The significance of sinistral portal hypertension complicating chronic pancreatitis

BACKGROUND: Sinistral portal hypertension, a localized (left-sided) form of portal hypertension may complicate chronic pancreatitis as a result of splenic vein thrombosis/obstruction. AIM:To determine appropriate surgical strategy for patients with splenic vein thrombosis/obstruction secondary to chronic pancreatitis. METHODS: We reviewed our experience with operative management of 484 consecutive patients with histologically documented chronic pancreatitis treated between 1976 and 1997. The diagnosis of sinistral portal hypertension was based on clinical presentation, preoperative endoscopic and radiographic imaging, and operative findings. "Symptomatic," herein defined, denotes those patients with sinistral hypertension and either gastrointestinal bleeding or hypersplenism. "Asymptomatic" patients were those with sinistral hypertension alone. RESULTS: Sinistral portal hypertension was present in 34 of the 484 patients (7%). Gastric or gastroesophageal varices were confirmed in 12 patients (35%), of whom 6 had variceal bleeding and 4 had hypersplenism (25%). All symptomatic patients were treated by splenectomy alone or in conjunction with distal pancreatectomy. Splenectomy at the time of pancreatectomy for primary pancreatic symptoms was also performed in 15 patients with (asymptomatic) sinistral portal hypertension. None of the 23 patients who had splenectomy rebled in mean follow-up of 4.8 years. In contrast, 1 of the 11 patients with asymptomatic sinistral portal hypertension who underwent pancreatic surgery without splenectomy died of later variceal bleeding 3 years after lateral pancreatojejunostomy. CONCLUSIONS: Symptomatic sinistral portal hypertension is best treated by splenectomy. Concomitant splenectomy should be strongly considered in patients undergoing operative treatment of symptomatic chronic pancreatitis if sinistral portal hypertension and gastroesophageal varices are also present.     

Significance of splenic vein thrombosis in chronic pancreatitis

BACKGROUND: Splenic vein thrombosis leading to sinistral portal hypertension and variceal bleeding is a complication of chronic pancreatitis. The management of these patients without variceal bleeding remains controversial. METHODS: A total of 157 patients with chronic pancreatitis were managed consecutively in our center between January 1996 and December 2005. Thirty-four patients with chronic pancreatitis were diagnosed to have splenic vein thrombosis. RESULTS: The incidence of splenic vein thrombosis in patients with chronic pancreatitis was 22%. Fifteen percent of patients with chronic pancreatitis and splenic vein thrombosis presented with gastroesophageal variceal bleeding. Nine patients underwent splenectomy along with pancreatic procedures and 21 patients underwent pancreatic procedures only. Adding splenectomy to the pancreatic procedure did not lead to increased morbidity or mortality. CONCLUSION: Splenectomy should be added to the pancreatic procedure in patients who have evidence of portal hypertension on preoperative evaluation, especially if gastric varices are found.     

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??Individualized treatment of pancreatic portal hypertension LOU Wen-hui, LI Jian-ang. Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
Corresponding author ??LOU Wen-hui??E-mail??lou.wenhui@zs-hospital.sh.cn
Abstract Pancreatic portal hypertension is a clinical syndrome characterized by splenic vein obstruction caused by pancreatic disease. The main clinical manifestation are splenomegaly, gastric varices while no liver function abnormality. Splenic vein obstruction are usually caused by endothelium inflammation and external compression induced by chronic pancreatitis, pancreatic tumor and pseudocyst. The treatment principle should be focus on the primary disease while considering the severity of sinistral portal hypertension. For patients without bleeding, splenectomy is suggested after the surgical treatment of primary pancreatic disease; for bleeding patients, devascularization should be considered. Generally, splenic artery embolism and endoscopic treatment are only considered in the acute setting or the nonoperative candidate     

A rare case of serous cystadenoma of the pancreas presenting with left-sided portal hypertension

We herein report the case of a 63-year-old woman with a serous cystadenoma of the pancreas presenting with left-sided portal hypertension secondary to isolated splenic vein occlusion. She was admitted to our hospital for sudden hematemesis. Emergency upper gastrointestinal endoscopy revealed hemorrhagic erosive gastritis and isolated varices in the gastric fundus. An abdominal angiographic study disclosed a large hypervascular tumor of the pancreatic tail which caused isolated splenic vein occlusion by tumor compression and formed large hepatopetal collaterals via the gastric varices. The patient underwent tumor resection with splenectomy and, as a result, the gastric varices disappeared and the postoperative course was uneventful. Left-sided portal hypertension secondary to splenic vein occlusion is an uncommon complication mostly associated with pancreatitis and pancreatic carcinoma. Although benign pancreatic neoplasms only rarely cause such a condition, the possibility of gastrointestinal bleeding due to this condition should be carefully taken into consideration when treating pancreatic disease.     

慢性胰腺炎并发门静脉高压症的诊断与治疗

慢性胰腺炎并发门静脉高压症（PHT）的主要发病机制为脾静脉受压或血栓形成,造成脾静脉闭塞;通常同时表现慢性胰腺炎和PHT症状,慢性上腹痛及腰背部疼痛是慢性胰腺炎最常见症状,PHT的表现是不同程度的脾肿大和脾功能亢进,孤立的胃底静脉曲张、上消化道出血不多见。通过多普勒超声、CT、MRI以及血管成像多可得出明确诊断。治疗应既针对原发病又要针对门静脉高压症,强调个体化治疗。由慢性胰腺炎引起的PHT是可以治愈的。     

Sinistral (left-sided) portal hypertension

Between 1953 and 1988, 21 patients with splenic vein thrombosis (SVT), 12 of whom had sinistral portal hypertension (SPH) were treated at our institution. SVT was identified at autopsy in nine patients. Twelve additional patients presented with SPH: bleeding esophageal varices, SVT and normal hepatic function. SVT was caused by pancreatic neoplasm (5), chronic pancreatitis (5), and pancreatic pseudocyst (2). SVT was diagnosed by splanchnic angiography, splenoportography, computerized tomography, and ultrasonography. Gastric varices were diagnosed by endoscopy (10) and barium swallow (2). Splenectomy was performed as primary therapy in 10 patients. Three of these 10 had en block distal pancreatectomy. Two high-risk patients had splenic artery embolization, one as a prelude to splenectomy performed 48 hours later and the other as definitive therapy. One splenectomized patient continued to bleed. No further bleeding occurred in 10 splenectomized patients in follow-up from 1 week to 14 years. Sinistral portal hypertension is a clinical syndrome of splenic vein thrombosis caused by pancreatic pathology and manifests as bleeding gastric varices in patients with a patent portal vein and normal hepatic function. Splanchnic arteriography is necessary for accurate diagnosis. Splenectomy is the effective treatment of choice.     

直接门静脉造影在门静脉高压症治疗中的作用

目的 研究直接门静脉高压症治疗中的作用。方法 采用直接门静脉造影观察１８５例门静脉高压症患者例支血管和冠状静脉解剖,根据造影结果对３５例门静脉高压症患者行经腹联合门奇断流术。结果 门静脉高压症患者显示冠状静脉２２３支,其中单支７９．４６％,双支２０．５４％,冠状静脉开口于门静脉主干、脾静脉和门脾静脉交汇处分别为６２．３３％、２７．３５％和８．０７％,出血和断流术后现出知患者主要位于门静脉主干,顽固     

Isolated Gastric Varices Resulting from Iatrogenic Splenic Vein Occlusion: Report of a Case

Iatrogenic splenic vein occlusion is known to be a rare cause of left-sided portal hypertension. We herein describe the clinical course of a 43-year-old woman with isolated gastric varices, which proved to be attributable to a segmental splenic vein resection during an operation for a benign pancreatic tumor 11 years previously. Seven years after the initial operation, prominent gastric varices due to left-sided portal hypertension were first noted. During the follow-up period of 4 years, she had no episodes of gastrointestinal hemorrhaging. Although the size of the gastric varices did not change, she decided to have a splenectomy considering the potential risk of variceal hemorrhaging. It may be reasonable to perform a splenectomy concomitantly when the splenic vein is to be resected or ligated during pancreatic surgery to avoid the future development of left-sided portal hypertension. However, the role of prophylactic surgery in asymptomatic patients with iatrogenic splenic vein occlusion remains to be determined. Received: June 3, 2002 / Accepted: November 19, 2002 RID="*" ID="*" Reprint requests to: Y. Ku     

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??Diagnosis and treatment of chronic pancreatitis with portal hypertension WU Zhi-yong??CHEN Wei.Department of General Surgery,Renji Hospital,Shanghai Jiaotong University School of Medcine,Shanghai 200127,China
Corresponding author: WU Zhi-yong, E-mail: zhiyongwu@gmail.com
Abstract It is the major pathogenesis of chronic pancreatitis with portal hypertension (PHT) that the splenic vein compression or thrombosis, resulting in splenic vein occlusion. It usually shows symptoms of both chronic pancreatitis and PHT. The most common symptoms of chronic pancreatitis is that chronic upper abdominal and lumbar back pain. The performance of PHT is the different degrees of splenomegaly and hypersplenism, and isolated gastric varices, but the upper gastrointestinal bleeding is rare. It can be diagnosed by Doppler ultrasound, CT, MRI and angiography. Treatment should be aimed at both the primary disease and PHT. The individual treatment should be emphasized. The chronic pancreatitis with PHT can be cured with good prognosis.     

Segmental portal hypertension.

Isolated obstruction of the splenic vein leads to segmental portal hypertension, which is a rare form of extrahepatic portal hypertension, but it is important to diagnose, since it can be cured by splenectomy. In a review of the English literature, 209 patients with isolated splenic vein obstruction were found. Pancreatitis caused 65% of the cases and pancreatic neoplasms 18%, whereas the rest was caused by various other diseases. Seventy-two per cent of the patients bled from gastroesophageal varices, and most often the bleeding came from isolated gastric varices. The spleen was enlarged in 71% of the patients. A correct diagnosis in connection with the first episode of bleeding was made in only 49%; 22% were operated on because of gastrointestinal bleeding, but the cause of bleeding was not found. The diagnosis should be suspected in patients with gastroesophageal varices, but without signs of a liver disease, especially if isolated gastric varices are found. The diagnosis is confirmed by portography.     

The different manifestation and outcome between pancreatitis and pancreatic malignancy with left-sided portal hypertension.

Left-sided portal hypertension can be induced by isolated splenic venous obstruction due to various etiologies, such as chronic pancreatitis and pancreatic malignancy. The patients may present with bleeding isolated gastric varices and hypersplenism in addition to their pancreatic lesions. In the past 3 years, we have encountered 24 patients with left-sided portal hypertension. They were diagnosed with an abdominal echogram, CT or splenoportography. Twelve patients had histories of acute pancreatitis for a few months to years. Eleven of them were found to have isolated gastric varices. Six of them underwent operation due to hypersplenism or pseudocyst. The postoperative courses were smooth and the gastric varices subsided after splenectomy. The other 12 patients with left-sided portal hypertension were diagnosed as having pancreatic malignancy. Only two of them were found to have isolated gastric varices. Seven of them received operations and only two patients with their tumors located at the pancreatic body and tail could be resected. The other 5 patients were diagnosed with abdominal CT and high serum CA 19-9. We concluded that the patients with left-sided portal hypertension can be suspected by isolated gastric varices without liver cirrhosis. The diagnosis can be confirmed by abdominal CT or splenoportography. The incidence of isolated gastric varices are significantly lower in the patients with pancreatic malignancy than those with chronic pancreatitis. The gastric varices subsided after splenectomy. The prognosis of pancreatic malignancy is poor and most of them are inoperable.     

Nonfunctioning pancreatic endocrine tumor presenting with hemorrhage from isolated gastric varices

Hemorrhage from gastric varices due to left-sided portal hypertension is an unusual presentation for pancreatic endocrine tumor. A case of pancreatic endocrine tumor presenting with gastric variceal hemorrhage secondary to left-sided portal hypertension associated with splenic vein occlusion is presented. A 53-year-old man with hemorrhage from isolated gastric varices was referred to our hospital. Laboratory studies revealed normal liver function. Surveys to identify the cause of gastric varices by an abdominal CT, MRCP, and abdominal angiography revealed splenic vein occlusion secondarily attributed to the pancreatic tail tumor and splenomegaly. The pancreatic tumor was suspected to be a resectable endocrine tumor. A distal pancreatectomy, splenectomy, partial resection of the gastric fundus, and limited lymph node dissection were performed. By the histological examination, the diagnosis of nonfunctioning pancreatic endocrine tumor with malignant potential was determined. Three years after the surgery, the patient is doing well and reveals no sign of recurrence. In this case, the unusual presentation for pancreatic endocrine tumors such as a gastric variceal hemorrhage had an advantage that led to early presentation prior to the development of metastases with possible curative surgery.     

Bleeding esophageal varices and portal vein thrombosis after pancreatic mixed-cell autotransplantation

A patient with chronic pancreatitis caused by congenital pancreatic duct atresia underwent total pancreatectomy and mixed-cell pancreatic autotransplantation by portal vein embolization. Two years later she developed massive upper gastrointestinal bleeding from gastroesophageal varices and required a mesocaval H graft. The cause of the portal hypertension was portal vein thrombosis caused by portal vein infusion of pancreatic homogenate, and it represents a serious complication of the procedure. Although this is the second report of portal hypertension that required portasystemic shunting after islet cell autotransplantation, it is the first reported case of the development of bleeding esophageal varices caused by portal vein thrombosis after pancreatic islet cell transplantation.     

Gastric portal hypertension.

Extrahepatic portal hypertension may spontaneously decompress by routes which produce gastric or esophageal portal hypertension. A syndrome of gastric portal hypertension has been identified in five patients with extrahepatic portal obstruction and gastric variceal hemorrhage. Patients were nonalcoholic with good liver function who had tolerated previous bleeding episodes well. Endoscopy and upper gastrointestinal series were not helpful in diagnosing bleeding gastric varices. The definitive diagnostic test was venous phase mesenteric arteriography of the gas-distended stomach, with confirmation of the bleeding site by splenoportography. Portosystemic shunting in two patients and splenectomy in three patients failed to stop gastric variceal bleeding. Emergency total gastrectomy was required in two patients and suture ligation in a third to prevent exigent bleeding.Gastric portal hypertension should be suspected in patients with upper gastrointestinal bleeding and good liver function. Since there is no standard therapy, recurrent bleeding requiring multiple operations is common. Determination of both location of obstruction and route of decompression are prerequisites to choosing the correct operation. Portocaval shunts in two patients failed to provide effective decompression due to compartmentalization of the portal hypertension to the gastric venous bed. In patients with a patent splenic vein, a distal splenorenal shunt may be effective. However, with splenic vein occlusion splenectomy may be ineffective, and a direct approach such as total gastrectomy or variceal ligation may be necessary to prevent exsanguination.     

Splanchnic venous obstruction. A complication of chronic pancreatitis

A retrospective review of 20 adult patients with splanchnic venous obstruction secondary to chronic pancreatitis was performed to identify factors important in the preoperative diagnosis and operative management of this disorder. Fifteen patients with isolated splenic vein obstruction, four with portal occlusion and one with isolated inferior mesenteric vein occlusion were studied. Chronic alcoholism was the etiology of the pancreatitis in 18 patients; two patients had a Type IV hyperlipidemia. Four patients with massive hemorrhage from gastric varices were treated with splenectomy. Most patients presented with complaints of chronic pancreatitis, requiring pancreaticojejunostomy to treat the underlying pancreatic disorder. Splenic artery inflow control was obtained preoperatively in six patients and offers a technique that is beneficial in decreasing operative blood loss. The dynamic computerized tomography (CT) scan was a valuable diagnostic tool in identifying splanchnic venous obstruction although selective angiography is required for confirmation of the diagnosis.     

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??Diagnosis and management of gastrointestinal bleeding caused by pancreatic sinistral portal hypertension XIE Kun, XIE Xue-hai, YANG Yin-mo . Department of General Surgery, Peking University First Hospital, Beijing 100034, China
Corresponding author: YANG Yin-mo??E-mail??yangyinmo@263.net
Abstract Pancreatic sinistral portal hypertension is a rare syndrome presented with splenomegaly, gastric varices and gastrointestinal haemorrhage, which due to a primary pancreatic diseases such as chronic pancreatitis, pancreatic tumors. The pathology arises in the pancreas and results in compression of the splenic vein, while the splenic artery blood supply is normal, which consequently result in congestive enlargement of the spleen and back pressure changes in the left portal system. Pancreatic sinistral portal hypertension should be considered in the presence of gastrointestinal bleeding with normal liver function and unexplained splenomegaly. Splenectomy can effectively control the bleeding, however treatment of pancreatic primary disease should be involved. The overall prognosis for patients with sinistral portal hypertension is clearly dependant on the primary pathology.     

The natural history of pancreatitis-induced splenic vein thrombosis

OBJECTIVE: To determine the natural history of pancreatitis-induced splenic vein thrombosis with particular attention to the risk of gastric variceal hemorrhage. SUMMARY BACKGROUND DATA: Previous studies have suggested that splenic vein thrombosis results in a high likelihood of gastric variceal bleeding and that splenectomy should be performed to prevent hemorrhage. Recent improvements in cross-sectional imaging have led to the identification of splenic vein thrombosis in patients with minimal symptoms. Our clinical experience suggested that gastric variceal bleeding in these patients was uncommon. METHODS: A computerized index search from 1993 to 2002 for the medical records of patients with a diagnosis of pancreatitis was performed. Fifty-three patients with a diagnosis of pancreatitis and splenic vein thrombosis were identified. The medical records of these patients were reviewed, and follow-up was completed, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ). RESULTS: Gastrosplenic varices were identified in 41 patients (77%) with varices evident on computed tomography (CT) in 40 of 53 patients, on esophagogastroduodenoscopy (EGD) in 11 of 36 patients, and on both CT and EGD in 10 of 36 patients. This risk of variceal bleeding was 5% for patients with CT-identified varices and 18% for EGD-identified varices. Overall, only 2 patients (4%) had gastric variceal bleeding and required splenectomy. Functional quality of life was better than historical controls surgically treated for chronic pancreatitis. CONCLUSION: Gastric variceal bleeding from pancreatitis-induced splenic vein thrombosis occurs in only 4% of patients; therefore, routine splenectomy is not recommended.     

Gastrointestinal hemorrhage from left-sided portal hypertension: An unappreciated complication of pancreatitis

Eleven of 16 patients with splenic vein thrombosis subsequent to pancreatitis had variceal hemorrhage. Variceal development tends to occur in the stomach, although esophageal varices may also occur, and is a result of left-sided or segmental portal hypertension. The antecedent pancreatitis may be quite mild and produce minimal symptoms. Angiography is required to establish the diagnosis as endoscopic detection of gastric varices is difficult and unreliable. Splenectomy is the definitive treatment, although transgastric ligation of varices must be added if active bleeding is taking place.     

胰源性门静脉高压症的诊断及外科治疗

胰源性门静脉高压症是一种少见的门静脉高压症类型,脾静脉血栓形成或梗阻是其根本原因,其原发疾病包括胰腺炎症、肿瘤及其他胰腺疾病,可引起单纯门静脉脾胃区域的压力增高,临床上可根据病人临床表现、生化检查和影像学手段等进行综合诊断。外科治疗应采用个体化的治疗原则,胰腺原发疾病的治疗是基础及关键,对于胃肠道曲张静脉出血,脾切除术是有效的治疗手段,静脉曲张严重者可加做断流术,对于病变在胰体尾的胰源性门静脉高压,可在解除胰腺病变的同时切除脾脏,但不主张预防性脾切除术,无法耐受手术病人可考虑介入治疗。     

Esophagogastric variceal hemorrhage: its treatment by percutaneous transephatic coronary vein occlusion.

The angiographic technique percutaneous transhepatic coronary vein occlusion was used to treat esophagogastric variceal bleeding in 38 patients. There were two categories of patients: those actively bleeding who had not been controlled by continuous vasopressin infusion and/or Blakemore tube tamponade, and those with portal hypertension who were not actively bleeding at the time of transhepatic portal venography but who were at high risk for recurrent variceal hemorrhage. Coronary vein occlusion was achieved in 33 patients by (1) metal clip and cotton devices(one); (2) balloon catheter occlusion (two); (3) heat-treated autogenous clot and powdered absorbable gelatin sponge (Gelfoam) (13); and (4) Gelfoam strips soaked in sodium tetradecyl sulfate (17). Percutaneous coronary vein occlusion was effective in controlling 81% of the patients with actively bleeding varices. In patients who were not actively bleeding, percutaneous transhepatic coronary vein occlusion seemed to afford good protection for recurrent variceal hemorrhage.