What is the initial management for a patient with splenic varices?

Management of Splenic Varices

For patients with splenic varices, the initial management should be splenic vein recanalization when splenic vein occlusion is the underlying cause, as this addresses the root problem and provides excellent outcomes with resolution of bleeding and no recurrence. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Contrast-enhanced CT or MRI is critical to identify:

  • Presence of splenic vein occlusion/thrombosis
  • Inflow and outflow patterns of varices
  • Presence of gastrorenal shunts
  • Associated splenomegaly 1

• Endoscopy should be performed to:

  • Confirm the presence of gastric varices
  • Assess risk of bleeding
  • Evaluate for concurrent esophageal varices 1

Treatment Algorithm Based on Etiology

1. Splenic Vein Occlusion (Sinistral Portal Hypertension)

First-line options:

• Splenic vein recanalization: Transjugular recanalization with stenting has shown excellent outcomes with resolution of upper GI bleeding without recurrence in all treated patients (median follow-up 17.5 months) 1

Alternative options if recanalization fails or isn't feasible:

• Partial splenic embolization: Reduces flow through varices by decreasing splenic volume, with 100% success rate in controlling bleeding in noncirrhotic patients with splenic vein occlusion 1

• Splenectomy: Historically the standard treatment for sinistral portal hypertension, with 100% success rate in controlling bleeding without recurrence in multiple studies 1, 2

• Endoscopic therapy: Less effective in splenic vein occlusion, with only 40% success rate for endoscopic sclerotherapy compared to 100% for splenic interventions 1

2. Portal Hypertension with Splenic Varices

• Endoscopic therapy combined with partial splenic embolization (EVL-PSE): Effectively controls esophageal varices and hypersplenism with significant reduction in portal flow rates 3

• TIPS (Transjugular Intrahepatic Portosystemic Shunt): Beneficial for mitigating bleeding risk in large gastric varices by diverting portal flow 1

• BRTO (Balloon-occluded Retrograde Transvenous Obliteration): Effective for gastric varices when a gastrorenal shunt is present, but high flow may reduce success rate 1

Special Considerations

1. Bleeding varices: Require immediate intervention with:

   • Blood transfusions
   • Correction of coagulopathy
   • Vasoactive medications
   • Antibiotic prophylaxis
   • Prompt endoscopic evaluation 4, 5

2. Concurrent esophageal and gastric varices: TIPS has proven efficacy for both types of varices 1

3. Pitfalls to avoid:

   • Endoscopic therapy alone for splenic vein occlusion has poor outcomes (40% success) and can lead to exsanguination during treatment 1
   • BRTO may increase risk of esophageal variceal hemorrhage 1
   • Splenectomy in patients with inferior mesenteric vein draining into the splenic vein may lead to portal vein thrombosis 1

4. Monitoring after intervention:

   • Regular endoscopic surveillance
   • Follow-up imaging to assess for recurrence of varices or thrombosis
   • Monitoring of platelet counts and spleen size if partial splenic embolization was performed 3

The management of splenic varices requires careful consideration of the underlying etiology, with splenic vein recanalization offering the most definitive solution when splenic vein occlusion is present, addressing the root cause rather than just treating the varices themselves.