Ahmad Abulawi, MBBS1, Rosa Bui, MD2, John Tremblay, DO1, Domenico Viterbo, MD3 1Albany Medical College, Albany, NY; 2Albany Medical Center, Albany, NY; 3Albany Gastroenterology Consultants, Albany, NY
Introduction: Left-sided portal hypertension is a rare condition that usually occurs as a result of isolated obstruction of the splenic vein. It is typically characterized by isolated gastric varices in the setting of splenomegaly with normal hepatic function. Here, we report a case of serous cystadenoma (SCA) of the pancreas presenting as an upper gastrointestinal bleed from isolated gastric varices.
Case Description/Methods: An 82-year-old female presented with an ischemic stroke, necessitating anticoagulation. While on intravenous heparin, she developed significant melena. An upper endoscopy showed large nonbleeding gastric varices. As this was completely unexpected given no history of liver disease or any risk factors, a CT scan was pursued. Surprisingly, this showed two large, cystic masses within the pancreatic head and tail with internal calcifications suspicious for serous cystadenomas. These measured 6.5 x 6.7 x 11.9 cm and 14.9 x 10.4 x 14.2 cm respectively. The mass in the pancreatic head compressed the portal vein and superior mesenteric vein while the mass in the pancreatic tail compressed the splenic vein and artery. A colonoscopy was done with no source of lower GI bleed. She then underwent transjugular intrahepatic portosystemic shunt and splenic vein stent placement. On follow-up, she denied any further episodes of GI bleeding.
Discussion: Pancreatic SCA is usually a benign condition, accounting for 1-2% of pancreatic tumors. Despite its benign course, large SCAs can be symptomatic due to compression of adjacent structures. To our knowledge, only 3 cases of pancreatic SCA with left-sided portal hypertension have been reported. Our case highlights an atypical presentation of SCA and the management strategies that are currently in practice. While variable, guidelines propose surveillance imaging for small lesions and resection of SCA greater than 4 cm, regardless of symptoms. Our patient showcases the sequelae of a lesion much larger than 4 cm left in place, causing mass effect, left-sided portal hypertension, and upper gastrointestinal bleed from gastric varices. Thus, while SCA is benign with rare malignant transformation, its size should be monitored and the development of splenomegaly and even gastric varices should be assessed via endoscopic ultrasound or cross-sectional imaging. Once left-sided portal hypertension is present, resection, TIPS, and splenic vein stent are management options, as seen in our patient.
Figure: Computed Tomography (CT) of the abdomen and pelvis Showing two large, well-circumscribed, cystic masses within the pancreatic head and tail with internal calcifications. These measured 6.5 x 6.7 x 11.9 cm and 14.9 x 10.4 x 14.2 cm respectively.
Disclosures: Ahmad Abulawi indicated no relevant financial relationships. Rosa Bui indicated no relevant financial relationships. John Tremblay indicated no relevant financial relationships. Domenico Viterbo indicated no relevant financial relationships.
Ahmad Abulawi, MBBS1, Rosa Bui, MD2, John Tremblay, DO1, Domenico Viterbo, MD3. P0054 - A Rare Case of Pancreatic Serous Cystadenoma Presenting as Gastric Variceal Bleed, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.