S4631 Rare Case of Non-Cirrhotic Isolated Gastric Varices Due to Complex Pancreatic Cyst Compressing Splenic Vein

Introduction: Non-cirrhotic isolated gastric varices (IGV) are rare and typically linked to isolated left-sided portal hypertension (LSPH), often caused by splenic vein thrombosis or compression. This is commonly due to pancreatic conditions such as pancreatitis, neoplasms, or cysts. IGV without esophageal involvement is especially uncommon. Although early recognition of high-risk bleeding is emphasized, standardized management for LSPH-related varices remains unclear. We present a case of IGV from splenic vein compression by complex pancreatic cysts, emphasizing the need for cohesive methodology and definitive interventions like splenectomy or interventional radiology-guided drainage in select patients. Case Description/Methods: Fifty-three-year-old man with a history of alcohol abuse and prior alcoholic pancreatitis presented with hematemesis. He reported to melena for 1 week prior to arrival. He denied nonsteroidal anti-inflammatory disease, antiplatelet, or anticoagulant use. Vitals were stable. Labs showed hemoglobin 4.5 g/dL, MCV 68 fL, and platelets 127,000/µL. He was treated with blood transfusions and IV proton pump inhibitors. Magnetic resonance imaging abdomen revealed fundal gastric bleed and a complex cystic mass in the pancreatic tail and splenic hilum with internal hemorrhage, causing localized pressure and IGV. No evidence of cirrhosis or splenorenal shunt was seen. Esophagogastroduodenoscopy showed large IGV with high-risk stigmata and no esophageal varices. Bleeding was controlled with N-butyl-2-cyanoacrylate and Lipiodol injection. The patient improved clinically. Given the high risk of rebleeding from the gastric varices and persistence of a cystic lesion with internal hemorrhagic content, the case was reviewed with interventional radiology. Balloon-occluded retrograde transvenous obliteration and transjugular intrahepatic portosystemic shunt were deemed unsuitable due to absence of splenorenal shunt and lack of generalized portal hypertension. The management plan included endoscopic ultrasound to reassess the varices and determine the need for repeat endoscopic glue injection, along with follow-up imaging in 4–6 weeks to evaluate for interventional radiology-guided drainage of the pancreatic cyst. Discussion: This case highlights the diagnostic and therapeutic challenges of IGV due to LSPH from splenic vein compression by pancreatic cysts. In the absence of cirrhosis, IGV may be overlooked, delaying life-saving intervention. Early recognition and multidisciplinary management are critical, especially with high-risk variceal bleeding. Structured follow-up with imaging and endoscopy, and consideration of definitive interventions such as interventional radiology-guided drainage or splenectomy are essential.