Splenic Vein Thrombosis Research Articles

2159 Endoscopic Management of Isolated Gastric Varices: Hematemesis in Pancreatitis-Induced Splenic Vein Thrombosis

INTRODUCTION: Brisk upper GI bleeding with acute blood loss anemia requires emergent endoscopic evaluation. Often, lesions are due to peptic ulcer disease or variceal hemorrhage. Here, we present a case of isolated bleeding gastric varices in a patient with splenic vein thrombosis likely due to recurrent episodes of acute pancreatitis. CASE DESCRIPTION/METHODS: A 48-year-old man with alcohol abuse, thrombocytopenia, and chronic LUQ abdominal pain presented with four days of hematemesis and melena. He intermittently takes PPI, but reported no NSAID use or history of H. pylori. Previously, two similar episodes associated with severe epigastric pain radiating to his back occurred with heavy drinking. On exam, he is hemodynamically stable with an unremarkable abdominal exam. His admission hemoglobin is 4.9 g/dl and BUN is 26 mg/dl. He is resuscitated with blood products and EGD reveals type 1 isolated gastric varices (IGV) in the fundus with stigmata of recent bleed (Figure 1). Subsequent EUS confirms presence of fundal varices. Hemostasis is achieved with coiling and cyanoacrylate (CYA) glue (Figures 2 and 3). CT A/P shows splenomegaly with chronic splenic vein thrombosis with collateral gastric varices. On discharge, he is counseled on alcohol cessation, as his bleeding gastric varices were attributable to pancreatitis-induced splenic vein thrombosis (PISVT). DISCUSSION: PISVT is a sequalae of acute and chronic pancreatitis. The pathophysiology is centered on left-sided portal hypertension with collateral blood flow developing in the splenoportal or gastroepiploic systems. Most patients with subsequent IGV are asymptomatic, but in high-risk symptomatic groups, EUS guided CYA glue injection and intravascular coil embolization is an emerging therapy that has the potential to achieve higher rates of hemostasis and lower rebleeding rates compared to sclerotherapy or balloon-occluded retrograde transvenous obliteration. A recent study demonstrated that out of 100 patients who underwent EUS-guided coil and CYA glue injection, 93 had complete obliteration (on Doppler study) of gastric fundal varices on follow-up EUS examination (Bhat, GIE 2016). Patients who do not achieve hemostasis after CYA injection and coil should be considered for splenic artery embolization or splenectomy, which is currently the gold standard for management of splenic vein thrombosis complicated by variceal hemorrhage. A large comparison trial would be most beneficial to validate this treatment modality compared to existing conventional therapies.

1945 Isolated Gastric Varices as the Sole Manifestation of Renal Cell Carcinoma

INTRODUCTION: Isolated gastric (fundal) varices (IGV) are a consequence of left (sinistral) portal hypertension commonly caused by splenic vein thrombosis (SVT). It occurs when SVT results in a backflow into the collateral short gastric and gastroepiploic vessels. Common causes of SVT include pancreatic and splenic pathologies. Renal cell carcinoma (RCC) is an extremely rare cause, and by itself, RCC is lethal because of the vagueness of its presenting symptoms. CASE DESCRIPTION/METHODS: A 76 year-old male with a past medical history of chronic anemia is presenting with two day history of hematochezia. He denies any personal or family history of colon cancer. He is not on anticoagulation or NSAID regimen. On evaluation, patient was noted to have non-remarkable vital signs. Physical exam was fairly unremarkable. Initial CBC was remarkable for severe anemia with hemoglobin of 6.1. MCV was normal. After routine transfusion, he was evaluated by gastroenterology and underwent an EGD, colonoscopy and capsule endoscopy. EGD was remarkable for 2 cm diameter non bleeding fundic gastric lesion. Colonoscopy and capsule endoscopy were unremarkable except for findings of dark blood in the distal ileum and throughout the colon. Tagged RBC scan was negative. Endoscopic ultrasound was obtained that showed multiple tubal, anechoic structures in the cardia of the stomach consistent with varices. CT abdomen and pelvis then confirmed a giant mass filling the left renal fossa presumably primary renal cell neoplasm with displacement of the pancreas and splenomegaly. CT chest was obtained and confirmed pulmonary nodules likely suggesting metastatic lesions. He then underwent splenectomy and nephrectomy with adjuvant chemotherapy for the metastatic disease. DISCUSSION: Sinistral (left) portal hypertension (SPH) was first outlined by Greenwald and Wasch in 1939. It is a clinical syndrome in which a patient with a patent portal vein and normal hepatic (liver) function tests develops isolated gastric variceal bleeding secondary to splenic vein thrombosis. Interestingly, only two cases have documented renal cell carcinoma as a cause of SPH in the last 30 years. Patients with this condition need to be considered for a prophylactic splenectomy and removal of associated arteries and veins, as well as a total nephrectomy. In this case, with metastatic lesions to his lungs, involving hematology/oncology and general surgery and gastroenterology in the multidisciplinary decision making process would be in his best interest.

1359 A Case of Pancreatic Pseudoaneurysm

INTRODUCTION: Pancreatic Pseudoaneurysm is a rare vascular complication of chronic pancreatitis. It may lead to fatal complications if left untreated. Here we report a case of pseudoaneurysm from a gastroduodenal artery in a patient with chronic pancreatitis which was managed successfully with coil embolization. CASE DESCRIPTION/METHODS: 30-year old male with history of alcohol abuse, chronic pancreatitis, and splenic vein thrombosis on Xarelto presented to emergency department with epigastric pain. He was recently discharged from the hospital after an episode of acute pancreatitis. On admission, the pain was dull, radiating to the back with nausea but no vomiting, hematemesis or melena. Physical examination was grossly unremarkable. He was hemodynamically stable and blood work was unremarkable except for lipase 318 U/L. Computerized tomography of abdomen showed development of a pseudoaneurysm branching from the gastroduodenal artery with pancreatic inflammatory changes and fluid collections (Figure 1). Interventional Radiology were consulted, angiography was performed with coil embolization of inflow, outflow vessels, and the pseudo aneurysmal sac (Figures 2 and 3). His hemoglobin remained stable, and his symptoms resolved. Diet was advanced and Xarelto was resumed. He was discharged on the third day to follow up as outpatient. DISCUSSION: Pancreatic pseudoaneurysms are formed by erosion of the pancreatic or peripancreatic artery into a pseudocyst. These may occur after pancreatitis, as well as after pancreaticobiliary surgery, pancreatic transplantation, trauma, and motor vehicle accident. They are classified according to the artery they originate from, communication with gastrointestinal tract and exposure to pancreatic juice. Most commonly involved is splenic artery due to its proximity to the pancreas, followed by gastroduodenal artery, pancreaticoduodenal arteries, then superior mesenteric, left gastric, hepatic and small intrapancreatic arteries. Gastro-Duodenal Pseudoaneurysm commonly presents as gastrointestinal bleeding secondary to rupture. It can also present as abdominal pain, asymptomatic, rarely as retroperitoneal bleed or bleeding into pancreatic duct or common bile duct, which can cause obstructive jaundice. Treatment modalities include either embolization or surgery. Surgery is necessary when embolization is unsuccessful. Prompt diagnosis and early treatment of pancreatic pseudoaneurysm is mandatory because of potentially life-threatening consequences and increased mortality if left untreated.

1399 DLBCL Mimicking a Cholangiocarcinoma: Earlier Diagnosis, Better Outcome?

INTRODUCTION: Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype (∼25%) of Non-Hodgkin's Lymphoma. In 40% of cases, disease arises in extra-nodal, extra-medullary tissues, primarily in the stomach or GI tract. This is a rare case presentation of DLBCL mimicking cholangiocarcinoma. CASE DESCRIPTION/METHODS: 56-year old male with no significant past medical history presented to the ER with progressive abdominal pain for the past three months. Patient had early satiety and unintentional weight loss of sixty pounds over the past year. Labs on admission were significant for WBC: 13.55 (93% Neutrophils), Hemoglobin: 7.3, AST: 158, ALT: 150, Total Bilirubin: 17.7, Alkaline Phosphatase: 846, Albumin: 2.1, and LDH: 442. HIV was negative. Physical exam was notable for cachexia, scleral jaundice, and diffuse abdominal pain. CT of abdomen showed 2.6 × 3.4 cm mass encasing the common bile duct, intra and extra-hepatic biliary ductal dilation, retroperitoneal lymphadenopathy, suspicious liver metastases, significant ascites, and main portal, superior mesenteric, and splenic vein thrombosis, all concerning for cholangiocarcinoma. Patient was started on heparin drip for the vein thromboses. Gastroenterology attempted an ERCP, but was unable to cannulate the biliary tree. Analysis of ascitic fluid was negative for malignant cells. EGD showed large varices in lower third of esophagus and two non-bleeding gastric ulcers. Both ulcers were biopsied for histology. Gastric biopsy from EGD demonstrated diffuse large B-cell lymphoma with neoplastic cells, strongly CD20+ and weak BCL 6. Bone marrow biopsy showed no marrow involvement. Hematology Oncology recommended chemotherapy with R-CHOP. Few days later, the patient developed a GI bleed and transferred to MICU. Repeat EGD showed esophageal varices with blood clot covering fundus and body. The next day the patient was made comfort measures and passed. DISCUSSION: DLBCL has an incidence of approximately 7 cases per 100,000 persons per year. Per case report by Zakaria et al, there have been 28 reported cases of NHL to arise in the extra-hepatic bile ducts between 1982 and 2012. Diagnosis is best made by excisional lymph node biopsy or immunophenotyping. Treatment options primarily include surgery and chemotherapy. Prognosis varies among reported cases of DLBCL involving the GI tract from death within 32 days to survival greater than 72 months. DLBCL with biliary tract causing obstructive jaundice is a rare presentation, but it should among the differential diagnoses.

1944 BRTO for Treatment of Persistent Gastric Variceal Bleed in a Patient With HCC

INTRODUCTION: Gastric varices are often associated with formation of spontaneous left-sided porto-systemic shunts, which arise to relieve portal hypertension or bypass obstruction. Gastro-renal shunts are the most common (80%), followed by gastro-caval shunts. Balloon Retrograde Transvenous Obliteration remains one of the primary measures to prevent re-bleeding from gastric varices. This procedure consists of inserting a balloon into the outflow vein of a shunt, allowing injection of a sclerosant for occlusion. It has the advantage of not diverting blood to bypass the liver, but it can worsen portal pressure and increase risk for ascites or esophageal variceal bleeding. CASE DESCRIPTION/METHODS: 67-year-old male with past medical history of untreated Hepatitis C was admitted after syncope. He also had nausea, lightheadedness and hematemesis. In the ED, his blood pressure was stable with an Hb of 9.5 mg/dL. Ceftriaxone, an octreotide drip and PPI were promptly started. 3 units of blood were transfused. Urgent endoscopy did not reveal esophageal varices, but profuse active bleeding in the fundus was seen. Attempts to control the hemorrhage were ineffective due to lack of visibility. CT scan of the abdomen showed a cirrhotic liver with a 6 cm mass in the right lobe and a large gastric varix with a gastrorenal shunt. Importantly, there was no evidence of portal or splenic vein thrombosis. Left-sided TIPS was tried, but attempts to pass from left portal vein to left hepatic vein were futile due to challenging anatomy. After multiple transfusions the patient eventually underwent successful BRTO. He had no further bleeding and was ultimately diagnosed with HCC. DISCUSSION: BRTO is indicated primarily for prevention of recurrent gastric variceal bleeding. It is useful in patients with elevated MELD score, right-sided heart failure or hepatic encephalopathy, who are at high risk for TIPS. Patients with gastric variceal bleeding and concomitant HCC usually have more advanced cirrhosis and lower possibility of HCC treatment. This is due to bleeding-related hepatic decompensation and overall poorer liver functional reserve. Although BRTO has its disadvantages, its ability to divert blood flow towards the liver is thought to possibly preserve hepatic function. This might make patients with HCC and gastric varices good candidates for BRTO, allowing better possibility for treatment and increased survival. Further long-term studies are needed to evaluate prognosis and complications of BRTO in these patients.

Splanchnic Vein Thrombosis: Current Perspectives.

Splanchnic vein thrombosis (SVT) including portal, mesenteric, splenic vein thrombosis and the Budd-Chiari syndrome, is a manifestation of unusual site venous thromboembolism. SVT presents with a lower incidence than deep vein thrombosis of the lower limbs and pulmonary embolism, with portal vein thrombosis and Budd-Chiari syndrome being respectively the most and the least common presentations of SVT. SVT is classified as provoked if secondary to a local or systemic risk factor, or unprovoked if the causative trigger cannot be identified. Diagnostic evaluation is often affected by the lack of specificity of clinical manifestations: the presence of one or more risk factors in a patient with a high clinical suspicion may suggest the execution of diagnostic tests. Doppler ultrasonography represents the first line diagnostic tool because of its accuracy and wide availability. Further investigations, such as computed tomography and magnetic resonance angiography, should be executed in case of suspected thrombosis of the mesenteric veins, suspicion of SVT-related complications, or to complete information after Doppler ultrasonography. Once SVT diagnosis is established, a careful patient evaluation should be performed in order to assess the risks and benefits of the anticoagulant therapy and to drive the optimal treatment intensity. Due to the low quality and large heterogeneity of published data, guidance documents and expert opinion could direct therapeutic decision, suggesting which patients to treat, which anticoagulant to use and the duration of treatment.

1366 Primary Antiphospholipid Syndrome, Acute Necrotizing Pancreatitis, and IgA Nephropathy in a Young Male: Single Pathogenesis or Rare Association?

INTRODUCTION: Primary Antiphospholipid syndrome (APS) is characterized by recurrent thrombosis, fetal loss and the presence of lupus anticoagulant (LA)/anticardiolipin antibodies. Primary APS is uncommon in males and poses diagnostic difficulties. Primary APS is considered as a rare cause of acute pancreatitis and IgA nephropathy (IgAN). We describe a patient of primary APS (probably the first reported case), who sequentially presented with cerebral venous thrombosis, later with recurrent episodes of acute necrotizing pancreatitis (ANP) followed by IgAN. Despite the initial diagnostic dilemmas, the patient was managed successfully. CASE DESCRIPTION/METHODS: A 30 year old male initially presented with sudden onset headache and generalized seizures. CECT brain revealed cerebral venous thrombosis. Cardiac and Pro thrombotic work up (including ANA and LA) was normal. He was treated with antiepileptics and warfarin. 3 months later, he presented with 3 episodes of acute pancreatitis. Each time the patient was managed conservatively with fluids and analgesics. However the last episode was very severe, CECT abdomen was suggestive of severe ANP with extensive splenic vein thrombosis (SVT). Anti-β2glycoprotein1 antibody test was strongly positive. APS was diagnosed according to revised Sapporo criteria. Low molecular heparin and steroids were started. After 5 months, although the patient recovered from ANP, he presented with hypoproteinemia and renal failure. Urine analysis showed RBC casts and proteinuria. Kidney biopsy showed mesangial IgAN with secondary segmental sclerosis. Patient recovered fully and is on follow up for two years. He is doing fine with low dose steroids, ACE inhibitors and warfarin with regular INR (target 2-3). DISCUSSION: This patient had multiple hospitalizations, all attributable to the rare manifestations of APS. It is perhaps the first case report where APS, ANP and IgAN are described in a single patient. Clinical suspicion can lead to early diagnosis, which makes it easy to manage such patients. Acute pancreatitis is considered as one of the rarest manifestation of APS, which is distinct from autoimmune pancreatitis. Renal biopsy was suggestive of IgAN, which is unusual and distinct from the APS nephropathy. Thrombosis of the pancreatic and renal microcirculation and vasculitis has been postulated as the underlying pathogenesis. To conclude, APS is a rare, yet treatable cause of acute pancreatitis. Urine examination is a must in cases of primary APS, with or without pancreas involvement.

3209 Mesenteric Vein Thrombosis: An Unusual Cause of Small Bowel Obstruction

INTRODUCTION: Mesenteric venous thrombosis (MVT) is an uncommon cause of acute to sub-acute abdominal pain. Early recognition and treatment have survival implications. CASE DESCRIPTION/METHODS: A 42 year-old male with past medical history of hypertension and obstructive sleep apnea presented with 3 weeks of worsening abdominal pain, nausea and vomiting. Physical exam revealed diffusely tender abdomen with mild guarding, no rebound tenderness and normoactive bowel sounds. Pertinent labs on admission included an elevated white count of 13.5 K/mm3 and lactate of 2 mmol/L. A non-contrast CT abdomen demonstrated small bowel loops with abnormal wall thickening and associated inflammatory changes. He was started on broad spectrum antibiotics for enteritis, however he had worsening abdominal pain and an abdominal x-ray revealed small bowel obstruction. Patient was made NPO and conservatively managed with IV fluids. His hospital course was complicated by fever of 100.8 F and leukocytosis of 26.3 K/mm3 Infectious work up was unremarkable and a CT abdomen with contrast revealed thrombosis of main portal, superior mesenteric and splenic vein. Hypercoagulable workup resulted in decreased Protein S activity (1779X) and Factor II heterozygosity (prothrombin G20210A mutation). DISCUSSION: MVT accounts for 6%–9% of all the cases of acute mesenteric ischemia. Most common presenting symptom is abdominal pain which occurs in 91–100% of the cases followed by nausea, vomiting and melena. Associated portal venous thrombosis can be seen if the disease originates in the major veins instead of the small vena rectae. Young patients without known risk factors for venous thromboembolic (VTE) and thrombosis in unusual sites such as portal, mesenteric and cerebral veins should be evaluated for thrombophilias. Approximately 20-40% of patients have previous history of deep vein thrombosis or may have a pre-existing hereditary hypercoagulable state such as protein C deficiency, protein S deficiency, anti thrombin III deficiency, factor V Leiden deficiency, or antiphospholipid syndrome. In general, outcomes in MVT are better when compared to arterial thrombosis with mortality of 44% as compared to 66–89% respectively. Studies have shown that early use of heparin has been associated with improved survival. Early recognition of MVT and treatment with anti coagulation has led to non-surgical treatment and improved outcomes.

3033 Acute Pancreatitis Complicated by Pancreatic Pseudocyst and Splenic Hematoma, Management Considerations

INTRODUCTION: Pancreatic duct disruption is a known complication of pancreatitis which leads to the formation of pancreatic pseudocysts, pancreatic ascites, and high amylase pleural effusions. Pancreatic pseudocysts migrate along with the pancreatic tissue and rupture either into surrounding organs or into the free peritoneal cavity. Splenic complications of pancreatitis are rare and include splenic vein thrombosis, splenic artery rupture, splenic rupture or infarction, and splenic hematoma. CASE DESCRIPTION/METHODS: 39 y/o alcoholic male admitted for acute pancreatitis. Imaging revealed pseudocysts and ascites. Initially, he improved with supportive care but abdominal pain recurred owing to splenic rupture with resultant splenic hematoma. Splenic artery coiling was employed to stop bleeding. He returned for recurrent abdominal pain and new chest pain with interval increase in size of pseudocyst and interval development of pleural effusion. EUS revealed a multiloculated pancreatic pseudocyst, as well as pancreatic duct disruption. Transgastric drainage of the pseudocyst was performed with an Axios stent. Repeat endoscopy at interval showed complete resolution of the cyst. DISCUSSION: Studies estimate the incidence of pancreatic pseudocyst rupture into the spleen at a rate of up to 1.1% of patients with acute pancreatitis. Another study of patients with chronic pancreatitis reports splenic pseudocyst as the most common lesion, followed by splenic rupture and hematoma. A more recent study of 500 men with chronic alcoholic pancreatitis found that only 2.2% develop splenic complications with intrasplenic pseudocyst being the most common lesion, followed by splenic rupture and subcapsular hematoma. Findings associated with the highest risk of developing splenic complications included pancreatic tail necrosis, distal pseudocyst, or splenic vein occlusion. Previously, the mainstay of treatment for splenic hematoma was splenectomy with distal pancreatectomy. However, with the advent of advanced endoscopic procedures, patients are safely managed with splenic artery embolizationand EUS guided pancreaticogastrostomy or percutaneous drainage. Endoscopic drainage and percutaneous drainage of symptomatic pseudocysts are preferred to surgical management. Furthermore, recent reviews show that endoscopic drainage is superior to percutaneous drainage with lower rates of reintervention, shorter hospital stays, and need for less follow-up imaging.

1952 Safety of Capsule Endoscopy During Pregnancy

INTRODUCTION: Currently there is limited literature on the safety of Video Capsule Endoscopy (VCE) during pregnancy. There is a theoretical risk of the growing uterus compressing the GI tract. Moreover the gastrointestinal transit is prolonged in the second and third trimester which may jeopardize VCE procedure. We hereby report a case of a pregnant patient who safely underwent a VCE without retention. CASE DESCRIPTION/METHODS: A 30 years old female who was 18 weeks pregnant with a history of myeloproliferative disorder and splenic vein thrombosis presented with hematemesis. She underwent an EGD that demonstrated type 1 isolated gastric varices without active bleeding that was doubted as the source. Colonoscopy found old blood in the terminal Ileum and the ascending colon. She was started on a beta-blocker for variceal bleeding prophylaxis. The patient was informed that there is limited literature on safety of VCE in pregnancy with a theoretical risk of capsule retention. As such pregnancy is deemed a relative contraindication to VCE. Therefore patient decided to pursue clinical monitoring. One week later the patient returned with similar symptoms. During this admission the manufacturer of the capsule was unable to provide any safety data as it had not been studied in pregnant patients. The Obstetrics (OB) service discussed the risks and benefits of VCE during pregnancy. The risk of a retained capsule is that it may require an x-ray of the abdomen and/or surgery. The patient was currently in the 2nd trimester which is the usual recommended trimester for any necessary surgery. Moreover the gestational age was beyond embryogenesis and per ACOG recommendations x-ray should be completed for maternal well-being. Since there were no safer alternatives and maternal wellbeing supersedes fetal health, VCE was performed. It found a small duodenal erosion but otherwise passed into the colon and was a normal examination of the small bowel. Hence recurrent bleeding was attributed to known gastric varices. She is now in her 30th week, following up with OB and per their review the fetus is doing well. She has had no more admissions for gastrointestinal bleeding. DISCUSSION: Elective VCE in pregnant patients should ideally be postponed until after delivery due to a lack of safety data. Nevertheless, VCE may be considered in indications related to maternal symptoms that put the mother or child at risk, such as small bowel bleeding. Accordingly, the FDA has assessed pregnancy as a relative contraindication to VCE.

IgG4-related autoimmune pancreatitis combined with splenic vein thrombosis leading to variceal bleeding of the fundus: A case report

IgG4-related autoimmune pancreatitis combined with splenic vein thrombosis leading to variceal bleeding of the fundus: A case report

Duodenal Varices: A Rare Manifestation of Portal Hypertension

We report a case of haematemesis & melaena due to ectopic varices located in the duodenum in a patient with NASH related CLD. Duodenal varices are a rare but potentially serious consequence of portal hypertension in the event of a bleeding. The etiology of duodenal varices can be classified into hepatic (e.g. cirrhosis) or extra hepatic (e.g. portal, splenic or superior mesenteric vein thrombosis). Endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) are widely accepted as primary therapies for esophageal variceal bleeding whereas bleeding gastric fundal varices are usually treated with cyanoacrylate injection or shunt procedures. However there is no widely accepted treatment modality for duodenal varices. In the case presented, we used injection sclerotherapy with ethanolamine oleate, to obliterate varices and control bleeding. A short review on the etiology pathogenesis and management of ectopic varices is presented.
 J Bangladesh Coll Phys Surg 2019; 37(3): 156-159

A preliminary study on predicting anastomotic occlusion in patients with cirrhosis underwent splenectomy combined with splenorenal shunt by ultrasonography

To predict anastomotic occlusion after splenectomy combined with splenorenal shunt surgery by ultrasound technique. Methods: To retrospectively analyze 53 cases of splenectomy combined with splenorenal shunt surgery. We divided these patients into 2 groups: a patency group (n=39) and an occlusion group (n=14), which were based on the results of splenorenal venous anastomotic stoma with spiral CT. The statistical methods were used to analyze the ultrasound detection indicators (the internal diameter, blood flow velocity, blood flow volume, thrombosis and blood flow direction of portal vein, splenic vein, and superior mesenteric vein) for those 2 groups, and then to figure out the predictive factors that affect splenorenal venous anastomotic stoma. Results: Compared with the patency group, there are significant broadening of the portal vein diameter, narrowing of the splenic vein diameter, reduction of the splenic vein blood flow velocity, reduction of splenic venous flow volume, splenic vein thrombosis formation and changes of the splenic vein blood flow direction (all P<0.05). Conclusion: Ultrasound indicators of portal vein diameter broadening, splenic vein diameter narrowing, splenic vein blood flow velocity reduction, splenic venous flow volume reduction, splenic vein thrombosis formation and change of splenic vein blood flow direction are influential factors for the splenorenal anastomotic occlusion in patients after splenectomy combined with splenorenal shunt surgery.

AN UNUSUAL CASE OF PORTAL, SPLENIC AND MESENTERIC VENOUS THROMBOSIS PRESENTING WITH ACUTE ABDOMEN

Porto-spleno-mesenteric vein thrombosis is a rare, life-threatening condition of extrahepatic portal venous system thrombosis. We report a rare case of a 49-year-old lady with late presentation of acute portal vein thrombosis in a non-cirrhotic liver with an incidental finding of left adnexal teratoma. She presented with a one-week history of severe abdominal pain associated with vomiting and diarrhea. She gave no history of prior risk for venous thromboembolism or liver diseases. Physical examination revealed a tender mass extending from suprapubic to left iliac fossa. Abdominal computed tomography scans showed a well-defined fatcontaining left adnexal mass, likely a benign teratoma, with no involvement of surrounding structures or calcification. There was evidence of porto-splenic-mesenteric vein thrombosis with liver infarction, bowel and splenic ischemia. Management of the extensive thrombosis causing multi-organ failure includes resuscitation, supportive care and treatment of thrombosis. Treatment options include early anticoagulation and if feasible, thrombolysis. Keywords: Acute Abdomen, Mesenteric Vein Thrombosis, Non-Cirrhotic Vein Thrombosis, Portal Vein Thrombosis,Splenic Vein Thrombosis

Splenectomy following JAK1/JAK2 inhibitor therapy in patients with myelofibrosis undergoing allogeneic stem cell transplantation

BackgroundAllogeneic hematopoietic stem cell transplantation (alloHSCT) is the only treatment option with curative potential in patients with myelofibrosis (MF). The aim of our study was to evaluate the safety of splenectomy before alloHSCT in MF patients who failed to achieve significant spleen response after ruxolitinib therapy. MethodsSplenectomy was performed in 12 patients for alloHSCT with myelofibrosis—primary (6 patients), post-polycythemia vera (3 patients). or postessential thrombocythemia (3 patients) between 2016 and 2018. The patients were prospectively included in the study if persistence of splenomegaly ≥ 25 cm was documented after at least 3 months of ruxolitinib therapy. In eight patients subsequent alloHSCT was performed. ResultsMedian length of hospital stay was 11 (8–30) days, median follow-up after splenectomy was 20.0 (0.6–31.1) months. No deaths were documented, perioperative morbidity was 50%. Three patients experienced portal vein thrombosis and one experienced splenic vein thrombosis. One patient developed pancreonecrosis and subdiaphragmatic abscess. Mean leukocyte count was significantly higher 1 month after splenectomy than before, 10.7 ± 1.7 versus 6.9 ± 2.3 × 109/L (p = 0.03). Platelets rate significantly elevated starting Day + 7 after splenectomy (p = 0.01). Median time between splenectomy and alloHSCT was 2.6 (0.17–4.5) months. All patients achieved engraftment. In early posttransplant period no cases of severe sepsis, intraabdominal infections were documented. One patient died after alloHSCT due to thrombotic microangiopathy. Seven patients are alive in disease complete remission. No relapses after alloHSCT were observed. Two-year overall survival in the whole group is 90% (95%CI 98–43%). ConclusionSplenectomy before alloHSCT might be a promising option in patients who failed to achieve significant spleen response after ruxolitinib therapy.

Clinical Case of Tubular Gastrectomy and Splenectomy, the Bleeding from Vericose Veins of the Stomach and Splenomegaly in the Background Idiopathic Myelofibrosis in Urgent Surgery

Relevance. Treatment of patients with surgical complications of oncohematological diseases is difficult due to their inherent critical disorders of blood coagulation, dependence of patients on hormonal drugs taken in connection with the existing pathology, as well as instability of systemic hemodynamics. Such patients are rarely hospitalized in a surgical hospital and can be classified as "difficult patients " because of the polysyndromic nature of the underlying disease and the high risk of death from complications of the disease.&#x0D; One of the most common oncohematological diseases is chronic idiopathic myelofibrosis, it is characterized by bone marrow fibrosis, hepato-splenomegaly (due to extramedullary hematopoiesis), as well as anemia. The clinical picture of primary (idiopathic) myelofibrosis is diverse and has no pathognomonic syndromes. Centers of extra-medullary hematopoiesis may occur in the liver with long-term disease, and thrombosis of splenic vein is possible, which can lead to subhepatic portal hypertension.&#x0D; In the available literature, we have found information on the successful treatment of bleeding from varicose veins of the stomach in a patient with splenic vein thrombosis and splenomegaly by performing only splenectomy preserving gastric varices, which does not completely eliminate the risk of re-bleeding. We found no publications on splenectomy with vertical tubular resection of the stomach at the height of bleeding from varicose veins of the stomach in a patient with myelofibrosis of the spleen.&#x0D; The aim is to show the possibility of performing a simultaneous operation (vertical tubular resection of the stomach and splenectomy) for bleeding from varicose veins of the stomach and splenomegaly against the background of idiopathic myelofibrosis in urgent surgery with impossible endoscopic hemostasis and to draw the attention of specialists in the field of surgery to the risk of bleeding in this group of patients.&#x0D; Materials and methods. The article describes a clinical case of vertical tubular resection of the stomach and splenectomy for bleeding from varicose veins of the stomach and splenomegaly on the background of idiopathic myelofibrosis in urgent surgery.&#x0D; Results. Vertical tubular resection of the stomach with splenectomy with impossible endoscopic hemostasis eliminates the risk of gastric bleeding in oncohematological patients and saves the patient's life.&#x0D; Summary. This clinical observation demonstrates the relevance of timely surgical treatment of patients with bleeding from varicose veins of the stomach. Vertical tubular resection of the stomach along with splenectomy allows to exclude the risk of bleeding in this group of patients in the future.

03:45 PM Abstract No. 78 Closure of transsplenic access tracts using microfibrillar collagen: success, clinical outcomes, and complications

To report clinical experience with transsplenic vascular access closure using microfibrillar collagen (Avitene, Bard; Murray Hills, NJ). 24 patients, mean age 52 years (range: 1.5-75), underwent 26 transsplenic vascular access procedures over 4 years in this retrospective study. Comorbidities, active hemorrhage, anticoagulation, hemoglobin, INR, platelets, prior TIPS, and variceal classification were recorded. Indications for transsplenic access, needle gauge, sheath size, variceal embolization method, tract embolization method, major/minor bleeding complications, and follow-up hemoglobins were recorded. Pre-procedure comorbidities included portal hypertension (n=19,79%), portal vein thrombosis (n=16,67%), hemorrhage (n=8,33%), splenic vein thrombosis (n=7,29%), anticoagulation (n=3,12.5%), and sinistral portal hypertension (n=2,8%). Mean baseline hemoglobin was 9.4 (range:6.3-13), INR 1.3 (range:1-1.9), and platelets 122 (range:18-492). 1 patient had prior TIPS (3.8%). Most common transsplenic access indications were gastric varices with non-patent portosystemic shunt (n=10,38%) and portal vein targeting for TIPS (n=8,30%). One transsplenic access was intentionally arterial. Most common access needle was 22-gauge (n=16,62%); and sheath size, 4-French (n=7,27%) and 6-French (n=7,27%). 13 procedures (50%) involved variceal embolization. Transsplenic tracts were embolized with microfibrillar collagen (n=8), coils and microfibrillar collagen (n=9), or other (n=9). Microfibrillar collagen tract embolizations included 1 major and 2 minor (18%) complications: one splenic artery pseudoaneurysm requiring embolization, and two self-limiting splenic bleeds requiring small-volume blood transfusion. 4 minor (44%) bleeds occurred in 9 tract embolizations without microfibrillar collagen. Transsplenic access tract embolization with microfibrillar collagen is an alternative method to achieve tract hemostasis. In a high-risk patient population, vigilance is necessary to treat potential complications.

Feasibility and Safety of Laparoscopic Partial Splenectomy: A Systematic Review.

Laparoscopic partial splenectomy (LPS) is a challenging procedure. The aim of this review was to evaluate its feasibility, safety, and potential benefits. We conducted a comprehensive review for the years 1995-2018 to retrieve all relevant articles. A total of 44 studies with 252 patients undergoing LPS were reviewed. Six studies described combined operations. Ranges of operative time and estimated blood loss were 50-225min and 0-1200ml, respectively. There are eight patients need blood transfusion in 231 patients with available data. The conversion rate was 3.6% (9/252). Overall, 27 patients (10.7%;27/252) developed postoperative or intraoperative complications. Overall mortality was 0% (0/252). The length of postoperative stay (POS) varied (1-11days). Among four comparative studies, one showed LPS could reduce POS than laparoscopic total splenectomy (LTS) (LTS 5.4 ± 1.8days, LPS 4.2 ± 0.8days, p = 0.027) and complications (pleural effusion (LTS 9/22, LPS 0/15, p = 0.005), splenic vein thrombosis (LTS 10/22, LPS 0/15, p = 0.002)). Another comparative study showed LPS may benefit emergency patients. However, one comparative study showed LPS was associated with more pain, longer time to oral intake, and longer POS in children with hereditary spherocytosis. The fourth comparative study showed robotic subtotal splenectomy was comparable to laparoscopy in terms of POS and complication. The main benefits were lower blood loss, vascular dissection time, and a better evaluation of splenic remnant volume. In early series of highly selected patients, LPS appears to be feasible and safe when performed by experienced laparoscopic surgeons.

Prevalence of splenic vein thrombosis and risk of gastrointestinal bleeding in chronic pancreatitis patients attending a tertiary hospital in western India.

Background:Splenic vein thrombosis (SVT) is most commonly caused by acute and chronic pancreatitis (CP). Variceal gastrointestinal (GI) bleeding is a potentially life-threatening event in such patients. The aim of this study was to determine the prevalence of SVT in CP patients and the risk of variceal GI bleeding.Materials and Methods:A total of 187 consecutive patients with a diagnosis of CP were assessed for the presence of SVT at the gastroenterology department of a tertiary care hospital. Thirty seven patients had evidence of SVT. Patients with portal vein thrombosis or cirrhosis were excluded. Potential factors associated with SVT were assessed.Results:Of the 187 CP patients assessed, 37 patients (19.8%) (male 33; female 4; mean age 41.9 years) had evidence of SVT. Among patients with SVT, most common etiology of CP was alcohol abuse (70.3%). Seven patients (18.9%) with SVT presented with clinically significant upper GI bleeding. The source of GI bleeding was gastric varices in three patients (8.1%) and non-variceal source in four patients (10.8%). All three patients with gastric varices were managed by splenectomy. There were no new variceal bleeding episodes in other 33 patients (89.2%) during mean follow-up of 16.4 months. On comparison of patients with and without SVT, the factors associated with significantly higher incidence of SVT were smoking (P = 0.019, odds ratio 3.021, 95% confidence interval 1.195–7.633) and presence of pseudocyst (P = 0.008, odds ratio 3.743, 95% confidence interval 1.403–9.983). Complete resolution of SVT was seen in three patients (8.1%) after resolution of underlying pseudocyst.Conclusion:SVT is a common complication of CP, particularly in patients with pseudocysts and history of smoking. Most patients remain asymptomatic and the risk of variceal bleeding is low. Splenectomy is the treatment of choice in patients with variceal bleeding. Conservative approach is preferred in other patients. Resolution of pseudocysts may lead to resolution of SVT in some patients.

Porto-mesenteric vein thrombosis following laparoscopic sleeve gastrectomy for morbid obesity: Case series and literature review

BackgroundPortal vein thrombosis is a rare and a potentially lethal complication of Laparoscopic sleeve gastrectomy. In this series, we describe the presentation, treatment, and outcome of 5 cases of PMVT post-laparoscopic sleeve gastrectomy (LSG) treated successfully at our hospital. Case reportFive patients presented to our emergency department with diffuse abdominal pain associated with anorexia, nausea and vomiting after laparoscopic sleeve gastrectomy (LSG). Computed tomography (CT) scan showed evidence of portal, mesenteric and splenic vein thrombosis and small bowel ischemia in three patients. Two patients were treated only with anticoagulant and the other three patients were treated with surgery in the form of diagnostic laparoscopy converted to laparotomy with Small bowel resection. ConclusionPortal and mesenteric venous thrombosis after laparoscopic sleeve gastrectomy is an unusual complication but it has life threatening consequences if it is not diagnosed early and treated adequately. The patients with porto-mesenteric venous thrombosis (PMVT) usually present themselves with vague abdominal symptoms. As so, the physicians should have high index of suspicion to recommend computed tomography (CT) abdomen to confirm diagnosis and start adequate treatment.