From the Guidelines
The correct answer is (d) chronic pancreatitis. Sinistral portal hypertension, also known as left-sided portal hypertension, is most commonly caused by chronic pancreatitis, as evidenced by a study published in the Journal of the American College of Radiology in 2020 1. This condition develops when there is obstruction or thrombosis of the splenic vein, which typically occurs due to inflammation and fibrosis from adjacent pancreatic disease.
Key Points:
- In chronic pancreatitis, the ongoing inflammation leads to compression or thrombosis of the splenic vein, causing increased pressure in the left portal system.
- This results in the development of collateral vessels, particularly gastric varices, as blood seeks alternative routes to return to the systemic circulation.
- Unlike typical portal hypertension which affects the entire portal system, sinistral hypertension is localized to the left side of the portal venous system.
- While schistosomiasis, hypercoagulable states, and alcoholism can cause portal hypertension, they typically cause generalized portal hypertension rather than the isolated left-sided variant that characterizes sinistral portal hypertension.
- A review of patients undergoing splenectomy for splenic vein occlusion and gastric variceal bleeding due to chronic pancreatitis showed successful management of bleeding in all patients without recurrence, as reported in the study 1.
From the Research
Causes of Sinistral Portal Hypertension
- The most common cause of sinistral portal hypertension is chronic pancreatitis, as it can lead to splenic vein thrombosis/obstruction, resulting in localized portal hypertension 2, 3, 4, 5.
- Other causes of sinistral portal hypertension include acute pancreatitis, pancreatic pseudocysts, and pancreatic carcinomas 3, 6, 4.
- Hypercoagulable states and schistosomiasis are not commonly associated with sinistral portal hypertension, and alcoholism is not a direct cause of this condition 2, 3, 4.
- Chronic pancreatitis is a significant risk factor for sinistral portal hypertension, with studies showing an incidence of 7-22% in patients with chronic pancreatitis 2, 5.
Clinical Characteristics and Treatment
- Sinistral portal hypertension can cause gastric or gastroesophageal varices, leading to gastrointestinal bleeding or hypersplenism 2, 3, 4.
- Treatment options for sinistral portal hypertension include splenectomy, distal pancreatectomy, and endoscopic treatment, depending on the severity of symptoms and the presence of varices 2, 3, 6, 5.
- Splenectomy is often recommended for patients with symptomatic sinistral portal hypertension, especially those with gastric varices or a history of variceal bleeding 2, 4, 5.