Prevalence of splenic vein thrombosis and risk of gastrointestinal bleeding in chronic pancreatitis patients attending a tertiary hospital in western India

Abstract

Background: Splenic vein thrombosis (SVT) is most commonly caused by acute and chronic pancreatitis (CP). Variceal gastrointestinal (GI) bleeding is a potentially life-threatening event in such patients. The aim of this study was to determine the prevalence of SVT in CP patients and the risk of variceal GI bleeding. Materials and Methods: A total of 187 consecutive patients with a diagnosis of CP were assessed for the presence of SVT at the gastroenterology department of a tertiary care hospital. Thirty seven patients had evidence of SVT. Patients with portal vein thrombosis or cirrhosis were excluded. Potential factors associated with SVT were assessed. Results: Of the 187 CP patients assessed, 37 patients (19.8%) (male 33; female 4; mean age 41.9 years) had evidence of SVT. Among patients with SVT, most common etiology of CP was alcohol abuse (70.3%). Seven patients (18.9%) with SVT presented with clinically significant upper GI bleeding. The source of GI bleeding was gastric varices in three patients (8.1%) and non-variceal source in four patients (10.8%). All three patients with gastric varices were managed by splenectomy. There were no new variceal bleeding episodes in other 33 patients (89.2%) during mean follow-up of 16.4 months. On comparison of patients with and without SVT, the factors associated with significantly higher incidence of SVT were smoking ( P = 0.019, odds ratio 3.021, 95% confidence interval 1.195–7.633) and presence of pseudocyst ( P = 0.008, odds ratio 3.743, 95% confidence interval 1.403–9.983). Complete resolution of SVT was seen in three patients (8.1%) after resolution of underlying pseudocyst. Conclusion: SVT is a common complication of CP, particularly in patients with pseudocysts and history of smoking. Most patients remain asymptomatic and the risk of variceal bleeding is low. Splenectomy is the treatment of choice in patients with variceal bleeding. Conservative approach is preferred in other patients. Resolution of pseudocysts may lead to resolution of SVT in some patients.

Splenic Artery Embolisation for the Emergency Treatment of Sinistral Portal Hypertension: A Systematic Review

“…The most common complication of SPH is bleeding, which occurs as a result of varices. 3,7,8 Splenic vein occlusion results in increased venous pressure in local venous collaterals that act as venous outflow to the spleen such as the short gastric, gastroepiploic and coronary veins. The increased pressure in these venous collaterals results in dilatation of the veins in the gastric wall and can develop into gastric and sometimes oesophageal varices.…”

“…As variceal bleeding occurs in up to 35% of cases, control of bleeding is the most common aim in symptomatic patients in addition to removing the primary cause. 7,8,11 Endoscopic measures to control bleeding in SPH patients include endoscopic sclerotherapy, balloon tamponade, band ligation and cyanoacrylate injection, which are associated with a high recurrence rate and are not without complication. 2,24 Splenectomy has widely been considered to be the definitive management in symptomatic SPH patients.…”

“…6 Upper gastrointestinal bleeding is experienced by 18-35% of patients with SPH. 7,8 Splenectomy is the definitive treatment of symptomatic SPH patients, but it is associated with significant mortality and morbidity in the acute setting. 8,9 Endoscopic techniques such as balloon tamponade, sclerotherapy, and band ligation may temporarily stop bleeding from varices, but have a high rate of failure.…”

Practice guidance for diagnosis and treatment of pancreatitis‐related splanchnic vein thrombosis (Shenyang, 2020)

“…Systemic hypercoagulability may be associated with pancreatitis-related SVT, 20 but the association is unclear and should be further studied. 15,16 Smoking can significantly increase the risk of pancreatitis-related SVT, 16,21 although the mechanisms remain unclear. Thus, current evidence does not support the efficacy of anticoagulation therapy for pancreatitis-related SVT.…”

“…Splenectomy is a treatment option for isolated splenic vein thrombosis because it can diminish the outflow of collateral vessels, thus alleviating the surrounding varices. 21,38 In case of chronic pancreatitis, pancreatic pseudocysts or peripancreatic fibrosis, single splenectomy is technically difficult, and thus a combination of splenectomy with the resection of the pancreatic body and tail may be considered. Some authors suggest that in patients with splenic vein thrombosis undergoing pancreatic surgery a prophylactic splenectomy can be routinely performed for decreasing the risk of variceal bleeding.…”