Splenic artery embolization for the treatment of pancreatic portal hypertension complicated by gastric variceal haemorrhage

Pancreatic sinistral portal hypertension (PSPH) is caused by splenic venous outflow tract obstruction, and it accounts for 5% of all cases of portal hypertension [1–3]. When the splenic vein is blocked, the splenic collateral circulation opens, including the short gastric veins (SGVs) and left gastroepiploic vein (LGEV) as the 2 main pathways. The SGVs return to the portal vein through the gastric coronary vein and the LGEV flows through the right gastroepiploic vein to the superior mesenteric vein. Continuous high pressure in the SGVs increases pressure in the gastric mucosal veins, which changes venous structure and results in mucosal varices in the gastric fundus [4, 5]. Gastric variceal bleeding (GVB) is a life-threatening complication of PSPH that requires rapid intervention [6]. Traditional splenectomy is considered the preferred treatment for this condition; however, severe inflammation, adhesions, and bleeding tendency resulting from pancreatitis make the operation difficult and risky. In addition, sepsis and uncontrolled increase in platelet count may occur after the operation [7, 8]. We report herein the success of partial splenic artery embolization (PSAE) in treating a patient with PSPH and associated GVB.
A 50-year-old woman with previous history of chronic pancreatitis presented on 16 July 2012 with persistent upper abdominal distension, nausea, vomiting of gastric contents, and pain of unknown cause. She was diagnosed with acute phase chronic pancreatitis at a local hospital. On 17 August the patient re-presented with melena and haematemesis; gastroscopy revealed ruptured gastric varices with haemorrhage. On 22 August 2012 the patient’s condition deteriorated, and she was transferred to our hospital for treatment. On 23 August the patient underwent abdominal computed tomography (CT; enhancement) and abdominal CT angiography (CTA). This imaging revealed severe acute pancreatitis, a large volume of effusion around the pancreas, local encapsulation, portal vein thrombosis, proximal superior mesenteric vein occlusion, and splenic vein occlusion; pancreatic portal vein hypertension was suspected (Figure 1). During hospitalization, the patient received mechanical ventilation, enteral nutrition, abdominal puncture catheter drainage, and other comprehensive treatments. Her condition gradually improved, and she was transferred to a rehabilitation hospital for further recuperation on 2 November.
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