Gastric varices

Question: A 60 year old male is found to have bleeding gastric varices. Liver biopsy shows a normal liver. CT scan of the abdomen shows a splenic vein thrombosis. Which of the following is an inappropriate treatment option?

A. TIPS

B. injection of glue

C. splenectomy

D. embolization of splenic artery

Answer: This is a case of left-sided portal hypertension. Effectively, the splenic vein thrombosis is causing portal hypertension referred to the stomach. This usually happens in cases of acute/chronic pancreatitis, because the splenic vein traverses the body of the pancreas.

Appropriate treatments for such varices include EGD with injection of glue, or splenectomy if the patient is hemodynamically stable. In certain cases of pancreatitis where pseudocysts have developed, the regional anatomy could become obscurred, and surgery is difficult. Instead, embolization of the splenic artery is another means to the same end (you want to decrease the splenic venous effluent one way or another).

TIPS in these cases is not indicated. TIPS will decrease portal pressures that are due to intrahepatic resistance; this patient has no intrahepatic resistance to relieve, and the high left-sided pressures will remain after the shunt is placed. So, remember, with isolated gastric varices, be sure you’re dealing with right-sided portal hypertension before ordering your intervention.

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