Sinistral Portal Htn Due To Pancreatic Serous Cystadenoma

INTRODUCTION: Sinistral Portal Hypertension (SPH), also known as left sided portal hypertension is defined as elevated pressure confined to the gastrosplenic side of the portal venous system. Stenosis, thrombosis or occlusion of the splenic vein can result in development of collateral vessels resulting in varices in the gastric fundal submucosa. Herein, we describe an initially obscure case of recurrent UGI bleeding ultimately found to be secondary to isolated gastric varices caused by a pancreatic serous cystadenoma impinging on the splenic vein causing SPH. CASE DESCRIPTION/METHODS: A 67-year-old female presented with a syncopal episode in the setting of melena and coffee ground emesis. On presentation her laboratory results were notable for hemoglobin of 4.6 g/dL requiring multiple blood transfusions. CT of the abdomen and pelvis was notable for obscured pancreatic tail secondary to large mildly enhancing septated multi-cystic mass measuring 13 cm × 9 cm in its largest dimensions with mass effect on the adjacent stomach and compression on the splenic hilum (Figure 1). EGD revealed isolated gastric varices (IGV1) located in the fundus (Figure 2). Endoscopic ultrasound (EUS) revealed a 60 mm × 55 mm pancreatic tail cyst with honeycomb appearance with multiple thin septations (Figure 3). The splenic vein could not be traced at the location of the cyst. Fine needle aspiration of the fluid revealed fluid carcinoembryonic antigen (CEA) of 2.4 ng/ml and cancer antigen (CA) 19-9 of 22 ng/ml. These findings were consistent with a diagnosis of pancreatic serous cystadenoma causing IGV1 as the source of UGI bleeding. Due to recurrent episodes of bleeding, the patient underwent splenic artery embolization (SEA) followed by distal pancreatectomy and splenectomy. DISCUSSION: Most believe that observation is an acceptable course of management in patients with SPH. However treatment of choice of symptomatic SPH is surgical correction of the primary cause in combination with splenectomy. The rationale for splenectomy is to interrupt the arterial supply feeding the collateral draining veins, reducing the pressure of the gastrosplenic system and subsequent risk of re-bleeding. Since intervention our patient had no further complications or episodes of bleeding. This case exemplifies the importance of having a broad differential when approaching a gastrointestinal bleed including rare etiologies such as SPH.Figure 1.: Pancreatic tail obscured secondary to large mildly enhancing septated multi-cystic mass measuring 13 × 9 cm in its largest dimensions with calcifications classic for pancreatic serous cystadenoma. There is mass effect on the adjacent stomach and left adrenal gland with compression of the splenic hilum. The mass encases the splenic artery without any clear invasion.Figure 2.: Highly suspicious for isolated gastric varices (IGV1) in the fundus.Figure 3.: Pancreatic tail lesion with honeycomb appearance with multiple thin septations. Isolated gastric varices likely related to pancreatic cyst impinging on splenic vein and encasing splenic artery causing Sinistral portal hypertension.