Colonic Varices Research Articles

Laparoscopic sigmoid colectomy for transverse colonic varices due to an inferior mesenteric arteriovenous fistula

BackgroundColonic varices are a rare gastrointestinal anomaly often associated with portal hypertension. Arteriovenous fistula (AVF) in the inferior mesenteric artery (IMA) region is even rarer. Diagnosis and treatment of these entities present unique challenges, especially when the IMA is involved.Case presentationA 48-year-old man with a history of cholecystectomy presented with after a positive fecal occult blood test. Investigations revealed varices from the splenic flexure to the transverse colon and suspected AVF in the IMA region. Given the high risk and low efficacy of endoscopic and radiological interventions, laparoscopic sigmoidectomy was performed. This surgical approach successfully addressed both the AVF and the associated varices.ConclusionThis case underscores the importance of surgical intervention for AVF and colonic varices in the IMA region, particularly when other treatment options pose high risks and have limited efficacy. The favorable postoperative outcome in this case highlights the effectiveness of carefully chosen surgical methods when managing such complex and rare conditions.

S2579 Colonic Varices: What Are the Therapeutic Options?

Introduction: Colonic varices are a rare case of lower gastrointestinal bleeding (LGIB) with an incidence of 0.07%. The most common sites of colonic varices are the rectum and cecum. Colonic varices are diagnosed on colonoscopy, mesenteric angiography, or computed tomography (CT) scans. Currently, there are no standardized treatments for treatment of colonic varices due to the heterogeneity in localization and vascular anatomy. We present a case of LGIB due to an ascending colon varix. Case Description/Methods: A 38 year-old-man with a history of decompensated alcoholic cirrhosis complicated by esophageal and gastric variceal bleed requiring balloon-occluded retrograde transvenous obliteration one month ago was transferred from an outside hospital (OSH) for liver transplant evaluation and hematochezia. He underwent a colonoscopy at the OSH which showed an ascending colon varix with white nipple sign. His vital signs were normal. His physical exam was benign except for scleral icterus with spider angiomas on his chest. His labs were pertinent for a hemoglobin of 8.0, hematocrit 24, platelet 50,000, alanine aminotransferase 50, total bilirubin 3.0, and international normalized ratio 2.0. The patient was treated with octreotide infusion and antibiotics for spontaneous bacterial peritonitis prophylaxis. A CT three phase abdominal imaging was revealed significant perisplenic and ascending colon varices with smaller varices supplying the descending colon. The case was reviewed with interventional radiology and hepatology and the patient underwent transjugular intrahepatic portosystemic shunt (TIPS) placement with coil and plug embolization of the splenic varix and gonadal varix feeding into the ascending colon varix. The patient did not have any further episodes of hematochezia and his hemoglobin stabilized. A few days later, the patient underwent an orthotic liver transplant. His post-operative clinical course was uncomplicated. Discussion: This is a rare case of a colonic varix resulting in a clinically significant LGIB. There is no standardization of therapy for ectopic varices due to the heterogeneity in vascular anatomy. Therapeutic options include endoscopic variceal band ligation, cyanoacrylate injections, surgery, TIPS and coil embolization. This case highlights the importance of a multi-disciplinary approach with gastroenterologists, hepatologist, interventional radiologists, and surgeons for the treatment of colonic varices.

Idiopathic Colonic Varix: Presenting as Lower GI Bleeding in an Elderly Male

Abstract not available
 Bangladesh Crit Care J March 2021; 9(1): 62-64

Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report

BackgroundColonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported.Case presentationA 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up.ConclusionsCARTO-II can be one of the effective treatment techniques for ascending colonic varices.

The left splenorenal venous shunt decreases clinical signs of sinistral portal hypertension associated with splenic vein ligation during pancreaticoduodenectomy with venous resection

BackgroundThe ligation of the splenic vein during pancreaticoduodenectomy with synchronous resection of the spleno-mesenteric-portal venous confluence has been associated with the development of left portal hypertension despite preservation of the natural confluence with the inferior mesenteric vein. This study aimed to assess whether a left splenorenal venous shunt might mitigate clinical signs of left portal hypertension associated with splenic vein ligation. MethodsWe retrospectively evaluated the presence of left portal hypertension based on biologic and radiologic parameters in patients undergoing pancreaticoduodenectomy with synchronous resection of the spleno-mesentericoportal confluence between January 1, 2012, and December 31, 2018. We compared several parameters between patients undergoing splenic vein ligation with preservation of the inferior mesenteric vein confluence and a splenorenal venous shunt: the early and late spleen volumes and spleen volume ratios, an early and late platelet count, the presence of thrombocytopenia, the presence of varices, and digestive bleeding in the long-term. ResultsThere were 114 consecutive patients: 36 with splenic vein ligation and 78 with splenorenal venous shunt. All had a pancreaticogastrostomy. Patients with splenic vein ligation had a comparable baseline and early and late platelet counts. Although baseline splenic volumes were comparable between the 2 groups (242 ± 115 mL vs 261 ± 138 mL; P = .51), patients with splenic vein ligation showed a statistically significant greater splenic volume beyond the 6th postoperative months (334 ± 160 mL vs 241 ± 111 mL; P = .004), higher early and late spleen volume ratios (1.42 ± 0.67 vs 1.10 ± 0.3; P = .001 and 1.38 ± 0.38 vs 0.97 ± 0.4; P = .0001) than patients with splenorenal venous shunt. Splenic vein ligation was also associated with a higher rate of varices (81% vs 50%; P = .002) and more frequent varices with a caliber greater than 1 cm (57% vs 36%; P = .05) and more colonic varices (33% vs 12%; P = .01). Only 1 patient had long-term digestive bleeding (splenic vein ligation). ConclusionThe left splenorenal shunt decreases clinical signs of left portal hypertension associated with splenic vein ligation and inferior mesenteric vein confluence preservation.

Bleeding from gastrointestinal ectopic varices is not associated with haemorrhage from oesophageal or gastric varices.

IntroductionEctopic varices are those that appear in a different region of the gastroesophageal junction. Bleeding from ectopic varices is rare but is usually massive and deadly.AimTo identify the possible factors that cause bleeding from ectopic varices in patients with portal hypertension.Material and methodsA cross-sectional and retrospective study; the data were collected between January 2004 and June 2014. We included patients with portal hypertension and gastrointestinal ectopic varices diagnosed by endoscopy.ResultsWe found 31 patients with gastrointestinal ectopic varices. Of these, 25 had liver cirrhosis, and six showed non-cirrhotic portal hypertension. There were 16 men and 15 women in the study. The median age of the patients was 60 years (range minimum–maximum of 27 to 80 years). Nineteen (61%) patients had rectal varices, 10 (32%) had duodenal varices, 1 (3%) had ileal varices, and 1 (3%) had colonic varices. We found bleeding in 4 (13%) of the 31 patients with ectopic varices; two belonged to the cirrhosis group, and the other two were from the non-cirrhotic portal hypertension group. Three of the 4 patients with bleeding from gastrointestinal ectopic varices had exhibited haemorrhage from oesophageal varices (odds ratio = 4.09, 95% CI: 0.37–44.78, p = 0.249), but none of them showed bleeding from gastric varices.ConclusionsBleeding from gastrointestinal ectopic varices is not necessarily associated with bleeding from oesophageal or gastric varices.

Clinical characteristics and efficacy of endoscopic treatment of gastrointestinal ectopic varices: A single-center study.

Background:Ectopic varices (EcVs) may cause massive bleeding, which can be difficult to control, with a high rate of mortality. The purpose of this study was to analyze the clinical characteristics of EcVs and the efficacy of endoscopic treatment.Methods:From January 2008 to July 2017, the clinical data of 150 patients with EcVs in our center were retrospectively collected and analyzed.Results:One hundred and fifty patients with EcVs (male 74.7%), with a mean age of: 54.1 ± 14.6 years were included. The prevalence of EcVs was 0.92% in gastrointestinal varices. Cirrhosis was the most common cause of EcVs (67.0%). The rates of bleeding were 57.14%, 4.34%, 30.0%, 33.3%, and 100% in the duodenal varices rectal varices, colonic varices, anastomotic varices, and small bowel varices, respectively. An age under 55 years, varices in the duodenum, and erythema were considered risk factors for EcV bleeding. Endoscopic treatments were performed in 15 patients with EcV bleeding. The follow-up period of the patients who underwent endoscopic treatment ranged from 0.5 to 24 months. The overall rate of treatment success was 73.33% for endoscopic treatment of EcV bleeding. The overall rates of rebleeding and mortality during 2 years were as high as 53.3% and 26.7%, respectively.Conclusion:Age, erythema, and the location of EcVs are considered risk factors for EcV bleeding, and the rate of bleeding is higher in patients with duodenal varices than in those with other EcVs. Endoscopic treatment is safe, effective, and feasible for controlling EcV bleeding.

Prevalence, nature, and predictors of colonic changes in children with extrahepatic portal vein obstruction

The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied. Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed. Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P= .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P= .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P= .03), and large EVs less often (12.5% vs 43%; P= .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy. Most EHPVO children had colonic changes, and 16% had ileopathy. "Colitis-like" changes and left-side involvement were more common. Patients with PHG and eradicated EVs had a higher risk of PHC.

Colonic Varices: An Under-Recognized but Potentially Deadly Complication of Cirrhosis

While esophageal varices are well-established sequela of portal hypertension, colonic varices are rare, with less than 100 published cases. Due to the paucity of data, there are no established clinical guidelines for treatment. We report a case of colonic varices associated with liver cirrhosis in a gentleman presenting with hematochezia. A 48 year old male with alcoholic liver cirrhosis and esophageal varices presented with profuse rectal bleeding resulting in shock. He was intubated and started on vasopressors for hemodynamic instability. Hemoglobin was 6.4 g/dL. The massive transfusion protocol was initiated for intractable bleeding. Urgent upper endoscopy revealed no active source of bleeding. Interventional Radiology was consulted for emergent embolization however his mesenteric angiogram showed a nonbleeding right colonic varix. Surgical intervention was deferred due to hemodynamic instability. Due to ongoing bleeding after his mesenteric angiogram, he underwent a CT angiogram which revealed bleeding in the cecum from colonic varices. Transjugular intrahepatic portosystemic shunt (TIPS) was performed for portal decompression and the varices were embolized controlling the bleeding transiently. He developed disseminated intravascular coagulation 7 hours later leading to recurrence of bleeding. The course was further complicated by acute respiratory distress syndrome. He eventually expired from his complications. Colonic varices can present with a variety of manifestations from abdominal pain to catastrophic gastrointestinal bleeding, as in our patient. The most accurate diagnostic modality is CT or mesenteric angiography, with varices identified on the venous phase. Unfortunately, due to scarcity of cases, there are no treatment guidelines. In cases of portal hypertension and severe bleeding, therapy targeted towards portal decompression can be effective, as seen in esophageal varices. Although our patient eventually passed away from complications, TIPS proved to be an effective temporizing measure to manage hematochezia. In rare cases of massively bleeding colonic varices, prompt diagnosis and treatment aimed to reduce portal hypertension is imperative in decreasing mortality.2017_A Figure 1. Varices seen to the right colon/hepatic flexure.2017_B Figure 2. Enlarged venous collateral (colonic varices) originating from the distal portal vein.2017_C Figure 3. TIPS extending from the right portal vein into the right hepatic vein.

An Interesting Case of End-Stage Liver Disease and Colonic Varices

An Interesting Case of End-Stage Liver Disease and Colonic Varices

Right Sided Colonic Varices: 2 Cases and Review of the Literature

Background: Colonic varices (CV) are a rare cause of lower gastrointestinal bleeding. Although approximately 90 cases of CV have been reported, mainly in bleeding patients with portal hypertension, the prevalence of (asymptomatic) CV is likely to be underestimated. Study/Results: We report two cases of portal hypertension related colonic varices and a literature review of colonic varices. These cases demonstrate the two clinical extremities: hardly any complaints versus medically refractory rectal blood loss and anemia, which ultimately needed surgical intervention. Conclusion: Colonic varices are rare and more prevalent in patients with liver cirrhosis. Especially in this group, rectal bleeding and anemia with normal upper GI investigations, should be investigated with a colonoscopy. Treatment of CV is not well established and depends on the etiology and severity of clinical presentation.

A case of ascending colon variceal bleeding treated with venous coil embolization

A 38-year-old female with a history of alcoholic liver cirrhosis visited our hospital with a massive hematochezia. An esophagogastroduodenoscopy did not demonstrate any bleeding source, and a colonoscopy showed a massive hemorrhage in the ascending colon but without an obvious focus. The source of the bleeding could not be found with a mesenteric artery angiography. We performed an enhanced abdominal computed tomography, which revealed a distal ascending colonic varix, and assumed that the varix was the source of the bleeding. We performed a venous coil embolization and histoacryl injection to obliterate the colon varix. The intervention appeared to be successful because the vital signs and hemoglobin laboratory data remained stable and because the hematochezia was no longer observed. We report here on a rare case of colonic variceal bleeding that was treated with venous coil embolization.

Isolated inferior mesenteric portal hypertension with giant inferior mesenteric vein and anomalous inferior mesenteric vein insertion

Extrahepatic portal hypertension is not an uncommon disease in childhood, but isolated inferior mesenteric portal varices and lower gastrointestinal (GI) bleed have not been reported till date. A 4-year-old girl presented with lower GI bleed. Surgical exploration revealed extrahepatic portal vein obstruction with giant inferior mesenteric vein and colonic varices. Inferior mesenteric vein was joining the superior mesenteric vein. The child was treated successfully with inferior mesenteric – inferior vena caval anastomosis. The child was relieved of GI bleed during the follow-up.

Ectopic varices.

Ectopic varices.

Colonic varices as a result of persistent mesocolon of the ascending and descending colon

Colonic varices as a result of persistent mesocolon of the ascending and descending colon

Transjugular intrahepatic portosystemic shunt in liver transplant recipients

To evaluate the efficacy of transjugular intrahepatic portosystemic shunts (TIPSs) after liver transplantation (LT). Between November 1996 and December 2005, 10 patients with severe recurrent hepatitis C virus infection (n = 4), ductopenic rejection (n = 5) or portal vein thrombosis (n = 1) were included in this analysis. Eleven TIPSs (one patient underwent two TIPS procedures) were placed for management of therapy-refractory ascites (n = 7), hydrothorax (n = 2) or bleeding from colonic varices (n = 1). The median time interval between LT and TIPS placement was 15 (4-158) mo. TIPS placement was successful in all patients. The mean portosystemic pressure gradient was reduced from 12.5 to 8.7 mmHg. Complete and partial remission could be achieved in 43% and 29% of patients with ascites. Both patients with hydrothorax did not respond to TIPS. No recurrent bleeding was seen in the patient with colonic varices. Nine of 10 patients died during the study period. Only one of two patients, who underwent retransplantation after the TIPS procedure, survived. The median survival period after TIPS placement was 3.3 (range 0.4-20) mo. The majority of patients died from sepsis with multiorgan failure. Indications for TIPS and technical performance in LT patients correspond to those in non-transplanted patients. At least partial control of therapy-refractory ascites and variceal bleeding could be achieved in most patients. Nevertheless, survival rates were disappointing, most probably because of the advanced stages of liver disease at the time of TIPS placement and the high risk of sepsis as a consequence of immunosuppression.

Portal hypertensive colopathy is associated with portal hypertension severity in cirrhotic patients

To assess the prevalence of portal hypertension (PH) related colorectal lesions in liver transplant candidates, and to evaluate its association with the severity of PH. Between October 2004 and December 2005, colonoscopy was performed in 92 cirrhotic liver transplant candidates. We described the lesions resulting from colorectal PH and their association with the grade of PH in 77 patients who underwent measurement of hepatic venous pressure gradient (HVPG). Mean age was 55 years and 80.7% of patients were men. The main etiology of cirrhosis was alcoholism (45.5%). Portal hypertensive colopathy (PHC) was found in 23.9%, colonic varices in 7.6% and polyps in 38% of patients (adenomatous type 65.2%). One asymptomatic patient had a well-differentiated adenocarcinoma. The manifestations of colorectal PH were not associated with the etiology of liver disease or with the Child-Pugh grade. Ninety percent of patients with colopathy presented with gastroesophageal varices (GEV), and 27.5% of patients with GEV presented with colopathy (P = 0.12). A relationship between higher values of HVPG and presence of colopathy was observed (19.9 +/- 6.2 mmHg vs 16.8 +/- 5.4 mmHg, P = 0.045), but not with the grade of colopathy (P = 0.13). Preneoplastic polyps and neoplasm (P = 0.02) and spontaneous bacterial peritonitis (P = 0.006) were more prevalent in patients with colopathy. We did not observe any association between previous beta-blocker therapy and the presence of colorectal portal hypertensive vasculopathy. PHC is common in cirrhotic liver transplant candidates and is associated with higher portal pressure.

Colonic Varices Secondary to Superior Mesenteric Vein Stenosis in a Patient with Crohnʼs Disease

Albeit rare, colonic varices are usually seen in the anorectum in the setting of portal hypertension, although idiopathic and familial cases of colonic varices have also been described. Cases have also been reported resulting from mesenteric hypertension secondary to portal or mesenteric vein (MV) thrombosis. The association of inflammatory bowel disease and MV thrombosis is well recognized. We are aware of only one case series describing Crohn's disease resulting in MV stenosis and subsequent portal hypertensive lower gastrointestinal varices. The series described 3 patients with small bowel (SB) varices. We report a case of superior MV stenosis resulting in colonic varices in a patient with Crohn's disease. The patient is a 43 year old male with Crohn's ileitis and proctitis, who had been in remission on oral mesalamine since the diagnosis 2 years prior. The patient presented with several weeks of intractable nausea and vomiting, intermittent melenic stools, and a reported 25 pound weight loss over 2 months. Physical examination was unrevealing and bloodwork was only remarkable for mild anemia. A CT-scan showed thickened distal SB, with possible narrowing of the superior MV with colonic collaterals. A SB follow-through was normal. The patient was started on antibiotics and immunosuppressive medications, with mild improvement. Upper endoscopy was unremarkable. Colonoscopy revealed erythematous mucosa and pseudopolyps in the distal ileum with an intrinsic stricture. Varices were seen in the ascending and transverse colon. An opening was seen at the rectosigmoid junction with passage of air and stool, which was consistent with an entero-colonic fistula when injected with contrast dye. The patient underwent angiogram with balloon angioplasty of the stenosed superior MV and ileocolic veins, which resulted in decomperssion of the varices. Surgical resection of the ileo-sigmoid fistula and multiple SB strictures was then performed. Pathology review revealed SB adenocarcinoma arising from the ileal aspect of the fistula, with positive lymph nodes. Severe intestinal inflammation from Crohn's Disease can result in stenosis in the adjacent vasculature. This is the first reported case of a patient with Crohn's disease and superior MV stenosis resulting in colonic varices.

Clinical relevance of colonic lesions in cirrhotic patients with portal hypertension

This prospective study was conducted in order to evaluate whether the colonic lesions previously described in cirrhotic patients may be of clinical relevance. Eighty-five patients with cirrhosis of the liver, but without colonic or systemic diseases unrelated to the liver disease, underwent colonoscopy and were followed up for at least 2 years. Colonic varices were observed in 31 % of the patients, portal hypertensive colopathy (PHC; defined as diffuse hyperemia, edema, spider angiomas, and spontaneous bleeding of the colonic mucosa) in 54 %, and normal colonic findings in 18 %. Colonic varices and PHC were present simultaneously in 27 % of the patients. Previous sclerotherapy or band ligation treatment for esophageal varices had been carried out in 27 % and 23 % of the patients, respectively. Portal hypertensive gastropathy was observed in 42 % of the patients. Polyps were found in 12 % of the cirrhotic patients and cancer in 3 %. All of the patients were followed up for at least 2 years; 34 % of them developed upper gastrointestinal hemorrhage (81 % from esophageal varices, 19 % from the stomach), while only 6 % developed lower gastrointestinal bleeding. Colonic lesions are frequent in cirrhotic patients, but statistical analysis showed that these lesions are not specific for the disease and do not correlate with the etiology and degree of cirrhosis, with the endoscopic treatment of esophageal varices, or with the risk of bleeding from the lower gastrointestinal tract.

Isolated, Idiopathic Splenic Vein Thrombosis, Presenting with Massive Lower GI Bleeding.

Isolated, also called idiopathic, splenic vein thrombosis (SVT) is a very rare clinical condition, which usually results in left-sided portal hypertension and isolated fundal varices. This syndrome is a rare cause of mostly upper, gastrointestinal bleeding. There are only a few hundreds of cases reported in the literature. Colonic varices are even much rarer, 0.07% post mortem autopsies, and 0.2% in a prospective large endoscopic trials. Pancreatic disorders, including malignancies are the most common underlying causes for SVT. Congenital aneurysm of the splenic vein is one of the theoretical explanations of the Isolated, Idiopathic SVT.Case report: A 53 year old Caucasian female with history of hypertension, and no history of smoking or alcohol abuse, presented with chronic lower gastrointestinal bleeding. Upper endoscopy and flexible colonoscopy revealed perigastric varices without any source of acute bleeding. A bleeding scan demonstrated marked splenomegaly and source of bleeding from left colon. Mesenteric angiogram during venous phase showed splenic vein thrombosis and extensive perigastric varices. In addition, a single large left colonic varix from the lower pole of the spleen was identified as the source of bleeding. The patient was treated with splenic artery embolization with coils, followed by splenectomy, without any major complication. Coagulation studies 8 weeks after the procedure did not show any hypercoagulable state.Conclusion: The Isolated, Idiopathic SVT, itself is a very rare syndrome. Our center has reported four cases of SVT, secondary to medical conditions, such as; pancreatic malignancy, MRSA sepsis, and multi-organ failure. Upper gastrointestinal bleeding has been more frequently reported than lower bleeding. Interestingly, in our case report, a single colonic varix secondary to SVT was proved to be the cause of chronic lower gastrointestinal bleeding. SVT should be suspected in any patient with a triad of gastric varices, splenomegaly, and normal liver function tests, who presents with gastrointestinal bleeding secondary to left sided or so called “sinistral” portal hypertension. Mesenteric angiography with venous phase is the gold standard for the diagnosis of SVT, as endoscopic studies may not be diagnostic of this syndrome. Splenectomy is the only and definitive procedure of choice in the patients with isolated SVT, followed by post splenectomy vaccination.