HOME
Return to Table of Contents
SPLENIC ARTERY COLLATERALS MIMICKING GASTRIC FUNDAL VARICES ON ENDOSCOPY: A CASE REPORT AND LITERATURE REVIEW
CS Wang1, G Mnatzakanian1, A Smaggus1, AA Common2, KN Jeejeebhoy1
Department of 1Medicine and 2Medical Imaging, St Michael’s Hospital, University of Toronto, Toronto, Ontario
Successful management of upper gastrointestinal bleeding (UGIB) depends on accurate diagnosis so as to utilize the most appropriate treatment modality. We report a 66-year-old man who was referred to our facility for endoscopic glue injection. He presented with melena to a peripheral hospital where an urgent gastroscopy revealed what appeared to be a large bulging gastric fundal varix (Figure 1). On further questioning, he denied any history of, or risk factors for portal hypertension. His physical examination did not reveal evidence of portal hypertension or other stigmata of chronic liver disease. Blood tests including complete blood counts, liver enzymes, and liver function tests were normal.
Given the absence of a cause or signs of portal hypertension, we were hesitant to proceed directly with cyanoacrylate glue injection. An enhanced computed-tomographic (CT) scan was obtained, which revealed a cluster of arterial vessels branching from an occluded splenic artery (Figure 2). The vessels extended to the posterior proximal stomach, with a cluster of vessels extending into, and eroding through, the medial gastric fundus. These findings were consistent with a submucosal arterial lesion as opposed to a gastric varix. Transcatheter embolization of the large collateral artery to the gastric fundus was subsequently performed, producing complete occlusion of the collateral (Figure 3).
Gastric bleeding secondary to arterial collaterals is rare, with only 3 reported cases in the English literature. Our case is significant in that it is the first to describe a submucosal gastric arterial lesion with an endoscopic appearance similar to gastric fundal varices. Given that the current therapy for isolated gastric varices with cyanoacrylate injection can be both ineffectual and carry significant risks of systemic embolization when injected directly into the arterial circulation, a high level of diagnostic certainty is required before proceeding with cyanoacrylate therapy. Importantly, the endoscopist should recognize that collateralization from an occluded splenic artery can produce endoscopic lesions that closely mimic the appearance of gastric varices from portal hypertension. A detailed medical history, physical examination, proper laboratory studies and imaging investigations remain essential, in conjunction with endoscopy, to most appropriately manage patients with gastric vascular lesions.