Left-sided portal hypertension: an extraordinary face of portal hypertension. Lecture for Physicians

The lecture is devoted to a relatively rare, but potentially fatal condition — left-sided portal hypertension (PH). Left-sided PH is characterized by increased venous pressure in the splenic vein (SV), formation of venous collaterals involving short gastric veins, and formation of varicose veins of the stomach and esophagus with concomitant splenomegaly. Left-sided PH is a potentially fatal condition in case of bleeding from the varices. The most common cause of left-sided PH is pancreatic disease, with acute pancreatitis, chronic pancreatitis, and pancreatic adenocarcinoma dominating. The course of acute and chronic pancreatitis can be complicated by thrombosis of the vessels adjacent to the pancreas, most often the SV. Left-sided PH can be asymptomatic, but it can also manifest with bleeding from the gastric ducts. Left-sided PH should be suspected in the setting of upper gastrointestinal bleeding in individuals with a history of previous pancreatic disease, concomitant splenomegaly, and preserved liver function. There are no international practice guidelines that regulate approaches to the diagnosis and treatment of left-sided PH; attitudes towards the management of patients with left-sided PH are based on limited evidence that requires further study. Drug therapy for left-sided PH is supportive: vasopressors (octreotide, somatostatin) can reduce blood pressure in the SV. Anticoagulation therapy does not seem to reduce mortality or prevent the development of complications of SV thrombosis, including left-sided PH. Surgical correction of left-sided PH involves surgical (splenectomy), interventional radiological, and endoscopic interventions.