Splenic vein thrombosis overview

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Splenic vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

Splenic vein thrombosis is formation of a thrombus in the splenic vein. When thrombosis of the splenic vein occurs, collateral vessels develop to shunt blood around the occluded splenic vein. The two most common collateral pathways use the short gastric vessels. In the distal esophagus, portosystemic collaterals connect the short gastric veins into the azygous system. There is no established system for classification of splenic vein thrombosis. Common causes of splenic vein thrombosis are : Pancreatitis, pancreatic pseudocyst, pancreatic carcinoma, lymphoma, adenopathy from metastatic cancer, iatrogenic causes: Splenectomy, partial gastrectomy, distal spleno renal shunt, Factor V leiden mutation, prothrombin G20210A mutation. he incidence of Splenic vein thrombosis was estimated to be 141,00 cases per 100,000 individuals worldwide. Splenic vein thrombosis affects men and women equally. There is no racial predilection for splenic vein thrombosis. ost patients are asymptomatic SVT should be suspected in a * A patient with a history of pancreatitis and GI blood loss, * A patient with splenomegaly in the absence of portal hypertension, cirrhosis, and hematologic disease, in the setting of isolated gastric varices, * Splenomegaly with rare leukopenia, thrombocytopenia, splenic pain and abdominal pain. Ultrasound, CT and MRI scans are important diagnostic modalities. Medical therapy for splenic vein thrombosis include anticoagulation to maintain INR between 2 to 3. The goal of anticoagulation is to prevent extension of the clot and to allow for recanalization. Splenectomy is recommended for all patients with bleeding varices associated with isolated splenic vein thrombosis. Splenectomy eliminates venous collateral out flow, decompresses surrounding varices.

Historical Perspective

Though thrombosis of the splenic vein is infrequently reported in the literature,1 , 2 it is common knowledge among surgeons that this condition may follow splenectomy. In fact, local thrombosis at the site of ligation of the splenic artery and vein with extension back to the first branching vessel is to be expected. This degree of involvement of the splenic vein, however, should be symptom less, but it is potentially important because of possible extension into the portal venous system and as a source of emboli to the liver.

Classification

There is no established system for the classification of splenic vein thrombosis

Pathophysiology

When thrombosis of the splenic vein occurs, collateral vessels develop to shunt blood around the occluded splenic vein. The two most common collateral pathways use the short gastric vessels. In the distal esophagus, portosystemic collaterals connect the short gastric veins into the azygous system. Splenoportal collaterals decompress the short gastric veins through both the coronary vein into the portal vein and via the gastroepiploic arcade into the superior mesenteric vein. In either case, the hypertensive short gastric veins cause increased pressure within the submucosal veins of the gastric fundus, resulting in varices.

Causes

Common causes of splenic vein thrombosis are :

Pancreatitis, pancreatic pseudocyst, pancreatic carcinoma, lymphoma, adenopathy from metastatic cancer, iatrogenic causes: Splenectomy, partial gastrectomy, distal spleno renal shunt, Factor V leiden mutation, prothrombin G20210A mutation.

Differentiating Splenic vein thrombosis from Other Diseases

Splenic vein thrombosis must be differentiated from hepatic vein thrombosis, portal vein thrombosis, testicular cancer, hyperhomocystenemia and deep vein thrombosis

Epidemiology and Demographics

The incidence of Splenic vein thrombosis was estimated to be 141,00 cases per 100,000 individuals worldwide. Splenic vein thrombosis affects men and women equally. There is no racial predilection for splenic vein thrombosis.

Risk Factors

Common risk factors in the development of splenic vein thrombosis include: Abdominal cancer, liver cirrhosis, surgery, thrombophilias, hormonal treatments, myeloproliferative disorders, sickle cell anemia

Screening

There is insufficient evidence to recommend routine screening for splenic vein thrombosis. However, routine screening of PSVT after elective splenectomy is warranted because it allows to start anticoagulant therapy and avoid further life-threatening complications. The incidence of PSVT is particularly high among patients operated on for lymphoma or with splenomegaly

Natural History, Complications, and Prognosis

  • If left untreated, patients with splenic vein thrombosis may progress to develop sinistral portal hypertension, gastric varices, ascites, splenomegaly, atraumatic splenic rupture

Diagnosis

Diagnostic study of choice

Venous phase angiography accurately visualises both the location of splenic vein obstruction and the routes of collateralization.The diagnosis of splenic vein thrombosis is confirmed on angiography when selective injection of the splenic artery shows nonvisualization of the splenic vein on delayed images.

History and Symptoms

Most patients are asymptomatic SVT should be suspected in a :

  • A patient with a history of pancreatitis and GI blood loss
  • A patient with splenomegaly in the absence of portal hypertension, cirrhosis, and hematologic disease
  • In the setting of isolated gastric varices

Other signs /symptoms:

  • Splenomegaly with rare leukopenia, thrombocytopenia, splenic pain
  • Abdominal pain

Physical Examination

Physical examination of patients with splenic vein thrombosis is usually remarkable for abdominal pain or distention, splenomegaly and signs of upper GI bleed

Laboratory Findings

Some patients with splenic vein thrombosis may have reduced hgb/hct which is usually suggestive of gastrointestinal bleeding. Splenic vein thrombosis secondary to pancreatitis might have elevated levels of amylase and lipase. Some patients may have elevated liver function tests if the underlying cause is liver disease.

Electrocardiogram

There are no ECG findings associated with splenic vein thrombosis

X-ray

There are no X-ray findings associated with splenic vein thrombosis

Ultrasound

Ultrasound is the initial test for diagnosing splenic vein thrombosis, accuracy may be limited by size or location of veins.

  • Endoscopic ultrasound appears to be a more accurate test than trans abdominal ultrasound for assessing

patency of the splenic vein. Because EUS is a sensitive imaging tool for assessing small pancreatic cancers and determining vascular invasion, it should be considered when other tests have failed to confirm SVT as a cause of bleeding gastric or gastroesophageal varices.

  • It should also be considered in cases of SVT occurring without a history of chronic pancreatitis to evaluate pancreatic carcinoma as a potential cause of SVT.

CT scan

CT scan is helpful in the diagnosis of Splenic vein thrombosis

Findings on CT scan in splenic vein thrombosis: The hyperattenuated material in splenic vein, non-enhanced intraluminal filling defect.

MRI

MRI of the splenic vein thrombosis shows:

  • Severely attenuated and partially calcified retro pancreatic splenic vein resulting in formation of a prominent gastroepiploic collateral channel ( arrow heads) between the superior mesenteric vein and the remnant splenic vein at splenic hilum( solid arrow) along the greater curvature of stomach.

Other Imaging Findings

There are no other imaging findings associated with splenic vein thrombosis.

Other Diagnostic Studies

here are no other diagnostic studies associated with splenic vein thrombosis.

Treatment

Medical Therapy

Medical therapy for splenic vein thrombosis include anticoagulation to maintain INR between 2 to 3. The goal of anticoagulation is to prevent extension of the clot and to allow for recanalization. The mainstay of therapy in splenic vein thrombosis with gastric varices is sclerotherapy and gastric banding.

Surgery

Splenectomy is recommended for all patients with bleeding varices associated with isolated splenic vein thrombosis. Splenectomy eliminates venous collateral out flow, decompresses surrounding varices.

Primary Prevention

There is no established method for prevention of splenic vein thrombosis.

Secondary Prevention

There is no established method for prevention of splenic vein thrombosis.

References


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