A 64-year-old man comes to the emergency department after an episode of hematemesis. He also reports dark stools and abdominal pain for the past several days. The patient has a history of chronic pancreatitis. Abdominal examination shows epigastric tenderness to palpation. Rectal examination is notable for black, guaiac-positive feces. Upper gastrointestinal endoscopy reveals a bleeding spot within a cluster of enlarged tortuous veins in the gastric fundus. The rest of the stomach and esophagus appears normal. Increased pressure in which of the following vascular structures is the most likely cause of this patient's condition?

Question

A 64-year-old man comes to the emergency department after an episode of hematemesis.  He also reports dark stools and abdominal pain for the past several days.  The patient has a history of chronic pancreatitis.  Abdominal examination shows epigastric tenderness to palpation.  Rectal examination is notable for black, guaiac-positive feces.  Upper gastrointestinal endoscopy reveals a bleeding spot within a cluster of enlarged tortuous veins in the gastric fundus.  The rest of the stomach and esophagus appears normal.  Increased pressure in which of the following vascular structures is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec160b_357d_06b6_9249_35d6a6579d53_MD0001_00 Gastric varices are dilated submucosal veins that can cause life-threatening bleeding in the upper gastrointestinal tract. The varices are commonly due to portal hypertension, which can be a complication of cirrhosis. Gastric varices can also be seen with splenic vein thrombosis due to chronic pancreatitis, pancreatic cancer, and abdominal tumors. The splenic vein runs along the posterior surface of the pancreas and can develop a blood clot from pancreatic inflammation. The short gastric veins drain the fundus of the stomach into the splenic vein. Splenic vein thrombosis can increase pressure in the short gastric veins and cause gastric varices only in the fundus. The rest of the stomach and esophagus are usually not affected. (Choice A) The azygos vein drains blood from the esophageal veins into the superior vena cava. The formation of esophageal varices in the setting of portal hypertension provides collateral drainage from the portal venous system to the azygos system. The azygos vein also provides collateral circulation between the superior and inferior vena cava and can become enlarged with caval obstruction. (Choice B) The left gastric vein drains blood from the upper stomach and lower esophagus into the portal vein. Portal hypertension can increase pressure in the left gastric veins and usually causes both gastric and esophageal varices. (Choices C and E) The pancreaticoduodenal vein drains the pancreas and duodenum into the superior mesenteric vein (SMV). The SMV also drains blood from the lower stomach (via the right gastroepiploic vein) and small intestine. Blockage of the SMV could lead to variceal formation in the lower stomach, but not the upper regions. Educational objective: The short gastric veins drain blood from the gastric fundus into the splenic vein. Pancreatic inflammation (eg, pancreatitis, pancreatic cancer) can cause a blood clot within the splenic vein, which can increase pressure in the short gastric veins and lead to gastric varices only in the fundus. __________ References: Repeated pancreatitis-induced splenic vein thrombosis leads to intractable gastric variceal bleeding: A case report and review. (http://www.ncbi.nlm.nih.gov/pubmed/26488031)

A 64-Year-Old Man Comes to the Emergency Department After an Episode