A 55-year-old man comes to the emergency department due to blood-tinged vomiting. The patient was at a party the evening prior to presentation and consumed a large quantity of alcohol. After leaving, he developed symptoms of nausea and retching, followed by vomiting several hours later. The emesis was initially clear but then became intermixed with small amounts of blood. He has no abdominal pain, weight loss, or changes in stool. The patient has a history of alcoholism and was admitted for acute pancreatitis a few months ago. He currently takes no medications or over-the-counter supplements. The patient drinks 4 or 5 beers daily but does not use tobacco or illicit drugs. Temperature is 36.7 C (98.1 F), pulse is 88/min, and respirations are 16/min. Physical examination shows dry mucous membranes, flat jugular veins, clear lung fields, and normal S1 and S2. The abdomen is soft and tender in the midepigastrium with no rebound tenderness or rigidity. Bowel sounds are normal. There is moderate splenomegaly without hepatomegaly. No edema is present. Laboratory results are as follows: The patient undergoes an esophagogastroduodenoscopy that reveals several small, erythematous erosions at the gastroesophageal junction as well as hyperemia and petechiae throughout the gastric mucosa. Incidentally, varices are seen in the fundus of the stomach but no esophageal varices are seen. Which of the following is the most likely cause of this patient's varices?

Question

A 55-year-old man comes to the emergency department due to blood-tinged vomiting.  The patient was at a party the evening prior to presentation and consumed a large quantity of alcohol.  After leaving, he developed symptoms of nausea and retching, followed by vomiting several hours later.  The emesis was initially clear but then became intermixed with small amounts of blood.  He has no abdominal pain, weight loss, or changes in stool.  The patient has a history of alcoholism and was admitted for acute pancreatitis a few months ago.  He currently takes no medications or over-the-counter supplements.  The patient drinks 4 or 5 beers daily but does not use tobacco or illicit drugs.  Temperature is 36.7 C (98.1 F), pulse is 88/min, and respirations are 16/min.  Physical examination shows dry mucous membranes, flat jugular veins, clear lung fields, and normal S1 and S2.  The abdomen is soft and tender in the midepigastrium with no rebound tenderness or rigidity.  Bowel sounds are normal.  There is moderate splenomegaly without hepatomegaly.  No edema is present.  Laboratory results are as follows:  The patient undergoes an esophagogastroduodenoscopy that reveals several small, erythematous erosions at the gastroesophageal junction as well as hyperemia and petechiae throughout the gastric mucosa.  Incidentally, varices are seen in the fundus of the stomach but no esophageal varices are seen.  Which of the following is the most likely cause of this patient's varices?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c15b_c589_8f63_376506da3b11_MD0005_00 This patient presenting with gastrointestinal hemorrhage and isolated gastric varices in the setting of prior pancreatitis likely has splenic vein thrombosis (SVT). Most patients with SVT have a history of acute or chronic pancreatitis or pancreatic cancer. Thrombosis occurs as the splenic vein runs along the posterior surface of the pancreas and can become damaged or compressed due to pancreatic inflammation (or pancreatic masses/pseudocysts). Patients with SVT are frequently asymptomatic; however, when symptoms do occur, the most common presentation is variceal bleeding. The isolated gastric varices, which are the hallmark of SVT, form when venous blood flow is redirected from the splenic vein to the collateral gastroepiploic system and short gastric veins. Patients with chronic SVT may also develop left-sided portal hypertension (due to isolated pressure increases in the splenic portion of the portal system), ascites, and congestive splenomegaly with associated features of hypersplenism (eg, anemia, thrombocytopenia). The diagnosis of SVT can be confirmed directly with multiple imaging modalities, including a contrast-enhanced CT scan, Doppler ultrasonography, and MRI. It can also be confirmed indirectly with esophagogastroduodenoscopy by identifying isolated gastric varices. The standard treatment for patients with SVT and gastrointestinal hemorrhage is splenectomy. (Choice A) Budd-Chiari syndrome is due to the thrombosis of hepatic (not portal) veins or intra-/suprahepatic inferior vena cava. Acutely, it presents with right upper quadrant pain, hepatomegaly, jaundice, and rapidly developing ascites. Chronic Budd-Chiari syndrome commonly presents with ascites, cirrhosis, and signs of portal hypertension (eg, gastroesophageal varices, splenomegaly). (Choice B) Patients with constrictive pericarditis frequently have signs and symptoms of right-sided heart failure (eg, dyspnea on exertion, peripheral edema, hepatomegaly), and portal hypertension can develop. Jugular venous distension would be expected. (Choice C) Hepatic veno-occlusive disease is due to the occlusion of terminal hepatic venules (not veins) and causes postsinusoidal portal hypertension. It most commonly occurs in patients with bone marrow transplant and presents with tender hepatomegaly, jaundice, and ascites. (Choice D) Chronic portal vein thrombosis is a potential complication of cirrhosis (rather than pancreatitis). Its presentation can be similar to SVT, but in portal vein thrombosis there is hypertension of the entire portal system with esophageal varices typically accompanying gastric varices. esophageal varices Educational objective: Splenic vein thrombosis, which commonly occurs in association with pancreatitis, may be asymptomatic or present with variceal bleeding due to isolated gastric varices, the disease's hallmark. Varices develop due to redirection of blood flow to the collateral gastroepiploic system and short gastric veins. References: Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/22081918) Gastric variceal bleeding due to pancreatitis-induced splenic vein thrombosis. (http://www.ncbi.nlm.nih.gov/pubmed/24663248) Sinistral portal hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/16964806)

A 55-Year-Old Man Comes to the Emergency Department Due to Blood-Tinged