Massive Gastric Bleed Post Splenic Embolization

Splenic embolization is a technique used to mitigate the physiological effects of portal hypertension by reducing splenic vein outflow thereby decreasing portal pressure and variceal bleeding. We present a case of massive variceal bleeding post splenic embolization. A 41 year-old-man with chronic and complete thrombosis of portal and splenic veins secondary to complicated appendicitis in childhood and no other significant past medical history was transferred to our institution for cyanoacrylate glue injection for management of gastric variceal bleeding. He underwent lower pole splenic pulp embolization of 30-50% of splenic parenchyma. His course was complicated by massive hematemesis 24-hours after the procedure. Emergent endoscopy revealed actively spurting gastric variceal bleed, which required 6 cyanoacrylate glue injections to achieve hemostasis. He had uncomplicated post-endoscopy course. He subsequently underwent endovascular splenic artery aneurysm repair and further splenic pulp embolization. He was discharged home without further complications. Gastric variceal bleeding can be a fatal complication of portal hypertension and splenic artery embolization (SAE) is a technique used to lessen this complication. SAE reduces blood flow to the splenic parenchyma, thereby, reducing blood flow to the short gastric varices, which relieves gastric bleeding. It has also been reported that partial splenic embolization can induce up to an 11% reduction in gastric mucosal hemoglobin content. Our patient underwent selective SAE of the lower pole of the spleen, thereby increasing splenic upper pole perfusion where the splenogastric veins are located, exacerbating his known gatric varices. Homogenous SAE may have prevented the massive gastric variceal bleed in our patient.1978_A Figure 1. Esophagogastroduodenoscopy showing actively spurting gastric variceal bleed (black arrow)1978_B Figure 2. Successful bland embolization of approximately 30-50 percent of the splenic parenchyma with relative sparing of the upper pole of the spleen