Splenic vein thrombosis

Splenic vein thrombosis is most commonly caused by chronic inflammation from adjacent pancreatitis. Other causes include hypercoagulable states and external compression of the splenic vein. Patients are usually asymptomatic but may present with abdominal pain, upper gastrointestinal bleeding (UGIB) from gastric varices, and splenomegaly. Diagnosis is typically confirmed with CT or MRI angiography. Management focuses on treating the underlying cause and using anticoagulation to prevent thrombus growth. For patients with active variceal bleeding, splenectomy is the recommended definitive treatment.

• Isolated splenic vein thrombosis (i.e., without concurrent portal vein thrombosis) occurs in approximately:
  • 12.4% of patients with chronic pancreatitis ^[1]
  • 22.6% of patients with acute pancreatitis ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Localized inflammation (e.g., secondary to acute or chronic pancreatitis) ^[2]
• Hypercoagulable states (e.g., cirrhosis, pancreatic cancer) ^[2]
• Splenic vein compression due to, e.g.: ^[2]
  • Splenic torsion
  • Pancreatic neuroendocrine neoplasm with invasion of the splenic vein
  • Lymphoma
  • Splenic artery aneurysm
  • Bochdalek hernia
  • Retroperitoneal fibrosis
• Splenic vein stenosis: idiopathic or secondary to ligation (e.g., after pancreaticoduodenectomy) ^[2]

Acute and chronic pancreatitis are the most common causes of isolated splenic vein thrombosis. ^[1]

• Most patients are asymptomatic. ^[1][2]
• If symptomatic, manifestations may include: ^[2]
  • Abdominal pain
  • Overt upper GI bleeding from gastric varices
• Splenomegaly in ∼ 70% of patients ^[2]

• Laboratory studies: LFTs are typically normal. ^[2]
• Imaging ^[2]
  • Abdominal ultrasound with Doppler to exclude cirrhosis and systemic portal hypertension
  • CT/MR angiography to confirm the diagnosis

Suspect splenic vein thrombosis in patients with UGIB bleeding, splenomegaly, and normal LFTs, particularly if they have gastric varices without esophageal varices. ^[2]

• Portal vein thrombosis ^[1]
• See also "Differential diagnoses of UGIB."

The differential diagnoses listed here are not exhaustive.

• Stable patients
  • Treat the underlying cause (e.g., to reduce splenic vein compression and/or localized inflammation). ^[2]
  • Initiate oral or parenteral anticoagulation in consultation with a specialist to determine choice of agent and duration. ^[1][3]
• Patients with acute variceal bleeding
  • Start initial management of overt GI bleeding, e.g.: ^[2]
    • Hemodynamic stabilization and resuscitation
    • Hemostatic control of GI bleeding
  • Consult a specialist (e.g., general surgery, interventional radiology) for definitive management with either:
    • Splenectomy ^[1]
    • Splenic artery embolization for patients who are not candidates for surgery ^[1][2]

• Splenic venous hypertension ^[2]
• Gastric varices ^[2]
• UGIB from variceal rupture ^[2]
• Splenomegaly ^[2]
• Hypersplenism ^[2]
• Progression to portal vein thrombosis ^[1]
• Bowel ischemia ^[4]
• Acute liver failure ^[4]

We list the most important complications. The selection is not exhaustive.