A 57‐year‐old woman with hepatitis C presented with sudden‐onset, large‐volume hematemesis. After initial resuscitation, an urgent upper endoscopy was performed. This revealed isolated gastric varices with evidence of a recent bleed. Despite no prior complications from hepatitis C, the varices were attributed to cirrhosis. She was then transferred to our institution for transjugular intrahepatic portosystemic shunt (TIPS) placement. The patient had been diagnosed with hepatitis C 9 year earlier and had declined treatment. She denied any other medical or surgical history. She had no splenomegaly, ascites, or other signs of cirrhosis on exam. Liver function tests including AST, ALT, and INR were normal. An abdominal MRI did indicated mild cirrhosis and portal hypertension. Based on this, TIPS was ordered. The portal‐systemic gradient was found to be normal, indicating unobstructed hepatic blood flow. Shunt was therefore not placed. When the left portal system was evaluated, the splenic vein was found to be severely stenosed. This had forced multiple collaterals to form, which fed a large gastric varix. Thrombus was not seen. A stent was successfully deployed in the splenic vein, and the gastric varix was coilembolized. Endoscopic ultrasound was performed in an attempt to find an extrinsic source of splenic vein compression. The pancreas appeared normal, and no other cause was identified. She was concluded to have an idiopathic splenic vein stenosis. This had led to the formation of gastric varices and an eventual bleed. The patient improved without recurrence and was discharged home.
Sinistral, or left‐sided, portal hypertension is an uncommon cause of gastrointestinal bleed that may account for less than 5% of all portal hypertension. It is often asymptomatic and found incidentally. Physical changes to the local anatomy and vasculature account for its presentation. Gastric varices and splenomegaly commonly develop because of collateralization from obstructed splenic venous flow. The right portal system is preserved, and liver function remains unaffected. Splenic vein thrombosis is the most common cause. Stenosis typically occurs from compression of the vein by an external source. The pancreas is often the cause because of its proximity to the splenic vein. Treatment of variceal bleeds has typically been surgical, requiring splenectomy. Our patient did well with less invasive stenting and embolization that successfully returned her portal blood flow to normal. Although her history heavily focused the initial workup on the liver and right portal system, the physical evidence pointed the problem to the opposite side.
Upper gastrointestinal bleeds from isolated gastric varices should suggest left‐sided, or sinistral, portal hypertension. Splenomegaly can also be seen. Because hospitalists are commonly involved with the treatment of acute gastrointestinal bleeds, we should be aware of this pattern to focus us to the left.
D. Cho ‐ none
To cite this abstract:Cho D. The Portal Systems Sinister Side. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 251. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/the-portal-systems-sinister-side/. Accessed November 19, 2019.