3026 Rare Complication of Chronic Pancreatitis: Chronic Portal Vein Thrombus Causing Pre-Hepatic Portal Hypertension

Abstract

INTRODUCTION: Portal vein thrombosis (PVT) is an uncommon complication of chronic pancreatitis. PVT more commonly occurs as a complication of acute pancreatitis and is an indicator of severity of disease. Patients with chronic pancreatitis can develop a pre-hepatic portal hypertension (HTN) in the setting of PVT. These patients are at risk for variceal hemorrhage. Early identification and management is critical. CASE DESCRIPTION/METHODS: A 34 year old female with a history of familial hypertriglyceridemia leading to necrotizing pancreatitis complicated by PVT in the past presented with sudden onset dizziness. She was documented to have a history of liver cirrhosis. On presentation to the outside hospital (OSH), patient was hypotensive and was noted to have a 5 g drop in Hb compared to baseline. She was transferred to the ICU and required support with blood transfusions and vasopressors. EGD at OSH demonstrated grade 1 non-bleeding esophageal varices and portal hypertensive gastropathy. Patient was transferred to our institution for TIPS evaluation. On presentation to our institution, patient remained hemodynamically stable. Examination was consistent with ascites and a R sided pleural effusion, which was confirmed by imaging. She underwent a work-up for chronic liver disease, which was negative. Her ascitic fluid volume was insufficient for paracentesis. Thoracentesis was performed with removal of 1.4 L of transudate consistent with hepatic hydrothorax. Her course was complicated by worsening jaundice. She subsequently underwent liver biopsy with hepatic venogram and pressure gradients. Biopsy did not show evidence of cirrhosis and hepatic venogram was consistent with pre-hepatic portal HTN. MRCP demonstrated dilated common bile duct and main pancreatic ducts. ERCP demonstrated stenosis in the main bile duct, which was treated with plastic stent placement. Following endoscopic intervention, patient's jaundice dramatically improved. TIPS was deferred given patient's history of PVT as well as limited efficacy in the absence of cirrhosis. DISCUSSION: Among reported cases of pre-hepatic portal HTN, chronic PVT secondary to chronic pancreatitis is rare. More commonly, splenic vein thrombus is described, resulting in a sinistral portal HTN with a predominance of gastric varices. Therapeutic considerations for pre-hepatic portal HTN are mainly focused on the prevention of variceal hemorrhage. Medical and endoscopic therapy is the standard of care. TIPS is an option for refractory cases.

Rare Complication of Chronic Pancreatitis: Chronic Portal Vein Thrombosis and Splenic vein thrombosis causing non cirrhotic portal hypertension

“…(1) Splenic vein thrombosis is a well-established complication of chronic pancreatitis, while portal vein thrombosis is a rare complication (2). Here, we present a case of chronic pancreatitis associated with both portal and splenic vein thrombosis, causing non cirrhotic portal hypertension.…”