S3297 Cavernous Transformation and Variceal Bleeding Following Portal Vein Thrombosis in Necrotizing Pancreatitis: A Case Report

Introduction: Non-cirrhotic, non-malignant portal vein thrombosis (PVT) is thrombus formation within the portal vein or its intra-hepatic branches without cirrhosis or malignancy. Although rare, about one third of cases are associated with inflammatory conditions, like pancreatitis. Complications of PVT include cavernous transformation and portal hypertension. Management of these complications is challenging and depends on multiple factors, especially considering the increased bleeding risk in these patients. A combination of medical, endovascular, and endoscopic interventions is often required. This case highlights the importance of imaging and clinical context in guiding management decisions for a patient with cavernous transformation and portal hypertension. Case Description/Methods: A 55-year-old man presented with gallstone-associated pancreatitis. During the initial admission, he developed necrotizing pancreatitis and had cholecystectomy. He was readmitted 2 months later for recurrent necrotizing pancreatitis requiring peripancreatic drainage and necrosectomy. Imaging during this admission showed an incidental PVT, and he was started on an anticoagulant. He returned 1 month later with signs of peripancreatic infection and gastrointestinal bleeding. Imaging showed cavernous transformation of the portal vein, and anticoagulation was discontinued due to bleeding concerns. Approximately 9 months after initial presentation, the patient presented with esophageal variceal bleeding which necessitated band ligation. He experienced another episode of variceal bleeding 30 months after the initial PVT diagnosis and was again treated with endoscopic therapy. Discussion: A key complication of necrotizing pancreatitis is non-cirrhotic, non-malignant PVT, which may progress to cavernous transformation and portal hypertension. Timely anticoagulation is often necessary but needs to be weighed against the risk of bleeding in such patients. If thrombosis persists, interventional techniques like TIPS may be needed to reduce the risk of portal hypertension and variceal bleeding. Routine endoscopic and imaging surveillance can be invaluable in these patients. The presented case demonstrated the complexities of clinical decision making for patients with cavernous transformation and portal hypertension and highlights the importance of a tailored approach to management.