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

Bleeding from isolated gastric varices as complication of a mucinous cystic neoplasm of the pancreas: A case report

INTRODUCTION

Bleeding from isolated gastric varices, though uncommon, may be life threatening and may occur as a consequence of splenic vein thrombosis by tumoral compression and subsequent left-sided portal hypertension.

CASE OVERVIEW

We report the case of a 37-year old woman, previously diagnosed with a benign pancreatic cyst, who presented with severe gastric variceal bleeding.

DIAGNOSIS, THERAPEUTICS INTERVENTIONS, AND OUTCOMES

Abdominal ultrasound (US) and computed-tomography (CT) revealed enlargement and changed morphology of the cystic tumor located on the body of the pancreas. Left-sided portal hypertension was disclosed resulting from splenic vein occlusion. Salvage left spleno-pancreatectomy with lymphadenectomy was undertaken with an excellent postoperative outcome. Histological analysis established the diagnosis of mucinous cystic neoplasm with foci of adenocarcinoma.

CONCLUSION

Surgical treatment proved to be the election one, leading to a steady hemostasis, removal of the lesion, positive diagnosis, and resolution of the varices. Imaging follow-up of pancreatic cyst should also assess vascular patency to identify the patient at risk for gastric bleeding and to select patients who benefits from surgical resection.

Case report and systematic literature review of a novel etiology of sinistral portal hypertension presenting with UGI bleeding: Left gastric artery pseudoaneurysm compressing the splenic vein treated by embolization of the pseudoaneurysm

INTRODUCTION

A novel case is reported of upper gastrointestinal (UGI) bleeding from sinistral portal hypertension, caused by a left gastric artery (LGA) pseudoaneurysm (PA) compressing the splenic vein (SV) that was successfully treated with PA embolization.

CASE REPORT

A 41-year-old man with previous medical history of recurrent, alcoholic pancreatitis presented with several episodes of hematemesis and abdominal pain for 48 hours. Physical examination revealed a soft abdomen, with no abdominal bruit, no pulsatile abdominal mass, and no stigmata of chronic liver disease. The hemoglobin declined acutely from 12.3 to 9.3 g/dL. Biochemical parameters of liver function and routine coagulation profile were entirely within normal limits. Abdominal CT revealed a 5-cm-wide peripancreatic mass compressing the stomach and constricting the SV. Esophagogastroduodenoscopy showed blood oozing from portal hypertensive gastropathy, small nonbleeding gastric cardial and fundal varices, gastric compression from the extrinsic mass, and no esophageal varices. MRCP and angiography showed that the mass was vascular, arose from the LGA, compressed the mid SV without SV thrombosis, and caused sinistral portal hypertension. At angiography, the PA was angioembolized and occluded. The patient has been asymptomatic with no further bleeding and a stable hemoglobin level during 8 weeks of follow-up.

DISCUSSION

Literature review of the 14 reported cases of LGA PA revealed that this report of acute UGI bleeding from sinistral portal hypertension from a LGA PA constricting the SV is novel; one previously reported patient had severe anemia without acute UGI bleeding associated with sinistral portal hypertension from a LGA PA.

CONCLUSION

A patient presented with UGI bleeding from sinistral portal hypertension from a LGA PA compressing the SV that was treated by angiographic obliteration of the PA which relieved the SV compression and arrested the UGI bleeding. Primary therapy for this syndrome should be addressed to obliterate the PA and not the secondarily constricted SV.

A case of a giant growing serous cystic neoplasm of the pancreas

Because of the widespread use of diagnostic imaging in recent years, serous cystic neoplasm (SCN) of the pancreas can often be detected even when small in diameter. SCNs are usually benign, but it is important to differentiate them from other types of cystic tumors. We report a case of a giant growing SCN that posed a challenge in differential diagnosis.

A case of solid pseudopapillary neoplasm of the pancreas presenting with left-sided extrahepatic portal hypertension

A 53-year-old woman was referred to our hospital for management of gastric varices that ran transversely across the greater curvature of the gastric body, detected during routine upper gastrointestinal endoscopy. CT identified a low-density calcified mass near the tail of the pancreas and the splenic hilum. Based on the results of radiographic and pathological investigations, the tumor was diagnosed as solid pseudopapillary neoplasm (SPN), and the gastric varices were considered to have developed secondary to occlusion of the splenic vein by the tumor mass. This is a rare case of SPN associated with splenic vein occlusion and left-sided extrahepatic portal hypertension.

Multi-visceral resection of pancreatic VIPoma in a patient with sinistral portal hypertension

Background

VIPomas are rare neuroendocrine tumors poorly described in the literature. Aggressive resection of patients with advanced VIPoma neuroendocrine tumors has rarely been reported.

Case presentation

A 46 year old women presented with abdominal pain and diarrhea. A three-dimensional (3-D) pancreas protocol computed tomography scan revealed an 18 × 12 cm pancreatic VIPoma abutting the liver, stomach, spleen, left adrenal, colon that also invaded the distal duodenum – proximal jejunum at the ligament of Treitz in association with sinistral portal hypertension. Following preoperative proximal splenic artery embolization, the patient with underwent successful en bloc resection of the locally advanced VIPoma in conjunction with a diaphragmatic resection, total gastrectomy, splenectomy, left adrenalectomy, as well as small and large bowel resection. The estimated blood loss was 500 ml. All margins were negative (R0 resection). The patient is alive and disease-free.

Conclusion

This case illustrates the role of aggressive resection of pancreatic neuroendocrine tumors and highlights several key technical points that allowed for successful resection.

Left-sided portal hypertension caused by serous cystadenoma of the pancreas: report of a case

We report a case of serous cystadenoma of pancreas causing left-sided portal hypertension and gastric varices. A 68-year-old man was admitted for treatment of a pancreatic body tumor. Contrast-enhanced computed tomography (CT) showed a honeycombed cystic mass. A celiac angiogram showed a hypervascular tumor supplied mainly by a dilated splenic artery and dorsal pancreatic artery. In the venous phase, the patent splenic vein had a large hepatopetal collateral vein via the coronary gastric vein. Upper gastrointestinal endoscopy showed isolated varices of the gastric fundus. We made a preoperative diagnosis of a serous cystic tumor of the pancreas with left-sided portal hypertension and performed distal pancreatectomy with splenectomy. The resected tumor was 8 cm in diameter and had a typical honeycombed microcystic pattern with central stellate scarring. The spleen was not enlarged. Histopathological examination confirmed a diagnosis of serous cystadenoma without any sign of malignancy. Postoperative endoscopy showed disappearance of the gastric varices.