Left-Sided Portal Hypertension - SASSiT

1144 Dig Dis Sci (2007) 52:1141–1149
Table 2 The origin of acute
gastrointestinal bleeding in
patients with left-sided portal
hypertension (LSPH)
a For prospective studies.
b Review of the literature.
c Prospective studies.
Number of Acute GI Mean
patients with bleeding due Esophageal Gastric Combined follow-up
Reference LSPH to varices varices varices varices time (mo) a
78
2
2 20
Moosa et al., 73 51 4 38 31
1985 [16] b
Warshaw 8 2 8
et al., 1987
[45]
Bradley 11 2 6
[44] c
et al., 1987
Evans et al., 12 10 10
1990 [5]
Bernades 22 1 100
[10] c
et al., 1992
Sakorafas 34 6 12
et al., 2000
[7]
Heider et al., 53 2 11 30
2004 [23]
Köklü et al., 24 6 21
2005 [22] c
most patients with gastric varices have thickened mucosal
folds in the fundus of the stomach, the abnormality is rarely
specific for the disorder [49]. These findings can be misinterpreted
as gastric carcinoma, lymphoma, multiple polyps,
or Menetrier’s disease [50, 51]. The reported accuracy of
barium contrast studies in patients with proved gastric varices
has ranged from 14% to 74% [52, 53]. Currently, bariumcontrast
examinations are not frequently used because newer
diagnostic techniques are preferred.
Upper gastrointestinal endoscopy can be used to detect
the presence of gastric varices. The endoscopic appearance
of gastric varices varies from clear-cut variceal veins to irregularities
or nodularities in the rugae [54]. If isolated gastric
varices are seen on endoscopy, LSPH should be considered,
and advanced diagnostic studies should be performed
to clarify the diagnosis. As endoscopists have become more
competent, the accuracy of visualizing gastric varices has
increased. In an early series, less than half of the patients
with gastric varices found on splenoportography were diagnosed
correctly by endoscopy [49]. In a more recent study,
gastric varices have been accurately diagnosed and localized
in nearly 90% of cases [55]. A careful examination should
be made to find gastric varices in every patient with gastrointestinal
bleeding of obscure origin, particularly if it is
accompanied by splenomegaly.
Two techniques of angiography are available for diagnosing
LSPH. Splenoportography was popularized by Leger
in 1951 as a method to visualize the portal venous system,
but that procedure is rarely used today because it is invasive
and has potential morbidity, particularly in patients with portal
hypertension [11]. Arteriography is the preferred method
for diagnosis and is a safer and more controlled technique
in patients with a prolonged prothrombin coagulation time
and elevated portal or systemic pressures [56]. Angiography
outlines the location of obstruction and the route of decompression.
Catheterization of the celiac axis provides access to
surrounding arterial structures, including abnormal hepatic
and pancreatic neoplastic vasculature. Subsequently, venous
phase studies can be performed [16]. The portal system is
generally shown clearly; however, arterographic studies often
fail to demonstrate collateral veins that can be seen on
splenoportography [1].
Venous phase angiography accurately shows both the location
of the splenic vein obstruction and collateral flow.
The diagnosis of SVT is confirmed on angiography when
the splenic vein fails to opacify on the venous phase of the
splenic artery injecton. Often venous collaterals in the splenic
hilum and dilated gastroepiploic and short gastric veins are
also seen [26].
Intra-arterial digital substraction angiography (DSA) reliably
shows the portal venous system, collateral circulation,
shunt location and postoperative changes. The major advantage
of intra-arterial DSA is the smaller amount of contrast
medium injected, so that local and systemic side effects
are rare [57]. Other well-known advantages of intra-arterial
DSA are quicker execution, less injury to arteries offered
by smaller-caliber catheters, and low cost. The major disadvantage
of intra-arterial DSA is that the field size of the
intensifier is limited to 6–9 in.
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