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Splenic Vein Thrombosis

Thrombosis of Splenic Vein

Splenic vein thrombosis (SVT) is thrombotic occlusion of the splenic vein. This is usually secondary to pancreatitis, which induces endothelial damage in the splenic vein, eventually leading to thrombosis. Although pancreatitis precedes most cases of SVT, other gastrointestinal pathologies are contributory.


Presentation

Splenic vein thrombosis (SVT) is a condition that is largely precipitated by both the acute and chronic forms of pancreatitis [1] [2]. Pancreatitis is responsible for about 60% of cases of SVT, although the latter does not usually transpire during an acute attack, but rather after repeated insult. Patients with a history of pancreatitis have up to a 20% risk of developing SVT [3]. There are other conditions that contribute to the development of SVT to a lesser extent, and these include pancreatic pseudocysts, malignancies, peptic ulcer disease, liver cirrhosis, Mallory-Weiss tears and pancreatic surgery [4] [5]. Pancreatitis can precipitate SVT because of the close association of the tail of the pancreas with the splenic vein. Any inflammation that occurs in the pancreas inflicts damage on the splenic vein wall, leaving it susceptible to thrombus formation [1]. The splenic wall may also be compressed and thus partially occluded by adjacent enlarged lymph nodes.

SVT leads to sinistral portal hypertension, which in turn leads to gastric and esophageal varices. Many individuals with SVT present with gastrointestinal bleeding from varices, which can be life threatening. Nevertheless, most patients with SVT are asymptomatic. SVT should be considered in patients who present with splenomegaly, but no signs of hepatic, hematologic or portal pathology.

The pathophysiology of SVT, sometimes referred to as pancreatitis-induced SVT when it is secondary to pancreatitis, as well as subsequent GI bleeding, is not understood clearly.

Pseudotumor
  • .: Left-sided portal hypertension from pancreatic pseudotumor. Am. J. Gastroenterol. 77 :639, 1982 Google Scholar 13.[link.springer.com]
Disability
  • Likewise, symptom scale scores suggest that pancreatitis complicated by splenic vein thrombosis does not result in disabling symptoms; in fact, most patients have few symptoms and function better than historical controls who had surgical treatment of[ncbi.nlm.nih.gov]
Splenomegaly
  • Seven of 9 patients (78 %) with massive splenomegaly ( 20 cm) developed PSVT compared with 4 of 13 patients (31 %) with moderate splenomegaly (15-20 cm) and 6 of 45 patients (13 %) without (p CONCLUSION: In patients scheduled for LS, screening for prothrombotic[ncbi.nlm.nih.gov]
  • SVT should be considered in patients who present with splenomegaly, but no signs of hepatic, hematologic or portal pathology.[symptoma.com]
Massive Splenomegaly
  • Routine ultrasound examination in the fourth month of the pregnancy revealed massive splenomegaly of unknown origin. Doppler ultrasonography subsequently revealed splenic venous thrombosis with absence of blood flow.[ncbi.nlm.nih.gov]
  • Other causes Increased hepatic blood flow: Increased splenic blood flow - eg, massive splenomegaly. Hepatoportal arteriovenous fistula. Idiopathic (a diagnosis of exclusion). Left-sided (sinistral) portal hypertension Rare.[patient.info]
Abdominal Pain
  • Splenic vein thrombosis is an uncommon cause of abdominal pain, but one that should be included in the treating physician's differential diagnoses when abdominal pain is ongoing despite medical therapy.[ncbi.nlm.nih.gov]
  • Abstract Abstract 4775 Abdominal pain is a common complaint among all ages of patients.[bloodjournal.org]
Epigastric Pain
  • We report a case of suspected gastrointestinal bleeding in a patient with a childhood history of pancreatitis, who also experienced severe epigastric pain while in hospital.[ncbi.nlm.nih.gov]
  • Case 4, a 45-year-old male with acute pancreatitis, presented with epigastric pain. CT showed splenic vein thrombosis, and the patient was treated with Coumadin.[bloodjournal.org]
  • He was presented to the hospital due to his upper respiratory symptoms complaints and noted mild-to-moderate epigastric pain. Results of chest radiography and electrocardiography showed...[connection.ebscohost.com]
Epigastric Pain
  • We report a case of suspected gastrointestinal bleeding in a patient with a childhood history of pancreatitis, who also experienced severe epigastric pain while in hospital.[ncbi.nlm.nih.gov]
  • Case 4, a 45-year-old male with acute pancreatitis, presented with epigastric pain. CT showed splenic vein thrombosis, and the patient was treated with Coumadin.[bloodjournal.org]
  • He was presented to the hospital due to his upper respiratory symptoms complaints and noted mild-to-moderate epigastric pain. Results of chest radiography and electrocardiography showed...[connection.ebscohost.com]
Left Upper Quadrant Pain
  • Case 1, a 45-year-old male with sickle cell trait (HbS of 38.7%), presented with left upper quadrant pain after 5-hour flight and alcohol binge prior to flight. CT showed splenic infarct and splenic vein thrombosis.[bloodjournal.org]
Abdominal Mass
  • CASE REPORT FB, a 10-year-old Caucasian girl who was in her usual state of good health, presented in August 2000 with a distended abdomen and palpable abdominal mass that was found to be a markedly enlarged spleen.[scielo.br]
Pancreatic Pain
  • Surgical candidates are those who present with Symptomatic SVO and those with severe pancreatic pain who needs surgery for pancreatic procedures.[pancreas.imedpub.com]
Purpura
  • The indications for LS were benign disease in 31 [19 had immune thrombocytopenia purpura (ITP)] and malignant disease in 9. A hand-assisted technique was used in 12 cases. PSVT was diagnosed in 9/40 patients (22.5%).[ncbi.nlm.nih.gov]
  • Three patients presented with abdominal pain and nausea, with or without fever, four, eleven and thirteen days after splenectomy due to hereditary elliptocytosis, thalassemia intermedia and idiopathic thrombocytopenic purpura, respectively.[scielo.br]
Sleep Disturbance
  • Symptom evaluation includes fatigue, nausea and vomiting, pain, loss of appetite, dyspnea, sleep disturbance, constipation, diarrhea, and financial strain.[ncbi.nlm.nih.gov]
Oliguria
  • The authors present the case of a 17 year old girl admitted to hospital for poor general state, mild scleral jaundice, deficient nutritional state, oliguria and massive ascites.[ncbi.nlm.nih.gov]

Workup

There are several diagnostic modalities for splenic vein thrombosis available to clinicians. These include:

Invasive techniques

  • Celiac angiography (late-phase): This is the preferred technique for detecting SVT, especially in the presence of GI bleeding.
  • Splenoportography.
  • Esophagogastroduodenoscopy (EGD): An endoscopic technique to diagnose varices. Its sensitivity varies because it is user dependent [6] [7].

Non-invasive techniques: These are increasingly instrumental in the diagnosis of SVT and pancreatitis, as their efficacy has improved.

  • Ultrasound
  • Computerized tomography: This is routinely carried out with contrast. It can also be useful as a screening tool [6] [8].
  • Magnetic resonance imaging (MRI)

A dated diagnostic technique was post mortem analysis.

Patients should be evaluated for GI bleeding, specifically esophageal and gastric varices. The isolated presence of gastric varices, in the absence of esophageal counterparts, is highly suggestive of SVT. About half of individuals with splenic vein thrombosis present with splenomegaly. This is helpful in diagnosis, but its absence does not rule out the possibility of SVT [2]. Given the ambivalence of signs and symptoms in SVT, its diagnosis relies heavily on medical imaging.

Gastric Varices
  • OBJECTIVE: To determine the natural history of pancreatitis-induced splenic vein thrombosis with particular attention to the risk of gastric variceal hemorrhage.[ncbi.nlm.nih.gov]
Left Pleural Effusion
  • A chest radiograph revealed left pleural effusion and computed tomography scan for ruling out subsplenic abscess was negative. On the seventh postoperative day, her platelet count rose to 9,900,000, and aspirin (80 mg, four times a day) was added.[scielo.br]
Gastric Lesion
  • We report a case of chronic anemia due to portal hypertensive gastropathy in a patient with splenic vein thrombosis, and suggest that the cure of gastric lesions in this condition may be obtained by splenectomy.[ncbi.nlm.nih.gov]

Treatment

  • BACKGROUND: Optimal modalities for diagnosis, treatment, and surveillance of portal or splenic vein thrombosis have not yet been defined.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis The overall prognosis is good, with 75% of patients alive after 10 years and an overall mortality rate of less than 10%.[emedicine.medscape.com]
  • […] paraoesophageal collaterals omental collaterals retroperitoneal collaterals mesenteric collaterals splenorenal collaterals gastrorenal collaterals splenomegaly ascites cause of portal hypertension often identified, most commonly liver cirrhosis Treatment and prognosis[radiopaedia.org]
  • Prognosis This depends on the prognosis of the underlying disease, and on the outcome of any complications such as variceal bleeding.[patient.info]

Etiology

  • The respective etiologies were pancreatic pseudocyst and previous gastric surgery. The diagnosis was confirmed prior to splenectomy by splenoportography. There was no recurrence of bleeding during 2 and 5 years of observation.[ncbi.nlm.nih.gov]
  • Nevertheless in about 1:4 cases the etiology remains unknown despite extensive evaluation. Before deciding about the treatment of portal vein thrombosis, one has to understand the timing of the finding.[angiologist.com]
  • The pathogenesis varies with the etiology.[pancreas.imedpub.com]

Epidemiology

  • The epidemiology and pathogenesis of PVT, as well as the approach to patients with chronic PVT are discussed elsewhere.[uptodate.com]
  • There are multiple other terms used globally, and although there are reported differences in etiology, epidemiology, and hepatic pressures, these various presentations likely reflect the vast spectrum of the condition itself and not the distinct diseases[cureus.com]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology United States statistics Portal vein obstruction is a relatively rare condition with an overall incidence of 0.05-0.5% in autopsy studies.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • We propose possible pathophysiologic mechanisms and recommend that splenic vein thrombosis be considered in the differential diagnosis of unexplained left-sided pleural effusions.[ncbi.nlm.nih.gov]
  • The pathophysiology of SVT, sometimes referred to as pancreatitis-induced SVT when it is secondary to pancreatitis, as well as subsequent GI bleeding, is not understood clearly.[symptoma.com]
  • García-Pagán JC, Gracia-Sancho J, Bosch J: Functional aspects on the pathophysiology of portal hypertension in cirrhosis .[cureus.com]
  • Home CCC Portal vein thrombosis by, last update April 25, 2019 OVERVIEW thrombus formation in the portal vein /- tributaries (SMV, IMV and splenic vein) PATHOPHYSIOLOGY can be acute or chronic clot can be within liver or external clot can be occluding[lifeinthefastlane.com]

Prevention

  • The three effusions due to splenic hematomas reported previously cleared only after splenectomy, suggesting splenectomy may be necessary to prevent reaccumulation.[ncbi.nlm.nih.gov]
  • The results suggest that early surgical intervention is beneficial in preventing progression of SVT to the portomesenteric vein.[unboundmedicine.com]
  • Repermeation prevents ischemic intestinal injury and extrahepatic portal hypertension. However, the standard protocol for anticoagulation in portal vein thrombosis has not yet been determined.[ekjm.org]

References

Article

  1. Bernades P, Baetz A, Lévy P, Belghiti J, Menu Y, Fékété F. Splenic portal venous obstruction in chronic pancreatitis. Dig Dis Sci.1992;37(3):340-346.
  2. Koklu SE, Yuksel OS, Arhan ME, et al. Report of 24 left-sided portal hypertension cases: a single-centre prospective study. Dig Dis Sci. 2005;50(5):976–982.
  3. Heider TR, Azeem S, Galanko JA, Behrns KE. The natural history of pancreatitis-induced splenic vein thrombosis. Ann Surg. 2004;239(6):876–880; discussion 880-882.
  4. Gianotti R, Charles H, Hymes K, Chandarana H, Sigal S. Treatment of gastric varices with partial splenic embolization in a patient with portal vein thrombosis and a myeloproliferative disorder. World J Gastroenterol. 2014;20(39):14495–14499.
  5. Thatipelli MR, McBane RD, Hodge DO, Wysokinski WE. Survival and recurrence in patients with splanchnic vein thromboses. Clin Gastroenterol Hepatol. 2010;8(2):200–205.
  6. Mortelé KJ, Mergo PJ, Taylor HM, Ernst MD, Ros PR. Splenic and perisplenic involvement in acute pancreatitis: determination of prevalence and morphologic helical CT features. J Comput Assist Tomogr. 2001;25(1):50–54.
  7. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastro-oesophageal varices and variceal haemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.
  8. Perri RE, Chiorean MV, Fidler JL, et al. A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for oesophageal varices. Hepatology. 2008;47(5):1587-1594.

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Last updated: 2019-06-28 10:27