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 thebleeding. 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


14 Responses

  1. ddddd

  2. a

  3. CBC

  4. D
    The condition is isolated splenic vein thrombosis, which is most commonly due to chonic pancreatitis.
    Splenic vein thrombosis results in sinistral or left sided portal hypertension.

  5. 3 Ds

  6. d

  7. D

  8. d

  9. E

  10. d,d,d

  11. CT abdomen may show mass at tail of pancreas,splenomegaly and splenic vein thrombosis

  12. sure

  13. Although early reports found that the most common cause of splenic vein thrombosis (SVT) was pancreatic carcinoma, more recent reviews have discovered acute or chronic pancreatitis, particularly in the caudal pancreas, to be the probable cause of SVT in the majority of cases. SVT in acute or chronic pancreatitis results from perivenous inflammation caused by the anatomic location of the splenic vein along the entire posterior aspect of the pancreatic tail, where it lies in direct contact with the peripancreatic inflammatory tissue. The exact mechanism of thrombosis is likely multifactorial, including both intrinsic endothelial damage from inflammatory or neoplastic processes and extrinsic damage secondary to venous compression from fibrosis, adjacent pseudocysts, or edema.

    Sinistral, or left-sided, portal hypertension caused by splenic vein thrombosis (SVT) can result in massive gastrointestinal (GI) bleeding from esophageal or gastric varices or hypertensive gastropathy.

    Because removal of the spleen eliminates venous collateral outflow and thereby decompresses surrounding varices, splenectomy is the treatment of choice for isolated SVT.

    • thanks for the explanation that was a difficult question, i need to get more familiar with CT image abdominal anatomy, but located the structures and understand the pathophysiological mechanism now

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