Successful treatment of colonic varices by recanalization and stenting of the splenic vein in a patient with splenic vein thrombosis and gastrointestinal bleeding

Background Splenic vein thrombosis is a known complication of acute or chronic pancreatitis (PISVT–pancreatitis-induced splenic vein thrombosis). It can lead to increased blood flow through splenoportal, gastroepiploic or mesenteric collaterals. This may result in the development of esophageal, gastric or colonic varices with a high risk of severe gastrointestinal bleeding. Hepatic venous pressure gradient (HVPG) is generally normal in these patients. While clear guidelines for treatment are lacking, splenectomy or splenic artery embolization are used to prevent bleeding.

Case-Report A 45-years old female patient was admitted to the hospital due to recurrent gastrointestinal bleeding. She was anemic with a hemoglobin of 8.0 g/dl. As a source of bleeding colonic varices were identified. CT Scans revealed thrombotic occlusion of the splenic vein, presumably as a result of a severe acute pancreatitis eight years before. In a selective angiography of the spleen a dilated mesenterial collateral vein leading from the spleen to enlarged vessels in the colon transversum and right colonic flexure draining into the superior mesenteric vein could be confirmed and simultaneously an arterio-portal-fistula was ruled out. Hepatic venous pressure gradient (HVPG) was 3 mmHg. Liver enzymes, platelets, and coagulation parameters were within the normal range. Transient elastography showed a value of 5.6 kPa. In an interdisciplinary board, interventional transhepatic (+/- transsplenic) recanalization of the vena lienalis via balloon-dilatation and consecutive stenting, as well as coiling of the aberrant mesenterial veins was discussed and successfully performed. Consecutive evaluation revealed regression of colonic varices and splenomegaly as well as normalization of red blood count during follow-up.

Conclusion Interventional recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to colonic varices. However, a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.

Publication History

Article published online:
26 August 2022