Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Large Intestine
Question 3#

A 38-year-old male presents after a bout of hematemesis at home and subsequently vomits another 400 mL of bright red blood in the emergency room. He is tachycardic and hypotensive. Large bore IVs are obtained and he receives 2 units of packed red blood cells. He is intubated for airway protection and admitted to the ICU. On chart review he is found to have a significant alcohol abuse history and several admissions for alcoholic pancreatitis, but his liver function studies and coagulation parameters are within normal limits. A recent MRI of the abdomen and liver biopsy show no evidence of cirrhosis. The patient is started on an IV proton pump inhibitor and IV octreotide. Bedside ultrasound showed no signs of ascites. He subsequently undergoes an EGD that demonstrates oozing gastric varices that were sclerosed with cyanoacrylate, and EUS shows thrombosis of the splenic vein and calcification of the pancreas. He remains hemodynamically stable and is extubated after the procedure. Six hours later he has another large volume hematemesis and becomes hypotensive. He receives an additional 3 units or packed red blood cells and it stabilizes his blood pressure. 

What is the next BEST step?

A. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
B. Nadolol
C. Continue massive transfusion protocol
D. Splenectomy
E. Catheter-directed tPA to splenic vein

Correct Answer is D

Comment:

Correct Answer: D

The patient has a history significant for chronic pancreatitis, which carries an 8% risk of splenic vein thrombosis. Splenic vein thrombosis can lead to left-sided (sinistral) portal hypertension. The majority of patients with splenic vein thrombosis have no gastrointestinal bleeding, and splenectomy is no longer considered the ideal treatment in asymptomatic patients. Patients typically have normal liver function tests and no signs of cirrhosis. Management includes EGD for diagnosis and management with banding and sclerotherapy/obliteration. However, in the acutely bleeding patient who has failed endoscopic management, splenectomy is the ideal choice to control gastric variceal bleeding. Nadolol is useful to decrease the portal pressures for chronic management but is not useful in the acutely bleeding patient. TIPS will not decrease the portal pressure within the splenic vein as the obstruction is proximal to the portal vein. The patient has now stabilized after receiving 2 units or pRBCs thus ongoing massive transfusion protocol would not be useful. tPA is currently not indicated for portal vein thrombosis. 

References:

  1. Agarwal AK, Raj Kumar K, Agarwal S, Singh S Significance of splenic vein thrombosis in chronic pancreatitis. Am J Surg. 2008;196:149-154.
  2. Fernandes A, Almeida N, Ferreira A, et al. Left-sided portal hypertension: a sinister entity. GE Port J Gastroenterol. 2015;22(6):234- 239.