132 - A Novel Approach to Upper Gastrointestinal Bleeding in Congenital Absence of the Splenic Vein
Purpose: Congenital absence of the splenic vein, a rare condition, can present with gastric bleeding due to isolated gastric varices. This condition may present similarly to left sided portal hypertension caused by complete obstruction of the splenic vein, which can result in splenomegaly. Patients present with typical signs of portal hypertension such as gastroesophageal varices, ascites and splenomegaly which cannot be attributed to hepatic disease.
Material and Methods: A 62-year-old male with no past medical history presented to the hospital with hematemesis and three episodes of dark black loose stools. Computed tomography (CT) showed splenomegaly with isolated gastric varices with non-visualization of a normal splenic vein. An Esophagogastroduodenoscopy (EGD) was performed and bleeding originating from hypertrophied gastric varices was found. Interventional radiology was consulted when the bleeding could not be controlled from the EGD. Embolization of the varices through Balloon-occluded Retrograde/Anterograde Transvenous Obliteration (BRTO/BATO) was considered however was deemed inappropriate as variceal embolization would likely worsen the upper gastrointestinal bleeding (UGIB) without proper splenic outflow. The decision was made to attempt splenic artery embolization to decrease the splenic inflow. The splenic arterial system was catheterized. Celiac and splenic artery angiography demonstrated hypertrophy of the splenic artery and delayed angiogram showed the enlarged gastric varices at the splenic outflow. Lower pole and mid pole branches of the splenic artery were subselected and Hydropearl particles were used to achieve complete stasis (contrast visible for at least 5 heartbeats but not static).
Results: Post embolization angiography showed approximately 66.7% reduction in splenic arterial flow. On follow up CT 3 days later, splenomegaly was again noted with splenic mid and lower pole evolving infarcts. Patient’s UGIB resolved and he was discharged without repeat episodes or adverse events including pleural effusion for 6 months. Patient has not presented for followup at this time.
Conclusions: Congenital absence of the splenic vein is a rare condition that may present with significant UGIB from hypertrophied isolated gastric veins in a patient without portal hypertension. We show that partial splenic embolization is a safe method to resolve UGIB in a patient with congenital absence of the splenic vein.