S4702 Non-Cirrhotic Gastric Varices Due to Retro-Aortic Left Renal Vein and Renosplenic Shunt Following Pelvic Surgery: A Rare Vascular Complication

Introduction: Gastric varices are typically caused by liver cirrhosis, portal vein thrombosis, or splenic vein thrombosis. Non-cirrhotic, non-portal hypertensive gastric varices are rare. Here, we present a case in which unique vascular anatomy and prior surgical history led to the development of gastric varices. Case Description/Methods: An 81-year-old woman with a past surgical history of total hysterectomy with bilateral salpingo-oophorectomy (BSO) presented to the emergency room with severe anemia and recent episodes of melena. esophagogastroduodenoscopy revealed isolated large gastric varices with signs of recent bleeding. Endoscopic intervention was deferred due to unavailability of coils for eradication of varices and due to lack of active bleeding. A computed tomography angiogram was subsequently performed to evaluate potential interventional radiology options. Imaging revealed a rare retro-aortic anatomy of the left renal vein, which passed posterior to the aorta rather than in its usual anterior position. Additionally, the patient had previously undergone hysterectomy with bilateral oophorectomy, during which the left gonadal vein—a potential collateral pathway—had been ligated. As a result, the patient developed a rare renosplenic shunt, leading to retrograde blood flow into the gastric veins and the formation of varices. Discussion: This case represents a rare cause of non-cirrhotic, non-portal hypertensive gastric varices. It highlights the importance of assessing renal vein anatomy, particularly the presence of a retro-aortic left renal vein, in patients undergoing pelvic surgery such as oophorectomy. Awareness of such vascular variants may help prevent future complications associated with altered venous drainage.