Treatment of gastric varices with partial splenic embolization in a patient with portal vein thrombosis and a myeloproliferative disorder

Abstract

Therapeutic options for gastric variceal bleeding in the presence of extensive portal vein thrombosis associated with a myeloproliferative disorder are limited. We report a case of a young woman who presented with gastric variceal bleeding secondary to extensive splanchnic venous thrombosis due to a Janus kinase 2 mutation associated myeloproliferative disorder that was managed effectively with partial splenic embolization.

Keywords: Gastric varices; Janus kinase 2, Portal hypertension; Myeloproliferative disorder; Partial splenic embolization; Portal vein thrombosis.

Figures

Figure 1

Magnetic resonance imaging - abdomen from two months prior to embolization. Massive splenomegaly is shown (A, asterisk) with associated cavernous transformation of the portal vein (B, arrow head) and large splenorenal varices (C, arrow).

Figure 2

Splenic artery embolization with a single, inferomedial branch targeted to achieve 30%-40% of splenic parenchymal embolization. The pre-embolization blood supply to this vascular territory (A, black arrow) is significantly reduced following the embolization (B, white arrow), with reactive hyperemia of the medial aspect of the spleen.

Figure 3

Five days following embolization the patient presented with symptoms of post-embolization syndrome and extensive splenic infarction, markedly exceeding that expected by the targeted vascular territory. Arrows demonstrate significant volume of non-enhancing spleen in both coronal (A) and axial (B) images

Figure 4

Abdominal magnetic resonance imaging 3 years post partial splenic embolization shows a significantly reduced splenic volume (A, asterisk) with partial recuperation of the previously embolized parenchyma (B) and near complete resolution of the peri-renal varices, confirming reduced variceal and portal venous pressures (B, arrow).