Question of the Week # 119, 120, 121

119) A 60-year-old woman presents to the Emergency Room with massive hemetemesis. The onset is acute. She denies any alcohol use or  any antecedent nausea, vomiting or retching. On physical examination, the patient is found to be hypotensive with a blood pressure of 80/40. The patient is started on Intravenos fluids and proton pump inhibitors. Prothrombin time and liver function tests are with in normal limits. Hemoglobin is low at 7gm/dl and the patient is now being transfused with 2 units of packed red cells. An immediate Endoscopy is scheduled which revealed bleeding gastric varices but no esophageal varices. Local vasocontrictor therapy and band ligation could not restrain the bleeding. Ultrasound and CT scan of abdomen revealed enlarged spleen, an engorged splenic artery and an intraluminal filling defect in the Splenic Vein as shown in the picture below 

The most common etiology of the condition mentioned above :
A) Polycythemia Vera
B) Inherited Thrombophilias
C) Liver Cirrhosis
D) Chronic Pancreatitis
E) Carcinoma Pancreas
120) The pathophysiology behind the development of Varices in this patient :
A) Systemic Portal Hypertension
B) Superior Mesenteric Vein Thrombosis
C) Liver Cirrhosis
D) Sinistral Portal Hypertension
E) Angiodysplasia
121) The most effective treatment for the condition described above:
A) Transjugular Intrahepatic Portosystemic Shunt
B) Thrombolysis
C) Anticoagulation with heparin
D) Splenectomy

8 Responses

  1. A,d,a

  2. D, B, D

  3. c

    Sinistral Portal Hypertension is very rare condition

  4. sinistral portal hypertension is caused by pancreatic pathology mainly pancreatitis compressing pancreatic vein..which engorges splenic vein in back flow

    So ans shud be D,D,D

  5. I agree: D, D, D.
    Although pancreatic CA can cause this condition however chronic pancreatitis is the most common cause.

    Pancreatic condition –> pancreatic venous compression –> back pressure on splenic vein causing thrombosis –> back pressure in the short gastric veins and the left gastro-omental vein (left portal systemic veins are now congested and hypertensive) –> gastric varices —> gastric bleeding.
    Tx is by correcting the underlying pancreatic condition plus splenectomy to decompress the left portal system.

    By the way “SINISTRA” literal meaning is “LEFT”
    sooo it is “LEFT portal HTN”.

    Great question

  6. this question is given in UW, isolated gastric varices seen without esophageal varices.its due to chronic recurrent pancreatitis,d/t splenic vein thrombosis,here option wud be Sinistral Portal Hypertension,tm is splenectomy

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