Ochsner Health System Shreveport, LA, United States
Christopher Oglesby, DO1, Aswani Thurlapti, MD1, Sukhmani Boparai, MBBS, MD2, Ioannis Papayannis, MD2 1Ochsner Health System, Shreveport, LA; 2Louisiana State University Health Sciences Center, Shreveport, LA
Introduction: Compared to arterial aneurysms, venous aneurysms are rare to come across in clinical practice. Only 3% of all the venous aneurysms belong to the portal venous system. Among these 52% occur in the main portal vein, 28% in the splenic vein, and 7% in the superior mesenteric vein (SMV). Here we present a case of SMV aneurysm along with cavernous transformation of the portal vein (CTPV) post pancreatojejunostomy. This finding is suggestive of chronic portal vein thrombosis.
Case Description/Methods: A 37-year-old thin-built male with a history of non-alcoholic, gallstone pancreatitis status post Puestow procedure and cholecystectomy 1 year ago was admitted to the hospital for new-onset large-volume ascites. He had recurrent hospital admissions for abdominal pain that was managed symptomatically by primary care. On examination, abdomen was diffusely distended, tense and tender. Serum chemistries, liver function tests, and lipase were normal. CT abdomen revealed fatty cirrhotic changes. Stenosis and CTPV due to portal vein thrombosis with periportal, perigastric, and perisplenic collateral formations was noted along with 1.6cm SMV focal aneurysmal dilatation as seen in the figure. These findings were not present in the CT performed 1 year ago prior to the surgery. Paracentesis was suggestive of portal hypertension. Infectious and autoimmune workup for liver disease was negative. Endoscopy showed small esophageal and fundal gastric varices. Liver biopsy revealed moderate micro and macrovesicular steatosis involving 40-50% of hepatocytes with no active inflammation or fibrosis. Patient was initiated on CREON supplements and referral placed to primary pancreatic surgeon for further evaluation of repair of SMV aneurysm. Ultimately conservative management was agreed upon during a multidisciplinary conference.
Discussion: SMV aneurysm and CTPV are rare complications of chronic portal HTN that can occur concomitantly due to cirrhosis. The rare finding seen here, however, was noted as a post-surgical finding. SMV aneurysms and CTPV may present as incidental findings or they can cause bouts of abdominal pain. Reported complications of untreated aneurysms include thrombosis or rupture . They require no treatment in most cases and studies suggest serial follow-up with abdominal ultrasound is sufficient . However, no definitive guidelines for management have been established.
Figure: SMV aneurysm
Christopher Oglesby indicated no relevant financial relationships.
Aswani Thurlapti indicated no relevant financial relationships.
Sukhmani Boparai indicated no relevant financial relationships.
Ioannis Papayannis indicated no relevant financial relationships.
Christopher Oglesby, DO1, Aswani Thurlapti, MD1, Sukhmani Boparai, MBBS, MD2, Ioannis Papayannis, MD2. P0061 - Double Whammy: Superior Mesenteric Vein Aneurysm and Portal Vein Cavernoma Post Puestow Procedure, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.