Left-sided portal hypertension: Update and proposition of management algorithm

Area of Science:

• Gastroenterology
• Vascular Surgery
• Radiology

Background:

• Left-sided or segmental portal hypertension (SPHT) is a rare condition, frequently linked to pancreatic diseases or prior pancreatic surgery.
• It arises from splenic vein obstruction, leading to splenomegaly and the formation of collateral porto-systemic circulation.
• SPHT should be considered in patients with a pancreatic history presenting with upper gastrointestinal bleeding and splenomegaly, despite normal liver function tests.

Purpose of the Study:

• To elucidate the pathophysiological mechanisms, clinical manifestations, and treatment options for SPHT.
• To address the lack of established management guidelines for SPHT, especially in asymptomatic cases.
• To propose a decision-making algorithm for managing SPHT based on current literature.

Main Methods:

• Literature review of pathophysiological mechanisms, clinical presentations, and therapeutic interventions for SPHT.
• Analysis of diagnostic approaches including imaging and endoscopic procedures.
• Evaluation of surgical and less invasive treatment modalities.

Main Results:

• The most common presentation of SPHT is severe upper gastrointestinal bleeding due to ruptured esophageal or gastric varices.
• Current management recommendations for SPHT are lacking, particularly for asymptomatic individuals.
• Treatment options range from medical and interventional hemostasis for bleeding to splenectomy for symptomatic cases, with emerging less invasive radiologic and endoscopic procedures.

Conclusions:

• SPHT necessitates a high index of suspicion in patients with relevant pancreatic history and specific clinical signs.
• A structured approach is needed for managing SPHT due to the absence of formal guidelines.
• The proposed decisional algorithm aims to guide the management of SPHT based on available evidence and patient status.