S4756 Sinistral Portal Hypertension: A Rare Presentation of Pancreatic Cancer With Melena

Introduction: Sinistral portal hypertension is a rare form of portal hypertension characterized by elevated venous pressure in the splenic vein due to non-cirrhotic causes, typically related to the pancreas. SVH is commonly associated with gastric varices, resulting in bleeding, which is an uncommon first sign of pancreatic malignancy. This case highlights the importance of recognizing sinistral portal hypertension as a diagnostic clue to underlying serious etiology. Case Description/Methods: A 74-year-old man with history of prostate cancer and stroke presented with shortness of breath, fatigue and melena for 1 week. His social history included remote tobacco use and regular alcohol use. His vitals showed mild tachycardia. Physical exam was remarkable for pallor. Lab work noted severely low hemoglobin and hematocrit (6.5/20.1). Gastroenterology was consulted and upper endoscopy revealed non-bleeding isolated gastric varices (IGV). Right upper quadrant ultrasound with doppler ordered for further evaluation of IGV showed a 6 cm complex mass within the splenic hilum and no evidence of portal or splenic vein thrombosis. However, a follow up computed tomography of the abdomen and pelvis revealed a cystic pancreatic tail lesion concerning for malignancy, rather than a splenic mass seen on the ultrasound. CA-19-9 was elevated. Tissue biopsy obtained via endoscopic ultrasound confirmed pancreatic adenocarcinoma. Discussion: Sinistral portal hypertension, also known as splenic venous hypertension (SVH), is a rare form of portal hypertension. The pathophysiology involves splenic venous congestion arising from causes like extrinsic compression from masses such as pancreatic cancer, among other etiologies, which leads to blood flow redirection into collateral venous pathways resulting in gastric varices with or without esophageal varices, in the absence of portal venous hypertension. The most common complication is upper gastrointestinal bleeding from varices. Our patient presented with symptomatic anemia without classic clinical history of weight loss or jaundice associated with pancreatic malignancy. The isolated gastric varices on endoscopy turned out to be the only diagnostic clue prompting further workup leading to the diagnosis of pancreatic cancer. In conclusion, SVH is a rare entity that warrants further investigation into the underlying etiology as it can often be the first sign of a serious underlying condition. Early recognition and prompt treatment can significantly impact patient outcomes.