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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.

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 0.001).[ncbi.nlm.nih.gov]
  • Splenomegaly is an unreliable sign of PISVT. Although the true natural history of PISVT remains unknown, the collective reported rate of associated GI bleeding is 12.3%.[ncbi.nlm.nih.gov]
  • We conclude that clinicians should consider that PSVT might occur after splenectomy for a huge splenomegaly or after a total colectomy for ulcerative colitis.[ncbi.nlm.nih.gov]
  • The diagnosis of spontaneous splenic vein thrombosis should be considered in the presence of gastrointestinal bleeding with unexplained splenomegaly.[ncbi.nlm.nih.gov]
  • Isolated splenic vein thrombosis may lead to a specific clinical presentation, namely, bleeding from isolated gastric varices (which are difficult to diagnose), splenomegaly, and normal liver function. The most common cause is pancreatic disease.[ncbi.nlm.nih.gov]
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]
  • 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 0.001).[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]
  • A 23-year-old female patient was referred with a complaint of abdominal pain. Preoperative imaging revealed an undefined cyst in the tail of pancreas.[ncbi.nlm.nih.gov]
  • Abstract Abstract 4775 Abdominal pain is a common complaint among all ages of patients.[bloodjournal.org]
  • A 49-year-old, previously healthy woman sought treatment for abdominal pain. Colonoscopy revealed ascending colon cancer.[ncbi.nlm.nih.gov]
  • The patients had either upper gastrointestinal bleeding from gastroesophageal varices or abdominal pain.[ncbi.nlm.nih.gov]
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]
  • This report details a 58-year-old gentleman who presented to his outpatient primary care physician's clinic several times over four weeks for ongoing epigastric pain radiating into his left flank, dry heaving, and constipation.[ncbi.nlm.nih.gov]
  • A 60-year-old Indian man presented with epigastric pain, diarrhea and vomiting. An abdominal imaging scan showed that he had concomitant pernicious anemia and concomitant portal, superior mesenteric and splenic vein thrombosis.[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... SPLENIC VEIN THROMBOSIS AN UNUSUAL CASE OF GASTRIC BLEEDING.[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]
Delayed Gastric Emptying
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]

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
  • 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]
  • Surgery for control of variceal bleed was performed more in the portal and splenic vein thrombosis group (33% vs. 15%, p 0.02), especially for gastric varices (28% vs. 9%, p 0.006).[ncbi.nlm.nih.gov]
  • This report presents a case in which arterial embolization was used to treat gastric variceal bleeding.[ncbi.nlm.nih.gov]
  • It may lead to gastric varices which are difficult to treat and splenectomy may be required to stop variceal bleeding.[ncbi.nlm.nih.gov]
  • In the upper gastrointestinal tract, gastric varices can be frequently overlooked on endoscopy, particularly if not suspected or volume depleted.[ncbi.nlm.nih.gov]

Treatment

  • Optimal modalities for diagnosis, treatment, and surveillance of portal or splenic vein thrombosis have not yet been defined.[ncbi.nlm.nih.gov]
  • The embolization was done as treatment for portal hypertension caused by splenic vein thrombosis from pancreatitis.[ncbi.nlm.nih.gov]
  • Splenectomy is the treatment of choice.[ncbi.nlm.nih.gov]
  • Splenectomy is the treatment of choice in this case. The patient was cured after splenectomy.[ncbi.nlm.nih.gov]
  • The 49 cases of splenic vein thrombosis published since 1970 are briefly reviewed and their treatment is discussed.[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 colleterals mesenteric colleterals 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]
  • Pancreatic diseases are among the most common etiologies of splenic vein obstruction. Renal disorders are rarely reported as a cause of splenic vein thrombosis.[ncbi.nlm.nih.gov]
  • Pancreatic etiology is among the most frequent for splenic vein thrombosis. Hemorrhage from isolated...[connection.ebscohost.com]
  • 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]
  • Therefore, the natural history of pancreatitis-induced splenic vein thrombosis may differ from that which results from other etiologies.[ncbi.nlm.nih.gov]

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]
  • García-Pagán JC, Gracia-Sancho J, Bosch J: Functional aspects on the pathophysiology of portal hypertension in cirrhosis .[cureus.com]
  • […] by , Last updated May 24, 2016 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 or non-occluding isolated thrombus[lifeinthefastlane.com]
  • Pathophysiology Portal hypertension develops due to: Increased vascular resistance in the portal venous system - from various mechanical causes (above), and also as an active process in which liver damage activates stellate cells and myofibroblasts, contributing[patient.info]

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]
  • 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.[ncbi.nlm.nih.gov]
  • Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.[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: 2018-06-21 23:39