligation of the LGV to redirect the portal flow to the liver graft. DISCLOSURES Author contributions: F. Laxague wrote the manuscript and is the article guarantor. V. Agustin provided the video. R. Dario and Q. Emilio edited the manuscript. C. M. Agustina provided the video and images. L. McCormack wrote and revised the manuscript for intellectual content. Financial disclosure: None to report. Informed consent was obtained for this case report.

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals.

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals. Retrospective analysis of collected database of patients (n=18; age 40.94±8.43years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals. Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3±0.79 and time to resolution was 4.4±1.3weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2weeks. EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

Splenic vein turndown for vascular reconstruction following pancreatic cancer resection in patients with high risk profile

Introduction: Vascular reconstruction is utilized following resections for pancreatic cancers with borderline resectability. This is defined by venous or partial superior mesenteric artery (SMA) involvement, where vessels are resected en bloc to achieve an R0 resection. There are many vascular reconstruction techniques post en bloc R0 resection, each with its own complication profile. The splenic turndown technique separates the vascular anastomosis from the pancreatic anastomosis, reducing the risk of vascular disruption should a pancreatic leak occur. Case Report: This is the first report in literature of the splenic vein turndown technique being utilized for vascular reconstruction post- pancreatic resection for borderline resectable pancreatic cancer. To date, splenic vein turndown repair has only been described in a trauma setting. In this case, splenic vein turndown was preferred as the patient was on long-term corticosteroids with a high risk of anastomotic leak. Conclusion: This case report showing that splenic vein turndown technique is a feasible option for vascular reconstruction post-pancreatic resection. The main disadvantage of this technique is high risk of segmental portal hypertension if the spleen is not removed concomitantly. For this reason, its utility should be restricted to patients at high risk of pancreatic leak.

Left-sided portal hypertension revisited

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.

Therapeutic Strategies for Advanced Pancreatic Neuroendocrine Tumors with Segmental Portal Hypertension

Pancreatic neuroendocrine tumors (PNET) locally advanced may lead to significant local symptoms especially segmental portal hypertension (SPH) with risk of bleeding. The aim of our study was to evaluate the role of SPH on the PNET management in an expert center. Forty-two patients treated for locally advanced PNET with SPH between January 1984 and December 2012 were retrospectively analyzed. The median age was 55 years (25-75). The median tumor size was 7.5 cm (3-20). Thirty four (80.9%) patients were metastatic mainly in the liver (n=33, 79%) with a frequent (n=16, 38.1%) involvement>20%. The surgery was impossible because of SPH in 7 (16.6%) cases. Pancreatic resection was performed in 28 (66.7%) cases by distal pancreatectomy. Neoadjuvant chemotherapy (n=24, 57%) had no impact on SPH with no modification of collateral circulation. Among operated on patients, complete macroscopic resection was obtained in 19 (67.8%) patients. The mortality and severe morbidity rate was respectively 3.6 and 18%. Five year overall survival (OS) was similar in operated and no operated patients. (61%; p=0.64). The 5-year OS was 77.9 or 55.4% in patients who underwent a complete or incomplete macroscopic resection of primary and metastases, respectively. PNET resection associated with SPH is feasible with a low morbimortality. SPH was not improved by chemotherapy. Prolonged survival was observed after complete macroscopic resection.

Isolated Gastric Variceal Bleeding Due To Segmental Portal Hypertension Developed As A Consequence of Pancreatic Ductal Adenocarcinoma: A case report

Isolated Gastric Variceal Bleeding Due To Segmental Portal Hypertension Developed As A Consequence of Pancreatic Ductal Adenocarcinoma: A case report

Systemic Venous Inflow to the Liver Allograft to Overcome Diffuse Splanchnic Venous Thrombosis.

Diffuse splanchnic venous thrombosis (DSVT), formerly defined as contraindication for liver transplantation (LT), is a serious challenge to the liver transplant surgeon. Portal vein arterialisation, cavoportal hemitransposition and renoportal anastomosis, and finally combined liver and small bowel transplantation are all possible alternatives to deal with this condition. Five patients with preoperatively confirmed extensive splanchnic venous thrombosis were transplanted using cavoportal hemitransposition (4x) and renoportal anastomosis (1x). Median follow-up was 58 months (range: 0,5 to 130 months). Two patients with previous radiation-induced peritoneal injury died, respectively, 18 days and 2 months after transplantation. The three other patients had excellent long-term survival, despite the fact that two of them needed a surgical reintervention for severe gastrointestinal bleeding. Extensive splanchnic venous thrombosis is no longer an absolute contraindication to liver transplantation. Although cavoportal hemitransposition and renoportal anastomosis undoubtedly are life-saving procedures allowing for ensuring adequate allograft portal flow, careful follow-up of these patients remains necessary as both methods are unable to completely eliminate the complications of (segmental) portal hypertension.

Aggressive Resection in Patients with Advanced Pancreatic Neuroendocrine Tumors: Case Report and Review of the Literature

There is considerable controversy about the treatment of patients with malignant advanced pancreatic neuroendocrine tumors (PNETs). Aggressive surgery remains a potentially efficacious anti-tumor therapy but is rarely performed because of its possible morbidity and mortality. The purpose of this work is to describe a case of PNETs who underwent aggressive multivisceral pancreatic resection and the literature's review. Case report : A 52- year old man with no medical history, who presented for abdominal pain, recent constipation and intermittent rectal bleeding. Clinically, we found a tender mass of 10x7 cm in the left upper quadrant. Colonoscopy revealed an irregular lesion of 2 cm in the splenic flexure with histological diagnosis at biopsies suggesting a pancreatic neoplastic origin. Computed tomography (CT) of the abdomen demonstrated a large mass in the left pancreas invading the spleen and its vessels, the adjacent left transverse colon with sign of segmental extrahepatic portal hypertension. There were no liver metastases or suspected adenopathies. He underwent laparotomy with extended resection of the left pancreas, the spleen and the left colon. Histological examination confirmed a well differentiated PNET with Ki67 < 2%. The post operative course was uneventful. After 16 months of follow, the patient remains well. There is no sign of recurrence at CT. Conclusion : Many retrospective studies and the European neuroendocrine Tumors’ (ENETs) guidelines claim that debulking and aggressive surgical resection in locally advanced PNETs should be considered in selected patients because it is technically feasible with encouraging disease-specific survival.

Clinical manifestations, diagnosis and treatment of pancreatic segmental portal hypertension

Clinical manifestations, diagnosis and treatment of pancreatic segmental portal hypertension

Clinical presentation and outcome of endoscopic therapy in patients with symptomatic chronic pancreatitis associated with pancreas divisum.

The results of endoscopic drainage in pancreas divisum with chronic pancreatitis have been debatable.To evaluate clinical presentation and long term results of endoscopic therapy in patients of calcific and non-calcific chronic pancreatitis with pancreas divisum.Between 1996 and 2011, 48 patients (32 males and 16 females) with chronic pancreatitis and pancreas divisum were treated endoscopically. Patients were considered to have clinical success if they had resolution of symptoms and did not require surgery.All patients presented with abdominal pain and symptoms were present for 36.6 ± 40.5 months. Pseudocyst, diabetes, pancreatic ascites, pancreatic pleural effusion, segmental portal hypertension and steatorrhea were seen in 13 (27.1%), 6 (12.5%), 3 (6.3%), 2 (4.2%), 2 (4.2%) and 1 (2.1%) patients, respectively. Ductal calculi and strictures were noted in 3 (6.3%) and 2 (4.2%) patients, respectively. In 47 patients, an endoprosthesis (5 or 7 Fr) was successfully placed in the dorsal duct. Following pancreatic endotherapy, 45/47 (95.7%) patients had successful outcome. The mean number of stenting sessions required to have clinical success was 2.6 ± 0.9. One patient each had mild post ERCP pancreatitis, inward migration of stent and precipitation of diabetic ketoacidosis. Over a follow up of 2-174 months (median: 67 months), 12 out of 31 patients with pain only and no local complications (38.7%) required restenting for recurrence of pain and none of these patients required surgery.Intensive pancreatic endotherapy is safe and effective both in patients with chronic calcific, as well as non-calcific, pancreatitis associated with pancreas divisum. It gives good long term response in patients having abdominal pain and/or dorsal ductal disruptions.

Clinical Profile of Calcific and Noncalcific Chronic Pancreatitis in North India

To compare the clinical profile of calcific and noncalcific chronic pancreatitis (CP) in north India. The profile of calcific CP has not been adequately studied. Detailed demographic data were recorded; hematologic, biochemical, and radiologic investigations were carried out on 225 patients with CP. The patients were divided into calcific and noncalcific groups based on the presence of pancreatic calcification, which was detected on computed tomography. Calcific CP was reported in 46.7% of the patients and noncalcific CP in 53.3%. The mean age, duration of symptoms before presentation, sex ratio, body mass index, and frequency of various symptoms and complications including abdominal pain, ascites, pleural effusion, and segmental portal hypertension was not statistically different between the 2 groups. However, pseudocysts occurred more frequently in noncalcific CP, whereas jaundice because of bile duct stricture, diabetes mellitus, and steatorrhea occurred more frequently in patients with calcific CP (P<0.05). On comparing calcific and noncalcific alcoholic pancreatitis, only steatorrhea was reported more frequently in patients with calcific alcoholic CP. However, pseudocysts and segmental portal hypertension occurred more frequently in noncalcific idiopathic CP, whereas diabetes mellitus occurred more frequently in patients with calcific idiopathic CP (P<0.05). On comparing calcific alcoholic CP with calcific idiopathic CP, we found significantly lower mean age in patients with idiopathic CP and a higher frequency of male patients and pseudocysts in alcoholic CP (P<0.05). Calcific CP has a higher frequency of bile duct stricture, diabetes mellitus, and steatorrhea, whereas noncalcific CP has higher frequency of pseudocysts and segmental portal hypertension.

Malignant solid pseudopapillary tumor of pancreas causing sinistral portal hypertension

Solid pseudopapillary tumor (SPT) of the pancreas is a rare benign or low-grade malignant epithelial tumor that occurs mainly in young females in second to fourth decades of life. Pathologic and imaging findings include a well-defined, encapsulated pancreatic mass with cystic and solid components with evidence of hemorrhage. We report a 23-year-old female who presented with upper abdominal pain of long duration and epigastric mass on palpation. Multidetector-row CT (MDCT) demonstrated a large well-defined heterogeneous attenuation mass, containing hyperdense areas of hemorrhage mixed with solid enhancing and cystic non-enhancing areas, arising from the pancreatic body and tail. Splenic vein thrombosis was present with dilated splenoportal collateral vessels between splenic hilum and portal/superior mesenteric veins, with dilated vessels seen in the gastric wall, with patent portal vein, compatible with sinistral portal hypertension. Typical imaging features and age and sex of the patient suggested a diagnosis of SPT of pancreas complicated by segmental portal hypertension due to splenic vein thrombosis. Histopathology of the biopsy material was confirmatory.

540Solid pseudopapillary tumor of pancreas causing sinistral portal hypertension

Solid-pseudopapillary tumour of the pancreas is a rare benign or low-grade malignant epithelial tumour that occurs mainly in young females. Pathologic and imaging findings include a well-defined, encapsulated pancreatic mass with cystic and solid components with hemorrhage. We report a 23-year-old woman that presented with epigastric pain of long duration and epigastric mass on palpation. MDCT demonstrated a large well defined heterogenous attenuation mass, containing hyperdense areas of hemorrhage mixed with solid enhancing and cystic non-enhancing areas, arising from the pancreatic body and tail. Splenic vein thrombosis was present with dilated splenoportal collateral vessels between splenic hilum and portal/ superior mesenteric veins and dilated vessels seen in the gastric wall with patent portal vein, compatible with sinistral portal hypertension. Typical imaging features and age and sex of the patient suggested a diagnosis of solid pseudopapillary tumor of pancreas complicated by segmental portal hypertension. Histopathology was confirmatory.

Prise en charge de la pancréatite chronique calcifiante symptomatique : endoscopie ou chirurgie ?

The indications for interventional treatment (endoscopic or surgical) of chronic pancreatitis can be classified in several major groups of lesions or symptoms: pain, consequences of fibrosis on neighboring organs (biliary, duodenal or even colic stenosis, thrombosis of the splenic vein with segmental portal hypertension), consequences of duct rupture above the obstacle (persistent symptomatic pseudocyst, refractory pancreatic ascites), and suspected cancer. Finally, surgery is indicated for patients for whom endoscopic procedures are impossible (papillae inaccessible) or too close together. Recently, two new criteria have been suggested: the number of procedures necessary for achieving the objective set, and the duration of hospitalization.

Clinical Profile of Idiopathic Chronic Pancreatitis in North India

Tropical pancreatitis, a form of idiopathic chronic pancreatitis (ICP) with unique features, has been described in South and North India. We investigated the clinical profile of ICP patients in North India. Detailed demographic data were recorded; hematological and biochemical analyses were performed on samples from 155 patients (mostly from North India) who had been diagnosed with chronic pancreatitis. Ultrasonography and computed tomography were performed on all patients. Magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, glucose tolerance tests, and fecal fat studies were performed on some patients. Patients were divided into groups based on early- or late-onset ICP (before or after 35 years of age). ICP was reported in 41.3% of patients and alcoholic chronic pancreatitis in 38.1%. The mean age of ICP patients was 33.0 +/- 13.0 years and the mean duration of symptoms at the time of presentation was 40.2 +/- 34.4 months. Pain was the dominant symptom in patients with early- (95.1%) and late-onset (100%) ICP; pseudocyst was the most common local complication. Diabetes was observed in 17.1% of patients with early-onset ICP and 34.8% with late-onset ICP. Pancreatic calcification was noted in 46.3% of patients with early-onset and 47.8% with late-onset ICP. Pseudocyst and segmental portal hypertension occurred more frequently in non-calcific ICP, whereas diabetes mellitus and abnormal fecal fat excretion occurred more frequently in patients with calcific ICP. In North India, ICP differs from the classical tropical pancreatitis described in the literature. It is associated with a higher prevalence of pain and lower frequencies of diabetes, calcification, and intraductal calculi.

This Month in Gastroenterology

This Month in Gastroenterology