A 60-year-old man presented with hematemesis. He had been diagnosed with pancreatic tail cancer and gastric varices due to sinistral portal hypertension, which had been observed on computed tomography (CT). An upper gastrointestinal endoscopy was undertaken to assess the gastric varices, and a recent gastric variceal bleed was suggested (Figure 1). Although splenectomy was a definitive therapy, considering his prognosis and the possibility of unknown shunts, endoscopic variceal ligation (EVL) was performed to achieve hemostasis due to the risk of embolization with other methods. Endoscopy also demonstrated pharyngeal varices with no signs of bleeding (Figure 2). After treatment, CT showed no evident cause of the pharyngeal varices; however, the left inferior phrenic vein ended in the left hepatic vein and formed a gastrocaval shunt (Figure 3). The bleeding ceased without any complication, and no further bleeding was observed.
Figure 1. Endoscopic views showing gastric varices with a red nipple that indicates a recent bleeding.
Figure 2. Endoscopic view of the pharyngeal varices.
Pharyngeal varices are extremely rare, and have been reported in only 2 cases.1,2 Sinistral portal hypertension is caused by thrombosis or obstruction of the splenic vein, resulting in back pressure changes in the left portal system, and mostly leads to the formation of gastric varices. A minority of gastric varices form the gastrocaval shunt that drains via the upper branch of the inferior phrenic vein into the inferior vena cava.3 The gastrocaval shunt is frequently contiguous with the pericardiacophrenic vein that drains into brachiocephalic vein.4 In our patient, these veins are presumed to play a role in the formation of the pharyngeal varices. To our knowledge, this is the first report of pharyngeal varices secondary to sinistral portal hypertension.
Figure 3. Abdominal CT showing gastric varices (black arrowhead) due to the splenic vein occulusion by pancreatic tail cancer (white arrowhead) and the gastrocaval shunt that drains via the left inferior phrenic vein (white arrow) into the left hepatic vein (black arrow).
Author contributions: S. Kitagawa wrote the manuscript and is the article guarantor. H. Miyakawa edited the final manuscript.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Correspondence: Sho Kitagawa, MD, Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan (firstname.lastname@example.org).
Received July 28, 2015; Accepted October 13, 2015
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