Gastrointestinal Bleeding due to Pancreatic Disease-Related Portal Hypertension

The management of splanchnic vein thrombosis in acute pancreatitis: a global DELPHI consensus study

BACKGROUND

Splanchnic vein thrombosis (SpVT) occurs in 17%-23 % of acute pancreatitis cases. Serious sequelae include hepatic and bowel ischaemia. However, management with therapeutic anticoagulation remains controversial due to potential bleeding risk. We aim to determine the level of consensus on prognosis, diagnosis, management, and outcomes of SpVT through a DELPHI process.

METHODS

Using purposive, non-probability sampling and DELPHI methodology, 173 clinicians with experience of SpVT in acute pancreatitis were approached. From April 2022 to April 2023, a three-round DELPHI process was implemented to completion. A total of 88 statements were posed for ranking via a four-point Likert scale.

RESULTS

The mean acute pancreatitis caseload per respondent per year was 68·0, 72·6 and 73·0 for DELPHI rounds 1,2 and 3 respectively. For SpVT anatomical location, there was strong consensus favouring anticoagulation for portal vein (89·1 %) and SMV thrombosis (90·9 %), and no consensus to treat splenic vein thrombosis (47·3 %). 74·1 % rejected radiological resolution as a definitive anticoagulation endpoint. Majority consensus favoured death, bleeding risk, bowel or liver ischaemia, hospital admission length and ITU admission as significant outcomes for experimental research design.

CONCLUSION

There was significant consensus for anticoagulation treatment of SpVT of the portal and superior mesenteric veins, especially with complete occlusion by thrombosis. Randomised controlled trials are required to grade management recommendations.

Development of a nomogram for predicting pancreatic portal hypertension in patients with acute pancreatitis: a retrospective study

INTRODUCTION

Pancreatic portal hypertension (PPH) is a rare complication of acute pancreatitis (AP) that can lead to severe gastrointestinal bleeding. The risk factors associated with PPH, as well as the overall prognosis, warrant further investigation. This study aims to develop and validate a nomogram to predict PPH in patients with AP.

METHODS

Consecutive patients with AP from 2015 to 2023 were retrospectively included in the study. Demographic data, clinical manifestations within the first week of AP onset, and initial contrast-enhanced CT findings were used to develop the predictive model. Univariate and multivariate Cox regression analyses were performed to identify risk factors for PPH. Based on the results of the multivariate analysis, a nomogram was developed. The patients were randomly divided into training and validation sets at a 7:3 ratio. The accuracy and discriminative power of the predictive model were assessed using the area under the curve (AUC) from the receiver operating characteristic curve and the calibration curve.

RESULTS

Of the 1473 patients with AP, 107 (7.3%) developed PPH within 6 months (range: 2-22 months) during follow-up. Multivariate regression analysis showed that body mass index (BMI) (HR, 1.10; 95% CI 1.04 to 1.16; p=0.001), moderately severe grade (HR, 9.36; 95% CI 4.58 to 19.13; p<0.001), severe grade (HR, 12.95; 95% CI 6.22 to 26.94; p<0.001), diabetes (HR, 2.26; 95% CI 1.47 to 3.47; p<0.001), acute fluid accumulation (HR, 2.13; 95% CI 1.31 to 3.47; p=0.002), and necrosis (HR, 3.64; 95% CI 2.30 to 5.78; p<0.001) were independent risk factors for PPH. A nomogram for predicting PPH was developed, with the predictive curves showing an AUC of 0.859 at 6 months and 0.846 at 9 months. In the validation set, the AUC at both time points was 0.812.

CONCLUSION

In summary, we identified BMI, moderately severe or severe AP, diabetes, acute fluid accumulation, and necrosis as risk factors for AP-related PPH. Using the largest cohort of patients with AP to date, we developed a highly accurate nomogram with strong discriminative ability for predicting PPH. Future studies with larger sample sizes are necessary to confirm our findings and conduct external validation.

Patterns of venous collateral development after splenic vein occlusion associated with surgical and oncological outcomes after distal pancreatectomy

Aims

Splenic vein occlusion (SpVO) due to a pancreatic tumor may result in the development of collateral circulation and left-sided portal hypertension. This study aimed to investigate the impact of SpVO on distal pancreatectomy (DP) and provide insights about the management of such cases.

Methods

This retrospective analysis included 124 patients who underwent DP from 2014 to 2022. A subgroup analysis was performed on 88 patients who underwent DP for pancreatic ductal adenocarcinoma (PDAC).

Results

SpVO was found in 26 (20.8%) patients. The patients with SpVO had significantly larger splenic volumes and lower platelet counts. Compared to the patients with patent splenic veins (SpVs), the patients with SpVO underwent significantly longer operations (p = 0.006), with a higher incidence of postoperative complications (p = 0.002). We classified the collateral routes associated with SpVO into five patterns. The most common pattern was the left gastroepiploic vein type, which was associated with a tumor of the pancreatic body. In patients with PDAC, SpVO was associated with larger tumors, microscopic vascular permeation, and peritoneal recurrence. However, the differences between overall and recurrence-free survival rates in the patients with SpVO vs those with patent SpVs were not significant.

Conclusions

SpVO causes left-sided portal hypertension, which can be a risk for perioperative complications in DP. Operative planning based on the classification of collateral flow patterns may help prevent intraoperative congestion and perioperative complications.

Splenectomy versus non-splenectomy for gastrointestinal bleeding from left-sided portal hypertension: a systematic review and meta-analysis

OBJECTIVES

Left-sided portal hypertension (LSPH) leads to life-threatening gastrointestinal (GI) bleeding. There are no recommendations or consensus about the management of GI bleeding caused by LSPH. This systematic review and meta-analysis were conducted to evaluate the incidence of GI bleeding and the mortality of patients with LSPH receiving different therapeutic strategies.

DESIGN

A systematic review and meta-analysis were performed to determine the efficacy of different therapeutic strategies for GI bleeding caused by LSPH.

DATA SOURCES AND METHODS

All relevant studies were searched from PubMed, Embase, Web of Science, Cochrane Library, Scopus, ScienceDirect, MEDLINE, Google Scholar, CNKI, and Wanfang Data without language restriction through 15 November 2023. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated through RevMan5.3 software. (The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

Seventeen retrospective studies and one prospective study involving 624 patients were included. This systematic review and meta-analysis found that: (1) splenectomy was more effective than non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding caused by LSPH (OR: 0.12; 95% CI: 0.06-0.27); (2) splenectomy was superior to partial splenic artery embolism (PSAE) (OR: 0.06; 95% CI: 0.01-0.62) or endoscopic interventions (OR: 0.04; 95% CI: 0.01-0.19) in the prevention of GI bleeding, respectively; (3) no significant difference in the mortality was observed between splenectomy and non-splenectomy therapeutic strategies (OR: 0.46; 95% CI: 0.20-1.08); and (4) patients receiving preoperative PSAE followed by splenectomy had less intraoperative bleeding and shorter operative time than those receiving splenectomy.

CONCLUSION

This meta-analysis demonstrated that splenectomy is superior to non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding from LSPH, which revealed that splenectomy should be recommended in the management of these patients.

TRIAL REGISTRATION

This study has been registered on the PROSPERO database with the registration number CRD42023483764.

Left-sided portal hypertension: Update and proposition of management algorithm

Left-sided or segmental portal hypertension (SPHT) is a rare entity, most often associated with pancreatic disease or antecedent pancreatic surgery. The starting point is splenic vein obstruction secondary to local inflammation or, less often, extrinsic compression. SPHT leads to splenomegaly and development of collateral porto-systemic venous circulation. SPHT should be suspected in patients with pancreatic history who present with episodic upper gastrointestinal bleeding and splenomegaly with normal liver function tests. The most common clinical presentation is major upper gastrointestinal bleeding secondary to rupture of esophageal and/or gastric varices. At the present time, there are no management recommendations for SPHT, particularly when the patient is asymptomatic. In patients with upper gastro-intestinal bleeding, hemostasis can be obtained either by medical or interventional means according to patient status and available resources. For symptomatic patients, splenectomy is the reference treatment. Recently, less invasive, radiologic procedures, such as splenic artery embolization, have been developed as an alternative to surgery. Additionally, sonography-guided endoscopic hemostasis can also be envisioned, leading to the diagnosis and treatment of the lesion by elastic band ligation or by glue injection into the varices during the same procedure. The goal of this article is to describe the pathophysiological mechanisms behind SPHT and its clinical manifestations and treatment, based on a review of the literature. Because of the absence of recommendations for the management of SPHT, we propose a decisional algorithm for the management of SPHT based on the literature.

Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND

Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension (LSPH). The hemorrhage is fatal and requires safe and effective interventions.

AIM

To evaluate the clinical safety and efficacy of modified endoscopic ultrasound (EUS)-guided selective N-butyl-2-cyanoacrylate (NBC) injections for gastric variceal hemorrhage in LSPH.

METHODS

A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted. Preoperative EUS evaluations were performed. Enrolled patients were divided into modified and conventional groups according to the NBC injection technique. The final selection of NBC injection technique depended on the patients' preferences and clinical status. The technical and clinical success rates, operation time, NBC doses, perioperative complications, postoperative hospital stay, and recurrent bleeding rates were analyzed, respectively.

RESULTS

A total of 27 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. In comparison to patients in the conventional group, patients in the modified group demonstrated significantly reduced NBC doses (2.0 ± 0.6 mL vs 3.1 ± 1.0 mL; P = 0.004) and increased endoscopic operation time (71.9 ± 11.9 min vs 22.5 ± 6.7 min; P < 0.001). Meanwhile, the two groups had no significant difference in the technical and clinical success rates, perioperative complications, postoperative hospital stay, and recurrent bleeding rates.

CONCLUSION

Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage, with advantages of reduced injection dose and no radiation risk. Drawbacks were time consumption and technical challenge.

Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND

Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension (LSPH). The hemorrhage is fatal and requires safe and effective interventions.

AIM

To evaluate the clinical safety and efficacy of modified endoscopic ultrasound (EUS)-guided selective N-butyl-2-cyanoacrylate (NBC) injections for gastric variceal hemorrhage in LSPH.

METHODS

A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted. Preoperative EUS evaluations were performed. Enrolled patients were divided into modified and conventional groups according to the NBC injection technique. The final selection of NBC injection technique depended on the patients' preferences and clinical status. The technical and clinical success rates, operation time, NBC doses, perioperative complications, postoperative hospital stay, and recurrent bleeding rates were analyzed, respectively.

RESULTS

A total of 27 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. In comparison to patients in the conventional group, patients in the modified group demonstrated significantly reduced NBC doses (2.0 ± 0.6 mL vs 3.1 ± 1.0 mL; P = 0.004) and increased endoscopic operation time (71.9 ± 11.9 min vs 22.5 ± 6.7 min; P < 0.001). Meanwhile, the two groups had no significant difference in the technical and clinical success rates, perioperative complications, postoperative hospital stay, and recurrent bleeding rates.

CONCLUSION

Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage, with advantages of reduced injection dose and no radiation risk. Drawbacks were time consumption and technical challenge.

Splenic Hilar Involvement and Sinistral Portal Hypertension in Unresectable Pancreatic Tail Cancer

BACKGROUND

Pancreatic tail cancer (PTC) frequently displays splenic hilar involvement (SHI), but its impact on clinical outcomes remains unclear. We investigated the clinical impact of SHI in patients with unresectable PTC.

METHODS

We retrospectively reviewed all patients with unresectable PTC who received first-line therapy at our institution from 2016 to 2020.

RESULTS

Of the 111 included patients, 48 had SHI at diagnosis. SHI was significantly associated with younger age, liver metastasis, peritoneal dissemination, larger tumor size, modified Glasgow prognostic score of 1 or more, splenic artery involvement, gastric varices, and splenomegaly. Shorter median overall survival (OS; 9.3 vs. 11.6 months, p = 0.003) and progression-free survival (PFS; 4.3 vs. 6.3 months, p = 0.013) were observed in SHI patients. Poor performance status of 1 or 2, tumor size > 50 mm, hepatic metastasis, mGPS of 1 or 2, and SHI (hazard ratio: 1.65, 95% confidence interval: 1.08-2.52, p = 0.020) were independent predictors of shorter OS. Splenic artery pseudoaneurysm rupture and variceal rupture were rare and only observed in cases with SHI.

CONCLUSIONS

Splenic hilar involvement is associated with worse outcomes in pancreatic tail cancer.

Two Cases of Gastric Varices with Left-sided Portal Hypertension Due to Essential Thrombocythemia Treated with Gastric Devascularization or Partial Splenic Embolization

Left-sided portal hypertension (LSPH) is a condition of extrahepatic portal hypertension that often results in bleeding from isolated gastric varices (GVs). LSPH is sometimes caused by myeloproliferative diseases, such as essential thrombocythemia (ET). We herein report two cases of GVs with LSPH due to ET that were successfully controlled by gastric devascularization (GDS) or partial splenic embolization (PSE). Since each patient with LSPH due to ET has a different pathology, optimal treatment should be performed depending on the patient's condition, such as platelet counts, hemodynamics, or the prognosis. We believe that these cases will serve as a reference for future cases.

Anticoagulation Therapy for Splanchnic Vein Thrombosis Associated With Acute Pancreatitis: A Systematic Review and Meta-Analysis

Splanchnic vein thrombosis (SVT) is not rare in patients with acute pancreatitis. It remains unclear about whether anticoagulation should be given for acute pancreatitis-associated SVT. The PubMed, EMBASE, and Cochrane Library databases were searched. Rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were pooled and compared between patients with acute pancreatitis-associated SVT who received and did not receive therapeutic anticoagulation. Pooled rates and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Heterogeneity among studies was evaluated. Overall, 16 studies including 698 patients with acute pancreatitis-associated SVT were eligible. After therapeutic anticoagulation, the pooled rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were 44.3% (95%CI = 32.3%-56.6%), 10.7% (95%CI = 4.9%-18.5%), 13.3% (95%CI = 6.9%-21.4%), 16.8% (95%CI = 6.9%-29.9%), 21.2% (95%CI = 7.5%-39.5%), and 29.1% (95%CI = 16.1%-44.1%), respectively. Anticoagulation therapy significantly increased the rate of SVT recanalization (RR = 1.69; 95%CI = 1.29-2.19; P < .01), and marginally increased the risk of bleeding (RR = 1.98; 95%CI = 0.93-4.22; P = .07). The rates of death (RR = 1.42; 95%CI = 0.62-3.25; P = .40), intestinal ischemia (RR = 2.55; 95%CI = 0.23-28.16; P = .45), portal cavernoma (RR = 0.51; 95%CI = 0.21-1.22; P = .13), and gastroesophageal varices (RR = 0.71; 95%CI = 0.38-1.32; P = .28) were not significantly different between patients who received and did not receive anticoagulation therapy. Heterogeneity was statistically significant in the meta-analysis of intestinal ischemia, but not in those of SVT recanalization, any bleeding, death, portal cavernoma, or gastroesophageal varices. Anticoagulation may be effective for recanalization of acute pancreatitis-associated SVT, but cannot improve the survival. Randomized controlled trials are warranted to further investigate the clinical significance of anticoagulation therapy in such patients.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

The clinical applicability of percutaneous splenic vein stent implantation for pancreatic portal hypertension

Background

Pancreatic portal hypertension (PPH) is a type of extrahepatic portal hypertension. We compared the clinical efficacy of different treatment methods for PPH caused by splenic vein stenosis in chronic pancreatitis.

Methods

This article retrospectively analyzed the PPH cases that were caused by splenic vein stenosis after chronic pancreatitis. Patients were divided into three groups according to the different treatments: splenic vein stent implantation (stent group), splenectomy, and only medications (conservative group). The treatment effects from each group were compared.

Results

A total of 33 patients were retrospectively analyzed in this study (9, 12, and 12 patients in each group respectively). All the procedures were successful in the stent and splenectomy groups. During the follow-up, no patient had gastrointestinal bleeding recurrence in the stent and splenectomy groups. However, in the conservative group, the incidence of portal hypertensive gastropathy and upper gastrointestinal bleeding were 50% and 25%. In the stent group, all the varicose veins at the base of the stomach had shrunk by varying degrees, and the red color signs regressed. The stent patency rate was 100%. No major complication occurred. The average platelet count at 1, 3, 6-months postoperatively were all significantly higher than the preoperative value (P < 0.05). The average postoperative hospital stay duration was significantly shorter than that of the splenectomy group (3.1 ± 1.4 days vs. 16.1 ± 8.1 days; P < 0.05). In the splenectomy group, postoperative fever occurred in 4 patients. Postoperative infection occurred in 2 patients (one with abdominal cavity infection and the other with incision infection). Delayed abdominal bleeding occurred in one patient. Portal vein thrombosis occurred in 2 patients during follow up.

Conclusion

Percutaneous splenic vein stent implantation for PPH treatment reduces the risk of gastrointestinal bleeding with minimal invasive. It has a high safety and reliable efficacy and is worthy of further clinical promotion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02214-z.

Preoperative splenic artery embolism followed by splenectomy is safe and effective in patients with sinistral portal hypertension

Background

Although preoperative splenic artery embolism (SAE) has been widely used for splenomegaly, the efficiency and safety of preoperative SAE in patients with sinistral portal hypertension (SPH) is unknown.

Methods

We designed a retrospective cohort of SPH patients who received preoperative SAE in our hospital (February 2018 to September 2020) and compared to those who received splenectomy only, in terms of intraoperative and postoperative outcomes.

Results

In all, 59 patients (18 patients received preoperative SAE) were analyzed. The median age was 44.7 years. Preoperative SAE reduced the intraoperative blood loss (637.0 vs. 420.3 ml, P = 0.041) and operation time (174.0 vs. 141.5 min, P = 0.012). The incidence of complications including postoperative pancreatic fistula (POPF), bleeding, and thromboembolism was comparable. Multivariate analysis showed that SAE was a protective factor for intraoperative blood loss and operation time, while prior pancreatic pseudocyst/abscess was a risk factor.

Conclusions

Preoperative SAE could reduce intraoperative blood loss and operation time in SPH patients without increasing the incidence of complications compared to splenectomy only.