Chronic Pancreatitis is the Most Common Cause of Sinistral Portal Hypertension
Chronic pancreatitis is the most common cause of sinistral portal hypertension. 1, 2, 3
Understanding Sinistral Portal Hypertension
Sinistral (left-sided) portal hypertension is a localized form of portal hypertension characterized by:
- Obstruction or thrombosis of the splenic vein, typically with normal portal vein pressure and liver function 1, 2
- Development of gastric or gastroesophageal varices due to collateral formation 1, 2
- Potential for gastrointestinal bleeding and hypersplenism as major clinical manifestations 3
Etiology of Sinistral Portal Hypertension
The primary causes of sinistral portal hypertension include:
- Chronic pancreatitis - most common cause, leading to splenic vein thrombosis/obstruction 1, 2, 3
- Acute pancreatitis - second most common cause 3
- Pancreatic neoplasms/cancer 2, 3
- Pancreatic pseudocysts 2
- Post-pancreatic surgery (including pancreaticoduodenectomy) 4, 3
- Arteriovenous malformations (rare) 3
Clinical Presentation and Diagnosis
Patients with sinistral portal hypertension may present with:
- Gastrointestinal bleeding from gastric or gastroesophageal varices - most common symptomatic presentation 1, 2, 3
- Hypersplenism with thrombocytopenia 1, 3
- Asymptomatic or with nonspecific abdominal pain 3
- Normal liver function tests despite potential elevation of liver enzymes 3
Diagnostic Approach
Diagnosis typically involves:
- Doppler ultrasound as first-line investigation 5
- CT for diagnostic confirmation and extension assessment 5
- Endoscopy to identify gastric or gastroesophageal varices 1, 2
- Splanchnic angiography for accurate diagnosis 2
Management Options
Treatment options include:
- Splenectomy - traditionally considered the treatment of choice for symptomatic sinistral portal hypertension 1, 2
- Splenic artery embolization - alternative minimally invasive approach 4, 2, 3
- Splenic vein stenting - emerging option with potential for good outcomes 6
- Endoscopic treatment for variceal bleeding 3
Prognosis
With appropriate treatment:
- Splenectomy has shown excellent outcomes with no rebleeding in most patients during follow-up 1, 2
- Untreated asymptomatic patients may develop variceal bleeding later 1
- Rebleeding rates vary by intervention: 7.1% for splenic vein stenting, 16% for splenectomy, and 47.8% for splenic arterial embolization 6
Clinical Pearls
- Patients without liver enzyme elevation appear more prone to gastrointestinal bleeding 3
- Sinistral portal hypertension should be considered in patients with pancreatic pathology and gastric varices, especially with normal liver function 2
- Concomitant splenectomy should be considered in patients undergoing surgery for chronic pancreatitis if sinistral portal hypertension is present 1